What is the appropriate management for a healthy adult male with undersurface penile pain after intercourse, and when should urgent medical evaluation be sought?

Management of Undersurface Penile Pain After Intercourse

For a healthy adult male with undersurface penile pain after intercourse, the primary concern is to exclude penile fracture (corpus cavernosum rupture) if there was sudden pain, swelling, or deformity during intercourse, which requires immediate surgical evaluation; otherwise, most cases represent minor trauma (friction edema or superficial injury) that resolve with abstinence from intercourse, though sexually transmitted urethritis must be ruled out in sexually active men.

Immediate Assessment: Exclude Surgical Emergencies

Penile Fracture (Corpus Cavernosum Rupture)

• Urgent surgical consultation is required if the patient experienced sudden pain during intercourse accompanied by swelling, discoloration, or penile deviation, as these indicate possible tunica albuginea rupture 1
• Penile fracture presents with acute onset of pain, immediate detumescence, swelling, and ecchymosis during vigorous intercourse 1, 2
• Approximately 10% of penile fractures involve associated urethral injury, which may present with blood at the meatus or difficulty voiding 1, 2
• Early surgical repair should be performed immediately to prevent permanent penile deformity and erectile dysfunction; nonoperative management results in 10% incidence of deformity 1

When to Seek Emergency Evaluation

• Sudden "popping" or "cracking" sound during intercourse 1
• Immediate penile swelling with deviation or deformity 1
• Visible hematoma or extensive ecchymosis 1, 2
• Blood at urethral meatus or inability to void 1

Non-Emergent Causes: Minor Coital Trauma

Penile Friction Edema and Superficial Injuries

• Most undersurface penile pain after intercourse represents minor trauma from friction, manifesting as localized or diffuse penile edema without acute rupture 3
• Self-reported penile coital injuries are common in sexually active men, including soreness (47.6%), scratches/abrasions/cuts (48.2%), and bleeding (16.7%) 4
• These injuries typically present as gradual swelling over hours to days rather than acute onset 3
• Treatment consists of temporary abstinence from sexual intercourse for several weeks until complete resolution 3

Risk Factors for Coital Trauma

• Vigorous or forceful intercourse 2
• Multiple recent sexual partners 4
• Penovaginal disproportion 2
• Certain sexual positions or practices 2

Rule Out Infectious Causes

Sexually Transmitted Urethritis

• All sexually active men with penile pain should be evaluated for urethritis, particularly if pain is accompanied by dysuria, urethral discharge, or discomfort during/after ejaculation 5
• Obtain urethral Gram stain (≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 5, 6
• Perform nucleic acid amplification testing (NAAT) for Neisseria gonorrhoeae and Chlamydia trachomatis from urethral swab or first-void urine 5
• If urethritis is confirmed, treat empirically with azithromycin 1 g orally single dose OR doxycycline 100 mg orally twice daily for 7 days 5

Epididymitis Consideration

• If pain extends to the scrotum or perineum, consider epididymitis 6, 7
• In sexually active men under 35 years, treat with ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 6
• Scrotal elevation, rest, and NSAIDs provide symptomatic relief 6

Chronic Pain Syndromes

Chronic Prostatitis/Chronic Pelvic Pain Syndrome

• Providers should consider chronic prostatitis/chronic pelvic pain syndrome in men with persistent penile, perineal, or pelvic pain lasting >3 months, especially if associated with pain during/after ejaculation 5
• This diagnosis is appropriate when pain persists despite negative infectious workup 5
• Management is complex and may require urological referral 5

Dermatologic Conditions

Lichen Sclerosus

• Consider lichen sclerosus if there are visible porcelain-white lesions, fissures, or scarring on the glans, frenulum, or coronal sulcus 5
• Male dyspareunia (painful intercourse) is a common presenting complaint with lichen sclerosus 5
• Biopsy should be performed if lesions fail to respond to treatment or if there is concern for malignancy 5
• Treatment involves potent topical corticosteroids under dermatologic or urologic guidance 5

Management Algorithm

Step 1: History and Physical Examination

• Timing of pain onset: Sudden during intercourse (fracture) vs. gradual after intercourse (friction trauma) 1, 3
• Associated symptoms: Swelling, deformity, ecchymosis, urethral discharge, dysuria, hematuria 1, 2
• Physical examination: Inspect for deformity, palpate for hematoma, assess urethral meatus for blood or discharge 1

Step 2: Risk Stratification

• High risk (immediate surgical referral): Acute onset during intercourse + swelling/deformity/ecchymosis 1
• Moderate risk (STI testing): Sexually active + dysuria/discharge/pain with ejaculation 5, 6
• Low risk (conservative management): Gradual onset + no systemic symptoms + normal examination 3

Step 3: Treatment Based on Diagnosis

• Penile fracture: Emergency surgical repair 1
• Urethritis: Antibiotics per CDC guidelines + partner treatment + abstinence for 7 days 5
• Friction edema: Abstinence from intercourse for 2-4 weeks + NSAIDs for pain 3
• Lichen sclerosus: Topical corticosteroids + specialist referral 5

Common Pitfalls to Avoid

• Do not dismiss acute penile pain with swelling as minor trauma; penile fracture requires immediate surgical intervention to prevent permanent complications 1
• Do not assume all post-coital penile pain is infectious; obtain objective evidence of urethral inflammation before prescribing antibiotics 5
• Do not overlook partner treatment when STI-related urethritis is diagnosed; all partners within 60 days require evaluation and empiric treatment 5
• Do not continue sexual activity during treatment; abstinence is required until symptoms resolve and partners are treated 5, 3

Follow-Up Recommendations

• Patients with conservative management should return if symptoms worsen, persist beyond 3-4 weeks, or recur 5, 3
• Men treated for urethritis should be retested for gonorrhea and chlamydia at 3-6 months due to high reinfection rates 5
• Persistent pain beyond 3 months warrants comprehensive urologic evaluation for chronic prostatitis/pelvic pain syndrome or other structural abnormalities 5