Pain in the penis can occur for a number of reasons. In this section we will discuss some causes of penile pain that result from erections. Types of penis pain that occur when the penis is flaccid (limp) are discussed in another section (click HERE to learn more). It is important to realize that pain in the penis is an indication that there is an injury, inflammation, or disorder of the male reproductive system that ought to be treated.
The penis can become injured in a number of ways. In this section we will focus on penile fractures and frenulum tears.
A penile fracture is when the erectile tissues of the penis tear or break. Penile fractures occur when the penis is erect and receives some sort of blunt trauma. It can also occur when the erect penis for some reason is forced to bend. Any of these situations can cause the thin tunica albuginea layer that surrounds the corpus cavernosa to tear.
Penile fractures occur most commonly during intercourse or sometimes during vigorous masturbation. During intercourse, it occurs when the penis slips out of the vagina and is forced against a non-movable object. Applied pressure of the erect penis to something that is non-movable can cause the penis to suddenly bend and break the tunica. In most cases, this occurs in sexual positions when the man is stationary on the bottom and the woman is on top and the penis is forced against her pubic bone. However, it has been known to occur when the penis slips out of the vagina and strikes a hard surface the couple may be lying on (such as the floor or hard mattress). Other reported cases have occurred in non-sexual situations where a man has an erection and receives some sort of blunt trauma to the penis. This has been reported in strike type injuries to the groin as well as saddle injuries with horses when an erect penis strikes the saddle suddenly, especially if it is caught in the clothing in a downward or forward direction instead of an upward direction.
Penile fractures are usually accompanied by sudden pain in the penis and a popping noise (sometimes described as a cracking or snapping sound). Both of these symptoms occur due to the sudden break in the tunica. As the tunica ruptures, blood that was contained inside the erectile tissues spreads into the area of the penis under the skin. Click HERE to see an example of blood draining from the penis into the pubic area.
For many men with penile fracture, the penis will bruise and swell with blood, taking on the appearance of an eggplant. Oftentimes the penis will bend or curve away from the sight of the injury thus taking on an S-shape in some cases; however, this can be difficult to see in some cases since the swelling of the penis can be so extreme. However, a classic S-curve penis fracture is shown at left. In any case, this is a medical emergency and requires immediate medical attention (often surgery) to correct the fracture and prevent loss of penile tissue. Immediate treatment is also necessary to preserve the ability to have an erection in the future.[i]
As a reminder, the frenulum is a small piece of tissue that connects the foreskin to the underside of the glans (it is often compared to the frenulum of the tongue which is the small cord of tissue under the tongue that attaches the tongue to the bottom of the mouth). It is often called a “banjo string” and tearing of the frenulum (typically during sexual activity) is often termed “snapping the banjo string”. Click HERE to see an example of a frenulum tear.
A short or tight frenulum is called frenulum breve. This occurs in about 1 out of 20 uncircumcised men, although some circumcised men can also have frenulum breve since the frenulum is not always fully removed during some circumcisions. This short/tight frenulum pulls the glans of the penis downward during an erection. This “pulling” of the glans downwards by the frenulum can be painful in and of itself during an erection. However, the greatest risk for pain and injury come during sexual activity. As the glans of the penis moves back and forth during sexual activity, the frenulum can actually tear as the glans is forced upwards. This tearing is extremely painful because one of the most sensitive nerves in the penis runs through the frenulum. Sometimes this tearing is slight and causes some bleeding, which can be controlled through applying pressure. However, in some cases the frenulum can snap or break causing extreme pain and bleeding.
In most cases, a frenulum tear will heal on its own. This may require abstaining from sexual activity for a short period of time (week or more) until the tear heals over. Unfortunately, some men reopen the wound during nocturnal erections, so in some cases healing can take longer in some men than others. If tearing occurs again after healing then medical treatment may prevent future tears since many of these men have a particularly tight frenulum that puts them at risk for repeated tears. The first treatment is circumcision. The second treatment is a frenulectomy. A frenulectomy is a procedure that simply removes the tight frenulum rather than the entire foreskin. In some cases, past tears have not completely torn the frenulum so surgical cutting/tearing of the remaining frenulum and allowing it to heal on its own can prevent future tears.
Penile strangulation is a condition where something wraps around the penis (usually the base of the penis) and cuts off blood supply. In young men it can occur when newly growing pubic hair wraps around the base of the penis – this is almost never seen in adult men. In adults, it almost always occurs due to the man putting something around his penis – such as a ring or band.
Strangulation traps blood inside the erectile columns of the penis and prevents blood flow from going out of the penis. This can cause problems with erectile tissues overfilling and potentially rupturing. There have been reports of the urethra also rupturing which can cause blood to be visible in the urine or semen. In addition, as blood vessels try to move blood and are blocked, they too can swell beyond capacity and rupture. Oftentimes a man will notice that the penis begins to get dark red to even a purple color as blood becomes trapped in the penis. Click HERE to see an example of strangulation by a ring, or click HERE to see an example of strangulation with a small tube.
Strangulation can also prevent oxygenated blood from reaching the erectile tissues leading to tissue damage that in some cases causes tissue death. For obvious reasons, this isn’t a good thing as it can cause gangrene infections and potentially a need to remove dead tissue from the penis which can alter erectile function or require amputation of the penis.
Perhaps one of the most common types of strangulation in men occurs with “penis bands” that are touted as helping enhance or prolong erections during sex. Although some penis bands are medically approved and used in erectile vacuum pump systems for erectile dysfunction, they should never be left on for more than 30 minutes. The purpose of these bands is to allow a man to maintain an erection long enough to have intercourse. Penis bands that are used in men who don’t have erectile dysfunction are often not medically approved and often interrupt blood flow that is moving into the penis naturally – this increases the risk of rupturing tissues within the penis and can cause permanent damage as stated before. Most “erotic” bands are made of rubber and can be removed more easily; however, even vibrating rings used to enhance sexual stimulation have caused penile strangulation. Unfortunately, there have been case reports of objects being placed around the penis (sometimes when it’s flaccid) with the intent to just “see if it fits”, then the man gets an erection and the man can’t get the object off the penis. This is when penile strangulation occurs – sometimes the pain and the strangulation can prevent the erection from subsiding. In these cases, the object has had to be removed by emergency medical professionals.
If you have used a penis ring and have any pain, swelling, or bleeding (either visible or in your urine or semen), seek the advice of a medical profession and discontinue the use of all rings or bands. For those who haven’t used a ring or band before – don’t start. For men who cannot remove the strangulating item, immediate medical attention is necessary. In some cases, removal of blood from the penis in order to remove the object may be necessary.[v]
POST-SURGICAL ERECTION PAIN
Recovery from any type of surgery can cause pain. However, the penis is quite susceptible to pain after surgery due to the change in size of the penis with erections. The most common surgery of the penis is circumcision (surgical removal of the foreskin). Other types of surgery for injuries or penile curvatures may include the erectile tissues of the penis. In these surgeries the skin, and sometimes the erectile tissues, undergo cutting and/or stitching. These tissues will stretch during erections (including nocturnal erections) and in some cases stitches may tear the skin or tissues, and may even snap during rigid erections. In order to prevent such post-surgical erectile pain, healthcare providers may recommend a number of treatments.
The first treatment is symptomatic pain relief with pain killers. This is helpful for general surgical pain when the penis is flaccid, but rarely is sufficient if the pain is being caused by an erection re-opening or pulling at a surgical site. This can be problematic as pain will often cause an erection to go away, but in some cases it can cause the erection to continue.
Oftentimes, medications are given to help erections go away or prevent erections from occurring while the tissue heals. One medication often used to stop an erection is the use of amyl nitrate. This is a large capsule that looks like smelling salts. It is snapped to break the covering allowing fumes to escape and be breathed in. Amyl nitrate contains nitric oxide or NO. Although NO usually is involved in a man starting to get an erection, an overabundance can cause all the blood vessels in the body to expand. This causes the blood vessels that are constricted in the penis to maintain an erection to open up allowing blood to flow out of the erectile tissues causing an erection to subside. Since all blood vessels will dilate, this can cause a drop in blood pressure and severe dizziness. Another option a healthcare provider may use is an anti-testosterone agent to prevent nocturnal erections from occurring (remember nocturnal erections are triggered by testosterone). This can allow a man to sleep through the night without waking up with erectile pain or tearing of sutures. In some cases, prescribers use an oral anti-fungal medication called ketoconazole that disrupts a man’s ability to produce testosterone for a short period of time making nocturnal erections less likely. This medication would be removed after healing has occurred.
FORESKIN INDUCED PAIN
Balanitis, BXO, phimosis, and paraphimosis can all cause penile pain – especially pain during an erection.
In balanitis, the inflammation of the glans and foreskin can be painful, and this pain can worsen as the skin stretches and moves during an erection. In men with BXO (balantis xerotica obliterans) the hard plaques that form on the penis can be tender and painful. These plaques do not expand during erections causing pain, especially if an erection forces the plaques to crack or split.
Phimosis involves a foreskin that won’t retract. In this case, erections can be painful as the penis tries to expand outwards, only to be constricted by a tight foreskin over the glans. Finally, when the foreskin is stuck and swollen in the retracted position, the swelling itself can be quite painful. However, getting an erection can be even more painful as the foreskin can act as a type of penile strangulation around the neck of the penis rather than the base or shaft of the penis. Circumcision is often a treatment in extreme cases of all four diseases.
PELVIC MUSCLE TENSION
It is possible for muscles to become tense and cause pain. If you think about clenching your hand really tight for a long period of time, you’ll notice that after a few seconds it will become painful. It is possible for the IC muscles that support the penis during an erection, and the BS muscles which surround the root of the penis, to become tense and even lock up – especially during prolonged erections. This can cause significant pain and aching. Typically this type of pain is noticed when a man has an erection or even after ejaculation. After ejaculation, the BS muscle in particular will have contracted strongly to help force semen out of the penis. If this BS muscle has not fully returned to a state of relaxation, it may lock up and cause some pain at the base of the penis which may extend up to the shaft of the penis. This is called Pelvic Tension Disorder.
Pain and aching due to muscle tension can also occur in men who prolong sexual activity for hours or engage in vigorous sexual activity. This most often occur in masturbation addiction when prolonged or multiple episodes within the same day lead to extended periods of time with an erection in addition to excessive friction. This type of pain usually resolves a few days after of abstinence.
REFERRED PENILE PAIN
Referred pain describes a type of pain that is felt in one area of the body, but the “problem” is actually in another part of the body. A good example that most people are familiar with is that a person with a heart attack may feel the pain in their left arm. The same holds true with pain in the penis. Pain in the penis may have absolutely nothing to do with a problem or injury to the penis. One common cause of penile pain is actually inflammation of the prostate (prostatitis). The nerves of the prostate and the penis, both eventually connect to the pelvic plexus, so the brain can interpret a pain signal from the prostate as actually coming from the penis. It is not uncommon for men with prostatitis to complain of pain in the penis during or after an erection. However, the penile pain can also occur when the penis is flaccid with the pain either being focused on the shaft or the glans. This can often occur after a bowel movement when the prostate becomes irritated as stool passes by it.
Post-ejaculatory erection pain occurs during the first erection after sexual ejaculation. Since this is so common, it is worth noting some common preventative measures for these men. First, some of the pain can be caused by prostatic fluid or semen being trapped in the ejaculatory duct of the prostate. A man simply urinating after ejaculation can often prevent post-ejaculatory penile pain. This is especially true if ejaculation took place at bedtime (or as a wet dream) and subsequent nocturnal erection pain wakes the man up. If a man has prostatitis, it can also be helpful for him to take an over-the-counter anti-inflammatory medication like ibuprofen or naproxen just after ejaculation to prevent inflammation. During ejaculation, the prostate contracts repeatedly to force sexual fluids out of the ejaculatory duct toward the penis so the semen can be released. These contractions can cause an already inflamed prostate to become more tender (think of running on an already sprained ankle…same principle). Taking an anti-inflammatory can reduce inflammation and thus reduce the transmission of nerves signals that could be interpreted by the brain as pain in the penis.
OTHER CAUSES OF PENILE PAIN
Painful erections can occur due to a number of different causes. Erection pain can be from structural abnormalities such as severe penile curvatures that cause “pinching” of the erectile tissues of the penis or from priapism.
[i] http://emedicine.medscape.com/article/456305-overview#a4 (12/16/2016)
Images on this page from top to bottom include: