📋 Key Information Summary
- Physiological phimosis is normal in boys <3 years; pathological phimosis in older children or adults usually results from balanitis xerotica obliterans (BXO/lichen sclerosus) and requires treatment.
- Topical corticosteroids (betamethasone 0.05% ointment) are first-line for childhood phimosis, with success rates of 70–90%, avoiding the need for circumcision in most cases.
- Paraphimosis is a urological emergency — the constricting foreskin must be reduced promptly to prevent glans ischaemia and necrosis.
- Manual reduction of paraphimosis involves steady distal compression of the glans for 5–10 minutes before pushing the foreskin forward; dorsal slit under local anaesthesia is the emergency backup.
- Sexually transmitted penile ulcers — syphilis (chancre), herpes simplex (HSV), chancroid, lymphogranuloma venereum (LGV), and donovanosis — require specific microbiological workup per the Australian STI Management Guidelines.
- Syphilis notifications in Australia have risen markedly since 2010, particularly among Aboriginal and Torres Strait Islander peoples and men who have sex with men (MSM); always test with treponemal and non-treponemal serology.
- Peyronie disease affects 3–9% of men ≥40 years; intralesional collagenase clostridium histolyticum (Xiaflex®) is PBS-authority listed for plaque curvature ≥30° in the stable phase.
- Squamous cell carcinoma accounts for >95% of penile cancers; risk factors include phimosis, HPV infection (especially HPV-16), smoking, and lack of neonatal circumcision.
- Penile cancer is staged with MRI of the penis ± inguinal ultrasound; sentinel lymph node biopsy or dynamic sentinel node scintigraphy is recommended for clinically node-negative disease.
- Haematospermia is most often benign and self-limiting in men <40 years; in men ≥40 years or with persistent/recurrent symptoms, exclude prostate cancer (PSA, transrectal ultrasound) and urogenital infection.
- Empirical antibiotics for suspected STI-related penile ulcer in Australia: IM benzathine penicillin G for syphilis, valaciclovir for genital herpes; azithromycin for chancroid — consult local antimicrobial guidelines.
- Every uncircumcised male should be counselled on gentle daily foreskin retraction and washing — poor hygiene is a modifiable risk factor for balanitis, phimosis, and penile cancer.
- Aboriginal and Torres Strait Islander men have higher rates of STI-related penile ulcers and advanced penile cancer due to delayed presentation; culturally safe care, community-based screening, and remote specialist access are critical.
Introduction & Australian Epidemiology
Penile disorders span a wide clinical spectrum — from benign and self-limiting conditions such as physiological phimosis in infancy, to urological emergencies such as paraphimosis, to cancers requiring multidisciplinary oncological management. In Australian primary care, general practitioners and emergency physicians commonly encounter foreskin disorders, sexually transmitted genital ulcers, and haematospermia, while Peyronie disease and penile malignancy are more frequently managed in urological specialist practice.
The foreskin is involved in the majority of paediatric penile consultations. Physiological phimosis is present in approximately 96% of newborn males and resolves spontaneously in most by age 3–5 years. Pathological phimosis, most commonly due to lichen sclerosus (balanitis xerotica obliterans), affects an estimated 0.6–1.5% of uncircumcised boys and a similar proportion of adults. Paraphimosis accounts for a small but urgent proportion of urological presentations and requires immediate intervention.
Sexually transmitted infections (STIs) remain a significant cause of penile ulceration in Australia. Notifications of syphilis have increased approximately ten-fold since 2010, with the highest rates among Aboriginal and Torres Strait Islander peoples in remote and very remote areas, and among MSM in urban centres. Genital herpes simplex (HSV-1 and HSV-2) remains the most common cause of genital ulceration nationally. Donovanosis, once endemic in northern Australian Aboriginal communities, has become rare following targeted public health interventions but has not been eliminated.
Peyronie disease has an estimated prevalence of 3–9% in men over 40 years in community-based studies, though the true prevalence may be higher owing to under-reporting. Penile cancer is rare in Australia — approximately 300–400 new cases per year — but carries significant morbidity, particularly when diagnosis is delayed. Squamous cell carcinoma constitutes >95% of cases, and HPV (especially types 16 and 18) is implicated in approximately 50% of tumours. Age-standardised incidence is higher in men from lower socioeconomic backgrounds and in those who are uncircumcised.
Haematospermia (blood in the ejaculate) is reported by up to 1 in 1000 men attending urology clinics. While the majority of cases in younger men are self-limiting and idiopathic, persistent or recurrent haematospermia warrants investigation to exclude malignancy, infection, or structural abnormality, particularly in men aged ≥40 years.
This article provides an Australian-focused clinical guide to the diagnosis and management of foreskin disorders, penile ulcers and lesions, Peyronie disease, penile cancer, and haematospermia, with emphasis on evidence-based therapy aligned with Therapeutic Guidelines, PBS-listed treatments, and considerations for Aboriginal and Torres Strait Islander health equity.
Foreskin Disorders & Foreskin Hygiene
Physiological vs Pathological Phimosis
Physiological phimosis is a normal developmental state in which the foreskin is non-retractile due to natural adhesions between the inner preputial epithelium and the glans. It is present at birth in ~96% of boys and resolves progressively, with ~90% of foreskins retractile by age 3 years and >99% by puberty. Physiological phimosis requires no treatment unless recurrent balanitis, urinary obstruction, or significant parental concern prompts intervention.
Pathological phimosis refers to a non-retractile foreskin caused by scarring, most commonly from lichen sclerosus (balanitis xerotica obliterans, BXO). Other causes include chronic balanitis, forceful foreskin retraction (causing scarring), and rarely, penile carcinoma. Pathological phimosis is distinguished from physiological phimosis by the presence of a tight, fibrotic preputial ring with a punctiform opening and whitish scarring.
Never force foreskin retraction in a child with physiological phimosis — this causes tears, scarring, and converts physiological to pathological phimosis. Counsel parents and carers against this.
Management of Phimosis
Betamethasone 0.05% ointment
Celestone® · Topical corticosteroid
Indication
First-line for childhood phimosis (physiological unresponsive to reassurance, or early pathological)
Adult / Paediatric dose
Apply a thin layer to the tight preputial ring twice daily for 4–8 weeks; gentle retraction attempted from week 2 onward
Efficacy
70–90% success rate in achieving full or partial retraction; higher in younger children and non-scarring phimosis
PBS status
✔ PBS General Benefit
Mometasone furoate 0.1% ointment
Elocon® · Topical corticosteroid (alternative)
Indication
Alternative topical steroid if betamethasone unavailable or not tolerated
Dose
Apply to tight ring once daily for 4–8 weeks
PBS status
✔ PBS General Benefit
Circumcision is indicated for phimosis that fails 2 courses of topical steroid therapy, for severe BXO unresponsive to steroids, or where there is concern about underlying malignancy. Refer to a paediatric urologist or general surgeon. In adults, circumcision may be performed as a day procedure under local or general anaesthesia.
Paraphimosis
Paraphimosis is a urological emergency. A tight constricting band of foreskin proximal to the glans impedes venous and lymphatic return, causing painful glans oedema. If not reduced promptly, arterial compromise can lead to glans ischaemia and necrosis within hours.
Manual reduction technique:
- Apply a topical local anaesthetic (lidocaine 2% gel) to the constricting band and glans, or perform a dorsal penile nerve block with lignocaine 1% without adrenaline.
- Apply firm, steady circumferential compression of the oedematous glans with both hands for 5–10 minutes to reduce oedema.
- Place both index fingers on the proximal edge of the retracted foreskin and push distally while the thumbs push the glans proximally through the ring.
- If manual reduction fails after 15–20 minutes, perform a dorsal slit of the constricting band under local anaesthesia (digital block with lignocaine 1%) in the emergency department. Formal circumcision is arranged at a later date.
Foreskin Hygiene Counselling
All uncircumcised males should be counselled on proper foreskin hygiene from school age onward:
- Gently retract the foreskin (as far as comfortable — never force) during bathing.
- Wash the glans and inner foreskin with warm water. Soap is not necessary and may cause irritation; if used, choose a fragrance-free product.
- Dry the area gently and replace the foreskin over the glans to prevent paraphimosis.
- Poor hygiene is a modifiable risk factor for balanitis, BXO, and penile carcinoma.
Penile Ulcers & Causes of Penile Lesions
Differential Diagnosis of Penile Ulcers
Penile ulcers may be infectious, traumatic, inflammatory, or neoplastic. A systematic approach incorporating sexual history, ulcer morphology, and microbiological testing is essential.
| Cause | Morphology | Key Features | First-Line Treatment |
|---|---|---|---|
| Syphilis (primary) | Single, painless, firm chancre with clean base | Incubation 10–90 days; regional lymphadenopathy; highly infectious; RPR/VDRL + treponemal serology | IM benzathine penicillin G 2.4 g single dose |
| Genital herpes (HSV-1/2) | Multiple shallow, painful ulcers on erythematous base; often vesicles precede ulceration | Incubation 2–12 days; dysuria; inguinal lymphadenopathy; PCR swab of lesion base is gold standard | Valaciclovir 500 mg PO BD for 3–5 days (first episode: 1 g BD for 7–10 days) |
| Chancroid (H. ducreyi) | Painful, soft, ragged ulcer with undermined edges; often multiple | Uncommon in Australia; suppurative lymphadenopathy (buboes); diagnosis by exclusion and PCR where available | Azithromycin 1 g PO stat |
| Donovanosis | Painless, beefy-red, non-indurated ulcers that bleed easily on contact | Endemic in remote northern Aboriginal communities; slow-growing; diagnosis by crush preparation showing Donovan bodies | Azithromycin 1 g PO weekly until healed (minimum 2 weeks); or doxycycline 100 mg PO BD |
| LGV (C. trachomatis L1–3) | Small, transient papule or ulcer; followed by painful inguinal lymphadenopathy | Genital ulcer may go unnoticed; buboes may fistulate; serology + NAAT; notifiable in Australia | Doxycycline 100 mg PO BD for 21 days |
| Balanitis / candidal | Superficial erosions with satellite lesions; erythema and white curd-like discharge | Risk factors: diabetes, uncircumcised, antibiotics; KOH prep shows hyphae | Clotrimazole 1% cream BD for 7–14 days |
| Traumatic / factitial | Variable; often linear or atypical distribution | History of injury, vigorous intercourse, zipper injury, or self-infliction; exclude underlying skin conditions | Wound care; exclude infection; psychological assessment if factitial |
| Fixed drug eruption | Well-demarcated, round, erythematous plaque → blister → erosion; recurs at same site | Common culprits: NSAIDs, sulfonamides, tetracyclines, paracetamol | Cessation of causative agent; topical corticosteroids |
Syphilis screening: All patients presenting with a penile ulcer should have syphilis serology (treponemal + non-treponemal) regardless of suspected aetiology. Syphilis co-infection with HIV and other STIs is common in Australia.
Non-Ulcerative Penile Lesions
- Genital warts (condylomata acuminata): Caused by HPV types 6 and 11; cauliflower-like papules on the glans, coronal sulcus, or shaft. Treated with podophyllotoxin 0.5% solution (self-applied) or cryotherapy with liquid nitrogen. Imiquimod 5% cream (3× weekly for up to 16 weeks) is an alternative. PBS-restricted benefit for imiquimod.
- Lichen planus: Violaceous, polygonal papules with Wickham striae; may cause erosive balanitis. Potent topical corticosteroid (mometasone 0.1% or clobetasol 0.05%).
- Lichen sclerosus (BXO): White, atrophic, sclerotic patches on the foreskin and glans; may cause phimosis and urethral meatal stenosis. First-line: clobetasol 0.05% ointment once daily, tapering over months.
- Pearly penile papules: 1–2 mm dome-shaped papules in concentric rows around the corona of the glans. Normal anatomical variant, no treatment required; counsel the patient.
- Zoon balanitis (plasma cell balanitis): Shiny, reddish-orange, well-demarcated plaque on the glans of uncircumcised middle-aged men. Circumcision is curative; topical tacrolimus or potent corticosteroids may be tried first.
- Squamous cell carcinoma in situ (erythroplasia of Queyrat / Bowen disease): Erythematous, velvety plaque on the glans or shaft. Biopsy is mandatory. Management: topical 5-fluorouracil, imiquimod, or wide local excision / Mohs micrographic surgery.
Peyronie Disease & Penile Cancer
Peyronie Disease
Peyronie disease is a fibrotic disorder of the tunica albuginea of the penis, characterised by formation of a palpable plaque that leads to penile curvature, pain (particularly during the acute inflammatory phase), and erectile dysfunction. Prevalence is estimated at 3–9% in men over 40 years. Risk factors include diabetes mellitus, Dupuytren contracture, erectile dysfunction, trauma during intercourse, and smoking.
Two Clinical Phases
Acute / Inflammatory Phase
Active Phase (6–12 months)
Penile pain (especially during erection), evolving curvature, palpable but soft plaque. Deformity may still be changing.
Setting: Urology outpatient; conservative management
Stable / Chronic Phase
Stable Phase (>3–6 months of stable deformity)
Pain resolved, plaque firm and calcified, curvature stable. May be associated with significant erectile dysfunction and psychological distress.
Setting: Urology; may require procedural intervention
Management of Peyronie Disease
Acute phase — conservative / pharmacological:
- Oral pentoxifylline 400 mg PO TDS — non-selective phosphodiesterase inhibitor with anti-fibrotic properties; limited evidence but commonly used. Not PBS-listed for this indication.
- Oral vitamin E 400 IU PO BD — weak evidence of benefit; well tolerated.
- Low-intensity extracorporeal shockwave therapy (Li-ESWT) — primarily for penile pain in the acute phase; does not improve curvature. Available at some Australian urology centres.
- Penile traction therapy — daily use of a traction device for 3–8 hours/day for 3–6 months may reduce curvature by 10–30°; best evidence is in the stable phase.
Stable phase — procedural / surgical:
Collagenase clostridium histolyticum (CCH)
Xiaflex® · Intralesional injection
Indication
Peyronie disease with palpable plaque and curvature ≥30° in the stable phase
Dose
0.58 mg injected into the plaque, every 6 weeks (up to 4 treatment cycles); penile modelling performed 24–72 hours post-injection
Efficacy
Mean curvature reduction of 17–34° in clinical trials (IMPRESS I & II)
PBS status
🔶 PBS Authority Required
Authority criteria
Must be prescribed by or in consultation with a specialist urologist; stable-phase disease with curvature ≥30° confirmed by photograph
Surgical options (for stable, severe deformity causing inability to penetrate):
- Nesbit procedure / plication surgery: Shortening of the longer (convex) side; best for curvature <60° without significant erectile dysfunction. May cause some penile shortening (1–2 cm).
- Plaque incision/excision + grafting: For curvature >60° or complex deformities (hourglass, hinge). Risk of postoperative erectile dysfunction.
- Penile prosthesis implantation: For concurrent severe Peyronie disease and medically refractory erectile dysfunction. Malleable or inflatable prosthesis ± manual straightening.
Penile Cancer
Penile cancer is rare in Australia (~300–400 cases/year) but carries significant morbidity. Squamous cell carcinoma (SCC) accounts for >95% of cases. Risk factors include HPV infection (especially types 16 and 18, implicated in ~50% of cases), phimosis, poor genital hygiene, lichen sclerosus, smoking, and lack of neonatal circumcision. The lifetime risk is higher in uncircumcised men and in immunosuppressed individuals (e.g., post-transplant).
Clinical Presentation
- Early: indurated papule, plaque, or non-healing erosion/ulcer on the glans (most common site), coronal sulcus, or inner prepuce.
- Late: fungating mass, phimosis preventing examination, bloody discharge, inguinal lymphadenopathy.
- Any penile lesion not responding to 4–6 weeks of appropriate topical therapy requires biopsy.
Biopsy all non-healing penile lesions. Delayed diagnosis of penile cancer is associated with more extensive surgery (partial or total penectomy) and worse outcomes. A punch biopsy under local anaesthesia is sufficient for histological diagnosis in most cases.
Staging and Management
| Stage | Treatment | Notes |
|---|---|---|
| Tis / Ta (in situ / non-invasive) | Topical 5-fluorouracil, imiquimod 5%, or wide local excision / Mohs surgery | Glans-sparing approaches preferred where feasible |
| T1 (subepithelial connective tissue invasion) | Wide local excision with ≥5 mm margins; consider glans-sparing surgery | Lymph node assessment required |
| T2 (corpus spongiosum / cavernosum) | Partial penectomy (≥2 cm margin from tumour) or total penectomy if inadequate margin | Inguinal lymph node dissection or sentinel node biopsy |
| T3 (urethral invasion) | Partial or total penectomy; bilateral inguinal lymphadenectomy | Multidisciplinary team (MDT) discussion essential |
| N+ (positive inguinal nodes) | Bilateral inguinal lymph node dissection ± neoadjuvant chemotherapy (paclitaxel/ifosfamide/cisplatin) | Pelvic lymph node dissection if ≥2 inguinal nodes positive |
Sentinel lymph node biopsy or dynamic sentinel lymph node scintigraphy is recommended for clinically node-negative (cN0) penile cancer ≥T1b to detect occult metastatic disease. This is available at major Australian urology-oncology centres (e.g., Peter MacCallum, Chris O'Brien Lifehouse, Royal Brisbane). Referral to a specialist penile cancer MDT is essential for all cases.
Haematospermia
Haematospermia (haemospermia) refers to the presence of blood in the ejaculate. It is a common and usually benign condition, particularly in men under 40 years of age, but warrants investigation in specific clinical contexts.
Aetiology
| Category | Causes | Likelihood |
|---|---|---|
| Idiopathic / self-limiting | No identifiable cause; often isolated episode in young men | Most common (~60–70%) |
| Infectious / inflammatory | Acute or chronic prostatitis (bacterial or non-bacterial), urethritis, epididymitis, seminal vesiculitis, STIs (chlamydia, gonorrhoea, TB) | Common in men <40 |
| Structural / iatrogenic | Prostate biopsy (most common iatrogenic cause; may persist 3–4 weeks), cysts of the prostate/seminal vesicles, urethral stricture, post-TURP | Common post-procedure |
| Neoplastic | Prostate cancer, bladder cancer, testicular cancer, seminal vesicle tumour | Rare (~2–5%); more concerning in men ≥40 |
| Systemic / vascular | Hypertension, liver cirrhosis, coagulopathy, anticoagulant therapy (warfarin, DOACs) | Uncommon; consider if on anticoagulants |
| Trauma | Perineal injury, vigorous sexual activity, prolonged sexual abstinence followed by vigorous activity | Rare |
Investigation Approach
Clinical decision point: Isolated haematospermia in a man <40 years with no risk factors is usually self-limiting. Reassurance, repeat urine MC, and STI screening are appropriate. Further investigation is warranted for men ≥40 years, persistent/recurrent episodes (>4–6 weeks), associated haematuria, or concerning prostate examination findings.
First-line investigations (all patients):
Essential
Urinalysis and midstream urine (MSU) microscopy, culture & sensitivity
Exclude urinary tract infection, haematuria
Essential
STI screening: NAAT for Chlamydia trachomatis and Neisseria gonorrhoeae (first-void urine)
MBS item 69396
Available
Digital rectal examination (DRE)
Assess prostate size, nodularity, tenderness
Available
Serum PSA (if ≥40 years or prostate examination abnormal)
MBS item 66655; baseline prostate cancer screening
Second-line investigations (persistent, recurrent, or ≥40 years with risk factors):
Referral
Transrectal ultrasound (TRUS) of the prostate and seminal vesicles
Evaluate for prostatic cysts, seminal vesicle pathology, calcification
Referral
MRI prostate (multiparametric)
If TRUS inconclusive or PSA elevated; MBS item 63543
Specialist
Cystoscopy / flexible cystourethroscopy
Exclude bladder or urethral pathology if concurrent haematuria
Specialist
Coagulation studies (if on anticoagulants or suspected coagulopathy)
PT/INR, APTT, FBC
Management
- Idiopathic / isolated episode: Reassurance. Avoid vigorous sexual activity for 1–2 weeks. Most resolve spontaneously.
- Infectious cause: Treat the underlying infection (e.g., doxycycline 100 mg PO BD for 7 days for chlamydia-associated prostatitis/urethritis). See STI management guidelines.
- Anticoagulant-related: Discuss with prescribing physician regarding temporary dose modification or drug holiday if recurrent and distressing. Do not stop anticoagulants without specialist advice.
- Post-prostate biopsy: Expected for up to 3–4 weeks; counsel the patient pre-biopsy. If persisting beyond 4 weeks, investigate further.
- Underlying malignancy: Refer to urology MDT; stage and manage per cancer-specific guidelines.
Investigations
The investigations required vary significantly by presenting complaint. The following provides a consolidated summary.
Essential
Syphilis serology (treponemal + non-treponemal: EIA + RPR/VDRL)
For all penile ulcers; MBS item 69312. Rapid point-of-care treponemal tests available in some Aboriginal health services.
Essential
HSV PCR swab of ulcer base
Gold standard for genital herpes diagnosis; swab the base of an active vesicle or ulcer; more sensitive than viral culture
Essential
NAAT for C. trachomatis and N. gonorrhoeae (first-void urine or urethral swab)
MBS item 69396; co-infection common with syphilis
Available
HIV serology
Offer to all patients with STI-related penile ulcer; syphilis-HIV co-infection common
Available
Punch biopsy of penile lesion
For any non-healing penile ulcer >4–6 weeks, suspected neoplasm, or atypical morphology; local anaesthetic, 3–4 mm punch
Available
Penile MRI (with and without contrast)
T-staging of penile cancer; assess corporal invasion; MBS item 63508
Referral
Inguinal ultrasound or CT/PET-CT
Staging of penile cancer: assess inguinal and pelvic lymph nodes; available at major cancer centres
Specialist
Dynamic sentinel lymph node biopsy / scintigraphy
Clinically node-negative penile cancer ≥T1b; available at tertiary urology-oncology centres (Peter MacCallum, Chris O'Brien Lifehouse)
Risk Stratification & Severity Scoring
Paraphimosis Severity
Mild
Early Paraphimosis
Mild glans oedema, no colour change, comfortable with analgesia alone. Foreskin can be reduced with manual technique.
Setting: ED or GP clinic; manual reduction
Moderate
Established Paraphimosis
Significant glans oedema, dusky or purplish discolouration, moderate pain. May require dorsal penile nerve block for reduction.
Setting: ED; dorsal nerve block + manual reduction or dorsal slit
Severe
Compromised Paraphimosis
Tense, dark purple or black glans, severe pain or loss of sensation, skin breakdown. Risk of glans necrosis.
Setting: ED → emergency urology; dorsal slit under local ± general anaesthesia; assess viability
Penile Cancer Risk Stratification
Low Risk
Tis/Ta/T1a, G1–2
Well-differentiated, superficial tumour confined to subepithelial connective tissue. No lymphovascular invasion.
Setting: Urology; glans-sparing surgery; surveillance
Intermediate Risk
T1b–T2, G2–3
Moderate to poorly differentiated; corporal invasion or lymphovascular invasion present.
Setting: Urology-oncology MDT; partial penectomy + lymph node assessment
High Risk
T3, N+, M+, G3
Urethral invasion, positive lymph nodes, or distant metastases. Poorly differentiated tumour.
Setting: Tertiary cancer centre MDT; multimodal therapy (surgery + chemotherapy ± radiotherapy)
Empirical & Directed Therapy
Empirical Antibiotic Therapy for Penile Ulcers
Do not wait for serological confirmation before treating syphilis if clinical suspicion is high. Treat empirically and follow up serology at 3, 6, and 12 months. Always test for HIV, hepatitis B, and hepatitis C in patients with syphilis.
Benzathine penicillin G
Bicillin L-A® · Penicillin antibiotic
Indication
First-line for all stages of syphilis (primary, secondary, early latent)
Adult dose
2.4 g (4 mL) IM as a single dose (divided into two gluteal injection sites)
Paediatric dose
50 000 units/kg IM single dose (max 2.4 g); congenital syphilis: 50 000 units/kg IM daily × 10 days
Renal adjustment
Not required; safe in renal impairment
Key caution
Ensure no penicillin allergy; if allergy, refer for desensitisation (doxycycline 100 mg PO BD × 14 days is an alternative for early syphilis only)
PBS status
✔ PBS General Benefit
Valaciclovir
Valtrex® · Antiviral (nucleoside analogue)
Indication
First-line for genital herpes (HSV-1 and HSV-2)
First episode — adult dose
1 g PO BD for 7–10 days
Recurrent episode — adult dose
500 mg PO BD for 3–5 days (start within 24 hours of symptom onset)
Suppressive therapy
500 mg PO daily (if ≥6 recurrences/year; or to reduce transmission risk in serodiscordant couples)
Renal adjustment
eGFR 30–50: reduce to 1 g PO daily (first episode) or 500 mg daily (recurrent); eGFR <30: 500 mg PO daily then 500 mg every 48 hours
PBS status
✔ PBS General Benefit (initial and repeat scripts); 🔶 Authority Required for suppressive therapy
Azithromycin
Zithromax® · Macrolide antibiotic
Indication
Chancroid, donovanosis, or as alternative for chlamydia co-infection
Chancroid — adult dose
1 g PO as a single dose
Donovanosis — adult dose
1 g PO weekly until lesions fully healed (minimum 2 weeks); relapse may require prolonged courses
Renal adjustment
No adjustment required
PBS status
✔ PBS General Benefit
Doxycycline
Doryx® · Tetracycline antibiotic
Indication
LGV (21 days), donovanosis alternative, chlamydia-associated prostatitis, syphilis (penicillin-allergic, early syphilis only)
LGV — adult dose
100 mg PO BD for 21 days
Chlamydia — adult dose
100 mg PO BD for 7 days
Renal adjustment
Not required; avoid in severe hepatic impairment
Paediatric note
Avoid in children <8 years (dental staining); may use in children ≥8 years for donovanosis if no alternative
PBS status
✔ PBS General Benefit
Directed Therapy for Specific Conditions
Balanitis (Candidal)
Clotrimazole 1% cream
Canesten® · Topical antifungal
Adult dose
Apply BD to glans and prepuce for 7–14 days
PBS status
✔ PBS General Benefit
Fluconazole
Diflucan® · Oral antifungal
Indication
Refractory or recurrent candidal balanitis; male sexual partner treatment if partner has recurrent vaginal candidiasis
Adult dose
150 mg PO as a single dose (may repeat after 72 hours if needed)
Renal adjustment
eGFR <50: reduce dose by 50%
PBS status
✔ PBS General Benefit
Lichen Sclerosus (BXO)
Clobetasol propionate 0.05% ointment
Dermovate® · Potent topical corticosteroid
Dose
Apply once daily to affected area for 4–6 weeks, then taper to alternate days, then twice weekly for maintenance. Long-term low-frequency maintenance often needed.
Renal / Hepatic
Topical — minimal systemic absorption
PBS status
✔ PBS General Benefit
Penile Cancer Chemotherapy (Neoadjuvant / Palliative)
Systemic chemotherapy for penile cancer should only be initiated by a specialist medical oncologist within an MDT. TIP regimen (paclitaxel + ifosfamide + cisplatin) is the most commonly used neoadjuvant/palliative regimen. Cisplatin requires nephrotoxicity monitoring (eGFR, electrolytes) and adequate hydration.
Monitoring
Syphilis Treatment Monitoring
- Non-treponemal antibody titres (RPR/VDRL): Repeat at 3, 6, and 12 months post-treatment. A ≥4-fold (2-dilution) drop in RPR titre indicates adequate treatment response. Failure to achieve a 4-fold decline by 6 months warrants re-treatment and investigation for neurosyphilis (lumbar puncture).
- Titres may take 6–12 months to decline. A >4-fold rise after an initial decline indicates re-infection or treatment failure.
- Notify state/territory health department: Syphilis is a notifiable condition in all Australian jurisdictions. Partner notification is mandatory.
Genital Herpes Monitoring
- Recurrence frequency typically decreases over time (especially HSV-2); counsel patients that antiviral suppressive therapy reduces recurrence by ~70–80% and reduces transmission to serodiscordant partners by ~50%.
- Re-assess for suppressive therapy at 6-monthly intervals. Trial discontinuation after 12 months of suppressive therapy to reassess recurrence rate.
- HSV type-specific serology (IgG) may be useful for serodiscordant couples but is not routinely recommended for all patients.
Peyronie Disease Monitoring
- During the active phase: review every 3 months to assess plaque stability (serial curvature measurement with goniometer or photograph).
- After intralesional CCH (Xiaflex®): review 2 weeks post-injection for adverse events (penile haematoma, corporal rupture — rare but serious). Repeat curvature assessment at 6 weeks before next injection cycle.
- Validated patient-reported outcome measures: Peyronie Disease Questionnaire (PDQ) and International Index of Erectile Function (IIEF-5) for concurrent ED assessment.
Penile Cancer Surveillance
- Post-treatment clinical review every 3 months for the first 2 years, then every 6 months for years 3–5.
- Self-examination education: patients should be taught to inspect the surgical site, glans (if preserved), and inguinal regions monthly.
- Inguinal ultrasound or CT if clinically suspicious lymphadenopathy detected on follow-up.
Haematospermia Follow-Up
- Isolated episode: no specific follow-up required unless recurrent.
- After treatment of identified cause (e.g., prostatitis): review at 4–6 weeks to confirm resolution.
- Persistent haematospermia beyond 6 weeks despite treatment warrants urological referral for TRUS ± cystoscopy.
Special Populations
Pregnancy
Syphilis in pregnancy
Benzathine penicillin G 2.4 g IM × 1 dose (as per non-pregnant). Penicillin is the ONLY effective therapy for preventing congenital syphilis — do NOT use alternatives (doxycycline, azithromycin) in pregnancy. If allergic, refer for penicillin desensitisation.
HSV in pregnancy
Aciclovir from 36 weeks' gestation (400 mg PO TDS) reduces risk of active lesions and neonatal herpes at delivery. Valaciclovir 500 mg PO BD is an alternative. Cesarean section is recommended if active genital lesions are present at the onset of labour.
Always test syphilis serology in the first antenatal visit (routine in most Australian jurisdictions). Early treatment of maternal syphilis prevents congenital syphilis, which remains an emerging concern in Australia.
Paediatrics
Physiological phimosis
Reassurance and watchful waiting in most boys. Topical betamethasone 0.05% BD for 4–8 weeks if intervention requested. Avoid forceful retraction.
Circumcision indications
Not routinely recommended. Consider for: recurrent balanitis/balanoposthitis (≥3 episodes), pathological phimosis failing topical steroids, or BXO with meatal stenosis. Refer to paediatric urology.
Sexual abuse consideration
Penile ulcers or STIs in pre-pubertal children must raise concern for sexual abuse. HSV and syphilis in a child require mandatory reporting and involvement of child protection services. Donovanosis or chancroid in a child is virtually pathognomonic of abuse.
Congenital syphilis: any infant born to a mother with untreated or inadequately treated syphilis requires evaluation (RPR, FBC, LFTs, long bone X-rays, CSF analysis) and treatment with IV benzylpenicillin 50 000 units/kg every 12 hours (first week of life) then every 8 hours for 10 days total.
Elderly
Penile cancer
Median age at diagnosis is 68 years. Elderly patients may present late due to embarrassment, social isolation, or cognitive impairment. Any non-healing penile lesion in an older man requires prompt biopsy. Comorbidities may limit surgical options; conservative glans-sparing surgery or topical therapy may be preferred.
Peyronie disease
Prevalence increases with age. Concurrent ED is common and may require combined management (PDE5 inhibitor + CCH or surgery). Assess cardiovascular risk before initiating PDE5 inhibitors.
Elderly men on anticoagulants (warfarin, DOACs) presenting with haematospermia: do NOT discontinue anticoagulation without specialist advice. Investigate if persistent (>4 weeks) or if additional risk factors for malignancy are present (PSA, TRUS).
Renal Impairment
Valaciclovir
eGFR 30–50: reduce dose; eGFR <30: halve dose and extend interval. Risk of neurotoxicity (confusion, hallucinations) in severe CKD if overdosed.
Cisplatin (penile cancer chemo)
Contraindicated if eGFR <60; carboplatin substitution may be considered. Ensure aggressive IV hydration pre- and post-infusion.
Doxycycline
Safe in renal impairment — no dose adjustment required. Preferred over tetracyclines in CKD.
Topical agents (clobetasol, clotrimazole, betamethasone) have negligible systemic absorption and do not require dose adjustment in renal impairment.
Hepatic Impairment
Valaciclovir / Aciclovir
No specific dose adjustment in mild-moderate hepatic impairment; use with caution in severe hepatic disease. Not contraindicated.
Doxycycline
Avoid in severe hepatic impairment; use with caution in mild-moderate disease.
Patients with chronic liver disease and coagulopathy may present with haematospermia or penile bruising/haematoma. Assess INR/platelets. Consider underlying aetiology (hepatitis B/C, alcohol-related liver disease) in STI screening context.
Immunocompromised
Penile cancer risk
Increased risk in solid organ transplant recipients (3–5× general population). HPV vaccination is recommended for all transplant candidates and recipients. More frequent genital self-examination and specialist surveillance recommended.
HSV management
HIV-positive individuals may require higher-dose or longer-course antiviral therapy for genital herpes (valaciclovir 1 g PO BD for 5–10 days). Suppressive therapy is often recommended long-term. Aciclovir resistance (rare) may require IV foscarnet.
Donovanosis
More likely to be associated with HIV co-infection in Australian case reports. Treatment may be prolonged; monitor for relapse.
HIV-positive men with syphilis are at higher risk of serological treatment failure; monitor RPR titres more closely (at 1, 2, 3, 6, 9, and 12 months). CSF examination should be considered for neurological symptoms.
Aboriginal and Torres Strait Islander Health
Aboriginal and Torres Strait Islander peoples are disproportionately affected by several penile disorders, particularly sexually transmitted genital ulcers and late-stage penile cancer. Addressing these disparities requires culturally safe healthcare, community-led prevention strategies, and enhanced access to specialist services in regional and remote areas.
Quick Reference — Penile Disorders
Phimosis (childhood)
Betamethasone 0.05% ointment
BD × 4–8 weeks
Reassure if physiological; avoid forced retraction
Paraphimosis
Dorsal penile nerve block → manual reduction
Immediate
Emergency: Dorsal slit if manual reduction fails
Primary syphilis
Benzathine penicillin G 2.4 g IM
Single dose
Do not wait for serology if clinical chancre present
Genital herpes (first episode)
Valaciclovir 1 g PO BD
7–10 days
Start within 72h of onset; PCR swab confirmation
Genital herpes (recurrence)
Valaciclovir 500 mg PO BD
3–5 days
Suppressive: 500 mg daily if ≥6 recurrences/year
LGV
Doxycycline 100 mg PO BD
21 days
Notifiable; serovar L1–3; NAAT + complement fixation
Donovanosis
Azithromycin 1 g PO weekly
Until healed (min 2 weeks)
Endemic in remote NT/QLD; crush prep diagnosis
Candidal balanitis
Clotrimazole 1% cream
BD × 7–14 days
Check HbA1c if recurrent; counsel on hygiene
BXO / Lichen sclerosus
Clobetasol 0.05% ointment
Daily × 4–6 weeks, then taper
Long-term maintenance; refer if phimosis or meatal stenosis
Peyronie (stable, curvature ≥30°)
CCH (Xiaflex®) intralesional
0.58 mg q6 weeks × 4 cycles
PBS authority; specialist urologist only
📚 References
- 1. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). STI Management Guidelines for Use in Primary Care. Sydney: ASHM; 2024. Available at: http://www.sti.guidelines.org.au.
- 2. Kirby Institute. HIV, Viral Hepatitis and Sexually Transmissible Infections in Australia: Annual Surveillance Report 2023. Sydney: Kirby Institute, UNSW Sydney; 2023.
- 3. Australian Government Department of Health and Aged Care. National Notifiable Diseases Surveillance System (NNDSS) — Syphilis Notifications. Canberra: DoHAC; 2024.
- 4. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: STI and BBV indicators. Canberra: AIHW; 2023.
- 5. Kuehhas FE, Djakovic N, Horenblas S, et al. Peyronie's disease: etiology, medical and surgical treatment options. Deutsches Ärzteblatt International. 2019;116(21):371–379.
- 6. Hatzimouratidis K, Eardley I, Giuliano F, et al. EAU Guidelines on Penile Curvature. European Urology. 2012;62(3):543–552.
- 7. National Cancer Institute (NCI). Penile Cancer Treatment (PDQ) — Health Professional Version. Bethesda: NCI; 2024. Available at: https://www.cancer.gov/types/penile/hp.
- 8. Cancer Council Australia. Penile Cancer: Clinical Practice Guidelines. Sydney: Cancer Council Australia; 2023. Available at: wiki.cancer.org.au/australiawiki.
- 9. Singleton A, Wines P, Hall J, et al. Neonatal circumcision: position of the Royal Australasian College of Physicians. Journal of Paediatrics and Child Health. 2023;59(9):1015–1019.
- 10. Nicolai M, Li Marzi V, Pecoraro S, et al. Management of haematospermia: a systematic review. European Urology Focus. 2022;8(5):1344–1353.
- 11. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook — Human Papillomavirus (HPV). Canberra: Australian Government Department of Health and Aged Care; 2024. Available at: immunisationhandbook.health.gov.au.
- 12. Patel M, Amini A, Spiess PE, et al. Penile cancer: current management and future directions. Nature Reviews Urology. 2023;20(8):473–491.
- 13. RHDAustralia (ARF/RHD Australia), Menzies School of Health Research. Syphilis in Aboriginal and Torres Strait Islander Communities. Darwin: RHDAustralia; 2023. Available at: www.rhdaustralia.org.au.
- 14. Bowen J, Ager A, Hengel B, et al. Syphilis: the ongoing epidemic in Aboriginal and Torres Strait Islander populations. Medical Journal of Australia. 2023;218(6):267–271.