Monday, May 19, 2008

Penile Pain

The patient is 40 yo heterosexual male in a monogamous relationship for the last 6 years. Neither he nor his partner has a history of having had sex with anyone else ever before.

Three months ago he had the onset of pain at the tip of his glans during coitus and experienced pain also on pulling at the tip of his foreskin. A month later he noticed a few grouped "vesicles" at the ventral tip of his glans. These lesions have persisted unchanged. The pain in these lesions persists since being first noticed.
Clinical Photo:

The wife is asymptomatic although she had symptoms suggestive of vaginitis 3-4 months back which improved on clotrimazole pessaries (this was almost the same time when the patient developed pain during coitus which has never subsided).

What is the diagnosis?
What would you do at this point?

Note: Two respondents have suggested "Pearly Penile Papules." This does not look like a typical case of PPP. For comparison a picture is below. PPP is usually around the corona and is rarely this symptomatic.


  1. I would culture the vesicles r/o herpes( and other STDs), and routine culture( for both pt and partners ). I would think at licken sclerosus as an alternative.

  2. This man has a genital pain syndrome. I think it would be extraordinarily unusual for the vesicles of HSV to be present unchanged for months on end. They usually last only a few days, and under the foreskin even less. These may be milia and are likely unrelated to the pain. A lesion can be biopsied easily and the guesswork taken out of this. Once that is cleared up, the nature of this genital pain needs to be addressed.
    There are pain syndromes, such as the Dynias that need to be considered. These are discussed best by Dr. U. Wesselmann from Johns Hopkins. Perhaps, one can think of a complex regional pain syndrome. This patient needs to sit down with a physician who will look at the big picture. Often, patients such as this are reluctant to discuss their symptoms and that can lead to inadequate and inaccurate assessment and treatment. Regional pain syndromes are difficult and take time, sympathy and understanding.
    More work needs to be done here to arrive at an accurate diagnosis.

  3. AnonymousMay 20, 2008

    The lesions in the clinical photo are suggestive of pearly penile papules. I doubt that they have much to do with this man’s discomfort.

    From your description, I assume he’s uncircumcised. Is there any evidence of atrophic scar tissue on the foreskin from traumatic intercourse?

    I agree—these genital pain syndromes are difficult to diagnose, and many times they persist for extended periods of time despite attempts at treatment.

  4. I would prick the pustules and send the "pus" for culture. The lesions do not look like either of HSV infection or benign pearly papules. Is the patient diabetic? It may be a good idea to drain/incise the "pustules", treat empirically with topical antibiotics, screen for diabetes and watch his response. If the pain persists, then perhaps we may be dealing with genital pain syndrome or dyspareunia.

  5. I agree with the biopsy - would use serrated Gradle scissors to get an ellipse containing one of the (unbroken) pustular lesions.

  6. Ashok Kumar SharmaMay 21, 2008

    Although the image is not sharp still I get the impression that the lesions are not papules; they appear like papules on the sides of fraenum. I can see some minute pinhead sized papules over the glans also (towards the lower right side of the picture).
    The pain at the tip of penis is an unusual symptom which reminds me of referred pain from a bladder stone; this should be ruled out. For the papular skin colored lesions on the sides of fraenum, I would like to rule out condylomata acuminata also; the smaller pinhead sized lesions visible over the glans could be lichen nitidus or if very itchy, candidiasis.

  7. From my understanding of Pearly Penile Papules, there is a variant that occurs on either side of the frenulum, and my initial opinion would be that those are indeed PPP, and that the patient has simply incidentally discovered since the onset of the pain.

    As to the pain itself, there could be a number of causes. It appears from the photo that the patient is uncircumcised, and could perhaps had torn his frenulum slightly.

  8. Erectile dysfunction is a common disease that can happen to anyone although it is more common in men over 40, it may affect all ages. In fact, almost all men experience difficulty in maintaining an erection. In many cases, it is a temporary condition and goes away with little or no treatment. In some cases, it can be an ongoing problem and requires treatment.


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