Reasoning GP · Algorithm · 1-page summary
Penile irritation — new or recurrent
For: males with penile itch, soreness, redness, rash or foreskin problems, face to face or remote. Not for: urethral discharge or a genital ulcer as the main problem (use the penile discharge or anogenital ulcers pathways), or children (use paediatric pathways).
Core rule: examine, don't just re-prescribe. Any persistent, ulcerated, indurated, changing or treatment-resistant penile lesion needs urgent specialist assessment, at any age. Recurrent candidal balanitis can be the first sign of diabetes: check HbA1c.
0Stop — emergencies — before any history
- Rapidly spreading penile or scrotal necrosis, pain out of proportion, spreading erythema, crepitus, fever (Fournier's; diabetes raises the risk) → 999
- Paraphimosis (retracted foreskin will not return, glans swelling) → Same-day urology / A&E immediately; 999 if the glans is dark or discoloured or the patient is systemically unwell.
- Urinary retention from phimosis (trickle, painful voiding, distended bladder) → Same-day urology / A&E for catheterisation.
- Systemically unwell (especially diabetic or immunocompromised), rapidly worsening pain or swelling, spreading erythema, suspected deep infection → Same-day hospital
1Triage by pattern — after a confidential sexual history
| Finding | Route |
|---|---|
| Persistent lesion | Ulcer, plaque, induration, changing → block 2 |
| STI features | Discharge, dysuria, ulcer, vesicles, new partner → offer STI tests |
| Itch + redness | White discharge, satellite lesions → candida |
| Trigger exposure | Soap, latex, product change → contact / irritant |
| White plaques | Fissuring, tightening foreskin → lichen sclerosus |
2Screen — penile cancer, at any age
- NG12: penile mass or ulcerated lesion once an STI is excluded; lesion persisting after completed STI treatment; unexplained or persistent glans or foreskin symptoms → consider Suspected cancer pathway
- Any persistent, indurated, changing or treatment-resistant lesion; hard inguinal nodes → Urgent urology / uro-oncology or dermatology. Biopsy is specialist-directed.
- Known lichen sclerosus with a new lump, ulcer, erosion or induration → Urgent specialist
- Glans cannot be inspected because of phimosis, with persistent symptoms or a suspicious lesion → Urgent urology
- Any genital ulcer, even painless → syphilis serology + STI screen; sexual health.
3Assess
☐ Sexual history: partners, practices, protection, past STI ☐ Retract gently where safe; inspect glans, inner prepuce, meatus, shaft; inguinal nodes; urinary flow ☐ Urine glucose; HbA1c if recurrent, severe or resistant ☐ By risk: NAAT (first-catch urine or urethral swab), gonorrhoea culture before treatment if discharge, HSV PCR from a fresh lesion, syphilis serology, HIV test
Never forcibly retract a scarred or painful foreskin. Clear irritant dermatitis with no STI risk or features needs no mandatory STI screen.
4Classify — only if the screen is negative
- Contact / irritant — after a product change → remove it, soap substitute, emollient, hydrocortisone 1% BD for 1 week.
- Aerobic (bacterial) — malodorous discharge, non-retractile foreskin, no satellites → swab; treat per culture and local guidance. No repeated topical antibiotics.
- Lichen sclerosus — clobetasol propionate 0.05% per a specialist-directed plan; emollient; teach self-examination.
- Psoriasis, Zoon's, fixed drug eruption (same site with each dose, e.g. co-trimoxazole) → dermatology if uncertain or not responding.
- Uncertain or not settling — say so; refer rather than re-prescribe.
5Treat today — doses: NICE/SPC, BNF, local formulary
- Candidal: clotrimazole 1% cream BD for up to 7–14 days to glans and inner prepuce; wash with water or emollient. Fluconazole is not routine; treat a partner only if symptomatic.
- Uncomplicated chlamydia: doxycycline 100 mg BD for 7 days. No sex until partners treated; urethritis → sexual health.
- Gonorrhoea: sexual-health-led; culture first where possible; ceftriaxone 1 g IM; no empirical ciprofloxacin. Syphilis → sexual health.
- Primary herpes: swab, then aciclovir 400 mg TDS for 5 days; discuss with sexual health.
6Refer routinely
- Sexual health: STI, urethritis, ulcers, recurrent or unexplained balanitis; partner notification.
- Urology: phimosis persisting despite a local-pathway steroid trial; suspected BXO/scarring, recurrent balanoposthitis, painful erections, obstruction or recurrent UTI; lichen sclerosus with meatal stenosis.
- Dermatology: difficult lichen sclerosus, patch testing, Zoon's, fixed drug eruption.
- Candida on an SGLT2 inhibitor: discuss with the prescriber; do not switch automatically.
7Never reassure by
- Repeat antifungal or antibiotic courses for a non-healing lesion.
- A painless ulcer — the syphilis chancre is painless.
- A glans you have not seen under the foreskin.
- Age or relationship status — take a sexual history from everyone.
- "Thrush again" without an HbA1c.
- Known lichen sclerosus — a new lump or ulcer needs urgent assessment.
8Safety-net — say it, then document it
999 “Call 999 if your foreskin is pulled back and will not go back over the tip, if the skin of the penis or scrotum turns dark or spreads with severe pain, or if you cannot pass urine.” Same day: “Contact us today (NHS 111 if we are closed) if a sore grows or changes, the glands in your groin become firm or bigger, swelling or redness spreads, or you feel unwell or feverish.”
Remote: do not re-prescribe for a persistent or recurrent problem without examining. Review candidal balanitis at 2–4 weeks; any lesion still present → block 2.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
Glans and inner prepuce seen, or urgent urology arranged
STI risk assessed; tests offered by risk
HbA1c if recurrent, severe or resistant
Safety-net given; review date set
Summary of the full Reasoning GP penile irritation algorithm, which holds the detail, examination, phimosis grading and follow-up. Sources: BASHH balanoposthitis (March 2026), chlamydia (2026), gonorrhoea (2025), syphilis (2024) and genital herpes guidelines; NICE NG12 (updated April 2026); NICE NG28; PCDS. Clinical reference — follow local sexual-health and urology pathways and check doses: NICE/SPC, BNF.