In an otherwise healthy adult male with pinpoint tenderness on the glans penis, what are the likely causes and how should it be evaluated and managed?

Pinpoint Tenderness on Glans Penis: Evaluation and Management

The most common cause of pinpoint tenderness on the glans penis in an otherwise healthy adult male is candidal balanitis, which should be treated with topical antifungal agents such as clotrimazole 1% cream or miconazole 2% cream applied 1-3 times daily for 7-14 days. 1

Initial Red Flag Assessment

Before proceeding with routine management, immediately evaluate for surgical emergencies:

• Assess for penile fracture if there is ecchymosis, swelling, a cracking sound during intercourse, and immediate detumescence—this requires urgent surgical exploration 1
• Rule out Fournier gangrene if fever, severe pain, crepitus, or rapidly progressive necrosis are present—this is a surgical emergency requiring immediate debridement and broad-spectrum antibiotics 1, 2
• Evaluate for urethral injury if blood is present at the urethral meatus, gross hematuria, or inability to void 1
• Check for paraphimosis in uncircumcised men, particularly if there is a history of genital piercing, as jewelry through the glans can cause this complication requiring emergency reduction 3

Most Likely Diagnosis: Candidal Balanitis

Candidal balanitis is the most frequent mycotic infection of the penis, with increasing incidence primarily transmitted through sexual intercourse 4, 5:

• Clinical presentation: Erythematous areas on the glans with pruritus, tenderness, and possible white discharge 1, 5
• Risk factors: Diabetes, immunosuppression, poor hygiene, uncircumcised status, and sexual transmission 4, 6

First-Line Treatment

• Apply topical clotrimazole 1% cream or miconazole 2% cream to the glans 1-3 times daily for 7-14 days 1
• Alternative topical options include terconazole 0.4% cream for 7 days or tioconazole 6.5% ointment as a single application 1
• Consider oral fluconazole 150 mg as a single dose for more widespread or recurrent infections 1
• Treat sexual partners if recurrent infections occur, as partners may develop symptomatic balanitis 1
• Advise abstinence from sexual activity until treatment is completed and symptoms resolve 1

When to Suspect Bacterial Infection

If the presentation suggests bacterial etiology (purulent discharge, more acute onset, associated urethritis):

For Men Under 35 Years

• Give ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days for suspected gonococcal or chlamydial infection 3, 1
• Obtain cultures before starting antibiotics: Gram stain of discharge and nucleic acid amplification testing for N. gonorrhoeae and C. trachomatis 3, 1

For Men 35 Years or Older

• Give ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days for suspected enteric organisms 3, 1

Mandatory Reassessment

• Reevaluate at 3 days if no improvement—consider abscess requiring surgical drainage or atypical organisms 3, 1

Important Differential Diagnoses Requiring Biopsy

Any persistent penile lesion in older men requires biopsy to exclude neoplastic changes 2:

Erythroplasia of Queyrat (Penile Intraepithelial Neoplasia)

• Presentation: Persistent erythematous plaque on the glans or prepuce, associated with HPV infection 3, 2
• Risk: Can progress to invasive squamous cell carcinoma, particularly in uncircumcised men 3, 2
• Management: If confirmed, options include topical imiquimod 5%, 5-FU cream, wide local excision, or Mohs surgery, with intensive surveillance every 3-6 months 3, 2

Lichen Sclerosus

• Early presentation: May show only mild erythema before classic porcelain-white atrophic patches develop 1, 2
• Complications: Can cause phimosis, paraphimosis, meatal stenosis, and urethral strictures 1, 2
• Biopsy indications: Persistent hyperkeratosis, erosion, erythema, or failure to respond to treatment 1, 2
• Management: Potent topical corticosteroids with long-term follow-up for squamous cell carcinoma risk 2

Plasma Cell Balanitis (Zoon's Balanitis)

• Presentation: Solitary, smooth, shiny, red-orange plaque on the glans in middle-aged to older men 4
• Importance: Cannot exclude squamous cell carcinoma clinically—biopsy required 4

Trauma-Related Causes

Genital Piercing Complications

• Jewelry through the glans can cause frictional irritation, infection, paraphimosis, urinary flow interruption, and urethral rupture 3
• Management: Remove jewelry if causing symptoms; treat infection if present; reduce paraphimosis emergently if needed 3

Critical Pitfalls to Avoid

• Do not delay surgical consultation if you suspect penile fracture, Fournier gangrene, or abscess formation 1
• Do not treat persistent penile erythema empirically in older men without biopsy—this delays diagnosis of potentially malignant conditions 2
• Do not use over-the-counter antifungal preparations indefinitely without confirming diagnosis if symptoms persist beyond 2 months or worsen 1
• Do not forget to evaluate and treat sexual partners for sexually transmitted causes to prevent reinfection 3, 1
• Do not confuse non-ischemic priapism with ischemic priapism—only the latter is an emergency requiring intracavernous treatment 1