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Pain with urination
In most cases, it is safer to initially assume a urinary tract infection (UTI) and treat with antibiotics (see UTI
section). Treat vaginitis if found (see Symptoms: GYN Problems).
Persistent erections (Priapism)
- A tender, painful erection with no history of trauma is low flow priapism. This is an emergent condition
best treated by a urologist. Although this condition may resolve spontaneously, cold water immersion and
manual compression of the penis may be successful. A persistent erection greater than 4 hours may
result in increasing tissue injury that may result in the loss of erectile function after the penis is
decompressed. - A painless partial or full erection especially with history of pelvic trauma can be observed. Similar
treatment can be used.
Skin lesions in the genital region
Ulcers (see Sexually Transmitted Diseases):
- Ulcers that form immediately after intercourse are from trauma.
- If always associated with the ingestion of one particular medication, the ulcer represents a fixed drug
reaction. - Painful - chancroid, herpes
- Painless - syphilis (hard or firm induration, chancre), granuloma inguinale, or LGV
Blisters and nodules
- If there is any question of the diagnosis, assume it may be sexually transmitted (herpes) and avoid
further sexual contact. - Persistent lesions should be evaluated electively to r/o cancer.
- Most causes are benign and/or self-limited.
Generalized edema
- Generalized swelling of the penile shaft skin with itching is usually either a contact allergic reaction or
idiopathic. If an offending agent can be identified (or suspected), treat with antihistamines and avoid the
chemical irritant. - Suspect a skin infection if there is significant erythema and pain, which may also involve the scrotum.
In a sick individual with fever, this can represent a life threatening condition called Fournier’s gangrene
(see Symptom: Male Genital Inflammation).
Cannot Move Foreskin (Phimosis/Paraphimosis)
Inability to retract the foreskin (phimosis) or to pull it forward to its normal position (paraphimosis) can be
problematic in the field. Often the foreskin is edematous from irritation or infection. Monitor this condition
for excessive circumferential swelling which could compromise blood flow in the penis. Anti-inflammatory
medications, ice water and lubricants may be helpful. If there are signs of systemic infection (fever, nausea,
fatigue, etc.), and prompt evacuation is not available, a dorsal slit should be performed in the field. Most
patients require circumcision later.
Dorsal Slit: Prepare the penis as with any surgical procedure (sterile scrub, Betadine, drape), and attempt to
clean between the head and the foreskin especially on the dorsal side. Anesthetize the dorsum of the foreskin
with lidocaine (NO EPINEPHRINE!) using the smallest gauge needle (25-26) available. Use forceps or needle
to ensure dorsal foreskin is numb. Clamp the dorsal foreskin tightly beginning at the tip and working back to
where the foreskin meets the shaft. Leave the clamp in place for several minutes, as this will compromise
blood flow in the area to be incised. Remove the clamp, and using sterile scissors or scalpel, carefully incise
the dorsum of the foreskin through its entire thickness, through the line of devascularized tissue formed by the
clamp. Do not incise the head of the penis. Fold the two sides of the incised foreskin back and away from
the penis. Clean the penis with sterile prep solution between the head and foreskin, then again with alcohol.