What are the causes of penile pain when pressure is applied to the lower abdomen?

Penile Pain with Abdominal Pressure: Differential Diagnosis

The most likely causes of penile pain when pushing on the lower abdomen are chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), interstitial cystitis/bladder pain syndrome (IC/BPS), or pudendal nerve compression—all of which can produce referred pain to the penis that is exacerbated by external pressure on the pelvic region. 1, 2

Primary Diagnostic Considerations

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)

• CP/CPPS characteristically causes pain at the tip of the penis, perineum, suprapubic region, or testicles, with pain often exacerbated by urination or ejaculation 3, 1
• The defining feature is pelvic pain or discomfort for at least 3 months, though many patients describe "pressure" rather than pain 1, 2
• Abdominal pressure can trigger or worsen symptoms by compressing inflamed pelvic structures or sensitized nerves 1
• Digital rectal examination may reveal pelvic floor muscle spasm, which can be a key diagnostic finding 1

Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS)

• IC/BPS should be strongly considered in men with pain perceived to be bladder-related, as clinical characteristics overlap significantly with CP/CPPS 1, 2
• Pain typically worsens with bladder filling and improves with urination, and external abdominal pressure can mimic bladder filling sensations 2
• The condition is defined by symptoms lasting at least six weeks, with pain typically perceived in the suprapubic region but may extend throughout the pelvis 2
• Some men meet criteria for both CP/CPPS and IC/BPS and may benefit from combined treatment approaches 1, 2

Pudendal Nerve Compression

• Neuropathic pain related to compression of the dorsal nerve of the penis (derived from the pudendal nerve) can occur at the inferior border of the pubis, and abdominal pressure may exacerbate this compression 4, 5
• This nerve compression syndrome is often associated with cycling and can cause decreased sensitivity of the glans and penis, genital paresthesia, and sometimes erectile dysfunction 4
• Patients may describe symptoms as "pressure," "burning," or "discomfort" rather than explicit pain 6, 7
• Pain is typically worsened by sitting and the patient is not usually woken at night by the pain 7

Essential Diagnostic Workup

Initial Clinical Assessment

• Obtain detailed history focusing on pain location (tip of penis, perineum, suprapubic region), duration (>3 months suggests CP/CPPS, >6 weeks suggests IC/BPS), and exacerbating factors 1, 2
• Perform digital rectal examination to assess for pelvic floor muscle spasm and check anal sphincter tone and lower extremity neuromuscular function 1
• Document whether pain is relieved when the testes are elevated over the symphysis pubis (Prehn sign), which would suggest epididymitis rather than these conditions 3

Laboratory Testing

• Obtain urinalysis and urine culture as basic laboratory testing to rule out infection 1, 2
• Consider urine cytology in men with predominantly irritative symptoms 1
• Serum PSA should be offered to men with ≥10-year life expectancy if prostate cancer detection would change management 1

Advanced Evaluation When Indicated

• Cystoscopy should be performed in patients for whom Hunner lesions are suspected in IC/BPS 2
• Pelvic MRI should be considered if red flags are present: waking at night with pain, excessively neuropathic pain with hypoesthesia, specifically pinpointed pain suggesting neuroma, or pain associated with neurological deficit 7

Critical Pitfalls to Avoid

• Do not dismiss patients who describe "pressure" rather than "pain"—this is common in IC/BPS, CP/CPPS, and pudendal neuralgia 1, 2, 6
• Do not treat with antibiotics when no infection is documented, as this leads to antibiotic resistance and disruption of protective flora 2
• Do not perform prostatic massage if acute bacterial prostatitis is suspected due to risk of bacteremia 1
• Recognize that some patients may meet criteria for both CP/CPPS and IC/BPS, requiring combined treatment approaches 1, 2

Less Common but Important Differentials

Peyronie's Disease (Active Phase)

• Active disease is characterized by penile and/or glanular pain or discomfort with or without erection 3
• Pain may be present even in the flaccid state and could theoretically be exacerbated by abdominal pressure 3
• Plaque(s) and penile deformities may not be fully developed in the active stage 3

Priapism (if erection present)

• Ischemic priapism presents with rigid, tender corpora cavernosa and patients typically report pain 3
• This would be an emergency requiring prompt evaluation if erection persists >4 hours 3
• However, this diagnosis requires persistent erection, which is not described in your scenario 3