What is the appropriate evaluation and management for a male patient presenting with genital pruritus?

Evaluation and Management of Male Genital Pruritus

For a male patient presenting with genital itching, begin by examining the skin for visible lesions, discharge, or excoriations, then test for sexually transmitted infections if urethritis is suspected, and treat based on the specific etiology identified—most commonly fungal infection, contact dermatitis, scabies, or lichen sclerosus.

Initial Clinical Assessment

Key Physical Examination Findings

• Inspect the glans, shaft, scrotum, and perianal area for erythema, scaling, nodules, ulcers, discharge, or burrows 1, 2
• Look for urethral discharge or meatal inflammation that suggests urethritis rather than pure dermatologic disease 3
• Perform dermoscopy of the entire genital area to identify scabies burrows, which may be subtle 4
• Check for inguinal lymphadenopathy which may indicate infection or malignancy 1

Critical Diagnostic Tests

• Obtain urethral swab or first-void urine for nucleic acid amplification testing (NAAT) for N. gonorrhoeae and C. trachomatis if any urethral symptoms or discharge are present 5
• Perform skin scraping with microscopy if scabies is suspected based on nodules or excoriations 4
• Consider biopsy of any persistent, non-healing, or atypical lesions to exclude squamous cell carcinoma or premalignant conditions 1, 2

Management by Specific Etiology

Fungal Balanitis (Candida)

Topical antifungal agents are first-line for symptomatic male partners of women with vulvovaginal candidiasis who present with balanitis characterized by erythematous areas on the glans with pruritus or irritation 3. The CDC guidelines specifically note that a minority of male sex partners develop balanitis and benefit from topical antifungal treatment 3.

• Apply clotrimazole 1% cream twice daily for 7-14 days to affected areas 3
• Alternative: miconazole 2% cream twice daily for 7 days 3
• For confirmed Candida urethritis with dysuria or discharge, use fluconazole 150 mg orally as a single dose 6

Scabies

Scabies presents with intense pruritus and may show nodules on the scrotum and penis, requiring treatment even when only genital lesions are present 4.

• Permethrin 5% cream applied to all areas of the body from the neck down, washed off after 8-12 hours 3
• Alternative: ivermectin 200 μg/kg orally, repeated in 2 weeks 3, 4
• Treat all household and sexual contacts simultaneously 3
• Decontaminate bedding and clothing by machine washing/drying on hot cycle 3

Pediculosis Pubis (Pubic Lice)

Patients typically notice visible lice or nits on pubic hair along with pruritus 3.

• Permethrin 1% cream rinse applied to affected areas and washed off after 10 minutes 3
• Alternative: pyrethrins with piperonyl butoxide applied and washed off after 10 minutes 3
• For treatment failure: malathion 0.5% lotion applied for 8-12 hours 3
• Treat sexual partners within the last month 3

Lichen Sclerosus

Lichen sclerosus appears as atrophic white patches on the glans and foreskin, commonly causing phimosis in uncircumcised men 3, 1.

• Potent topical corticosteroid (e.g., clobetasol 0.05% ointment) applied twice daily is first-line treatment 3
• Circumcision is indicated for persistent phimosis unresponsive to medical therapy, with 100% success rate in one series of 34 cases 3
• Monitor long-term as lichen sclerosus carries premalignant potential 3

Contact or Irritant Dermatitis

Contact dermatitis results from condoms, lubricants, soaps, or persistent moisture and maceration 1.

• Identify and eliminate the offending agent 1
• Hydrocortisone 1% cream applied to affected area 3-4 times daily for symptomatic relief 7
• Emphasize gentle cleansing and thorough drying 1

Sexually Transmitted Urethritis

If urethritis is documented (≥5 WBCs per oil-immersion field on urethral Gram stain OR ≥10 WBCs per high-power field on first-void urine microscopy), treat empirically for both gonorrhea and chlamydia 5.

• Ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 7 days 8, 5
• Alternative: ceftriaxone 250 mg IM once PLUS azithromycin 1 g orally once 5
• Treat all sexual partners from the preceding 60 days 8, 5

Critical Pitfalls to Avoid

• Do not assume all genital itching is fungal—scabies can present with isolated genital involvement even in immunocompetent patients 4
• Do not use topical calcineurin inhibitors (tacrolimus, pimecrolimus) as first-line therapy for lichen sclerosus due to concerns about neoplasia risk in a premalignant condition 3
• Biopsy any persistent, ulcerating, or non-healing lesion as squamous cell carcinoma in situ (erythroplasia of Queyrat) can mimic benign inflammatory conditions 1
• Do not treat asymptomatic candiduria—it represents colonization rather than infection and does not require antifungal therapy 6
• Recognize that psoriasis on the genitals lacks typical scale due to moisture and maceration, making diagnosis challenging 1

Follow-Up Strategy

• Re-evaluate within 1 week if symptoms persist after initial treatment 3
• Consider alternative diagnoses including red scrotum syndrome (chronic erythema with burning, often following prolonged topical steroid use) if standard treatments fail 9
• Perform HIV testing and syphilis serology in all patients with suspected sexually transmitted etiology 8, 5