Painful erections never indicate normalcy, and sometimes signal a medical emergency. Severe pain may necessitate immediate medical attention, while intermittent pain may subside once the penis becomes flaccid.

Potential causes of this pain include recent or past injury, blood circulation issues, drug use, or neurological problems.

Painful Erections Symptoms

The underlying cause determines the characteristics of pain associated with a painful erection. For instance:

• The pain may vary from dull to severe.
• It might occur during erection or solely during sexual intercourse.
• It could be localized in specific areas of the penis or affect the entire shaft.
• It may be present consistently during erections or only during nighttime ones.

Healthcare providers can use these symptoms and others to identify the correct diagnosis and treatment.

Painful Erections Causes

Painful erections can stem from various causes, each presenting distinct signs and risk factors that aid in distinguishing them.

Priapism 

It presents as an erection persisting for hours without sexual stimulation, and it manifests in three distinct types:

Ischemic priapism, also termed low-flow priapism, is the most prevalent type wherein blood remains trapped in the penis post-erection. Causes include prescription medications, recreational drugs, certain insect venoms, leukemia, spinal cord injury, and penile cancer.

Intermittent priapism, or stuttering priapism, is a less common variant of ischemic priapism, primarily linked with sickle cell disease, a genetic disorder affecting red blood cells.

Non-ischemic priapism, known as high-flow priapism, occurs when the body continues to pump excessive blood into the penis, resulting in engorgement. Typically, this arises from an injury to the perineum, the area between the anus and genitals.

Pain is a hallmark of ischemic priapism but not non-ischemic priapism. In ischemic priapism, the shaft of the penis remains rigid while the glans stays soft, with pain intensifying progressively.

Peyronie’s Disease

Peyronie’s disease (PD) is a condition that commonly affects older individuals, characterized by a sudden abnormal curvature of the penis. It is believed to result from scar tissue accumulation following mild sexual trauma or injury. 

This scar tissue can form on the thick membrane enveloping the sponge-like tissues within the penis, known as the corpora cavernosa. Consequently, the membranes may contract abnormally at the scar tissue site, leading to curvature.

PD can induce pain during erections due to the stretching of shortened membranes. The severity of PD dictates whether the pain occurs during erection or solely during sexual intercourse. Additionally, some individuals may experience pain even when the penis is flaccid.

Risk factors for PD include:

• A family history of Peyronie’s disease
• Engaging in vigorous sexual activity
• Diabetes
• Erectile dysfunction
• Connective tissue diseases like Dupuytren’s contracture
• Autoimmune diseases
• History of prostate cancer surgery

Penile Fracture

A penile fracture refers to the rupture of the fibrous membrane encompassing the corpora cavernosa, known as the tunica albuginea. It typically arises due to blunt force trauma to the penis during sexual intercourse or vigorous masturbation. Occasionally, other structures such as veins, nerves, or vessels, including the urethra, may sustain injury.

This condition constitutes a medical emergency and can result in alterations in penis shape, erectile dysfunction, and difficulties with urination. While pain is commonly experienced at the time of fracture, in rare instances, individuals may only perceive pain later, particularly during erections or sexual activity.

Certain sexual positions can precipitate a penile fracture by causing collision of the erect penis with the bony pelvis structures. Additionally, some injectable drugs used for Peyronie’s disease treatment may heighten the risk by dissolving scar tissues and weakening the tunica albuginea.

Sleep-related painful erection (SRPE)

Sleep-related painful erection (SRPE) is an infrequent condition characterized by painful erections during deep rapid eye movement (REM) sleep, contrasted with normal, painless erections while awake.

The exact cause of SRPE remains unclear, although most studies suggest a central role for obstructive sleep apnea (OSA). It is hypothesized that interruptions in breathing associated with OSA may enhance blood flow to the penis and trigger the release of neurotransmitters, heightening sensitivity to pain.

Additionally, SRPE may stem from intermittent (“stuttering”) priapism, which often manifests more frequently at night than during the day.

Penile Tumors

Occasionally, painful erections stem from the development of benign (non-cancerous) tumors on blood vessels or nerves within the penis.

One such instance involves an uncommon tumor known as epithelioid hemangioma, which typically manifests as a painless growth around the head or neck but can also occur within penile blood vessels. During erection, the tumor may exert sudden pressure on nearby nerves, leading to acute pain or discomfort.

Another example is the schwannoma, a rare, painless tumor usually found on nerves in the head, neck, or limbs. However, when it occurs in the penis, it can induce painful erections, predominantly at night. Associated symptoms may include pain during ejaculation and erectile dysfunction.

Penile Lichen Sclerosus

Penile lichen sclerosus, a rare condition more prevalent in individuals with uncircumcised penises, involves progressive tissue hardening of the foreskin and glans. Left untreated, it can result in scarring that affects both sexual and urinary function.

Painful erections in penile lichen sclerosus arise from increased vascular pressure on stiff, inflexible tissues. Common accompanying symptoms include itching, pain, redness, and swelling. While the exact cause remains unclear, some theorize it may involve autoimmune mechanisms, where the body’s immune system attacks its tissues. Additionally, persistent urine dribbling under the foreskin may contribute to long-term tissue injury.

Painful Erections Treatment

Diagnosis and treatment of a painful erection often necessitate consultation with a urologist, a specialist in this field. 

The diagnostic process may entail a physical examination, blood tests, biopsy, and imaging studies such as penile ultrasound or magnetic resonance imaging (MRI).

Treatment for a painful erection depends on both the underlying cause and the severity of the pain.

Summary

Many factors can lead to a painful erection, some of which are serious. Potential causes encompass Peyronie’s disease, penile fracture, penile tumors, penile lichen sclerosus, and a rare condition known as sleep-related painful erection (SRPE).

References

1. James Myhre & Dennis Sifris, M. (n.d.). Signs that a painful erection may be serious. Verywell Health. https://www.verywellhealth.com/painful-erection-6455942 
2. Painful erections: What you need to know. Painful Erections: What You Need to Know: Urology Associates Medical Group: Urologists. (n.d.). https://www.urologymedicalgroup.com/blog/painful-erections-what-you-need-to-know