Balanitis is inflammation of the glans penis. If the foreskin is also inflamed, the correct term is balanoposthitis, though balanitis is commonly used to refer to both.

Epidemiology

• Balanitis is more common in men than boys.
• It is present in approximately 11% of attendees at genitourinary medicine (GUM) clinics.¹
• Affects about 3% of boys at some time.²

Risk factors

• The most important risk factor is diabetes mellitus
• Use of oral antibiotics
• Poor hygiene in uncircumcised males³
• Immunosuppression
• Chemical or physical irritation of glans

Aetiology

• Infection with candida is the most common cause seen in general practice.
• Bacterial cases may be polymicrobial.

Infection

• Candida spp.
• Staphylococci/streptococci (especially Group B)
• Anaerobes
• Gardnerella vaginalis
• Trichomonas spp.
• Entamoeba histolytica (can cause severe oedema and rupture of foreskin)
• Borrelia vincentii
• Treponema pallidum (syphilis)
• Viral, e.g. herpes simplex, human papillomavirus

Dermatological

• Fixed drug eruption (particularly with sulphonamides and tetracycline)
• Circinate balanitis (may be associated with Reiter's syndrome)
• Balanitis xerotica obliterans/lichen sclerosus
• Zoon's balanitis (plasma cell infiltration); a benign, idiopathic condition presenting as a solitary, smooth, shiny, red-orange plaque of the glans and prepuce of a middle-aged to older man⁴
• Queyrat's erythroplasia (penile Bowen's disease - carcinoma in situ)
• Psoriasis
• Lichen planus
• Leucoplakia
• Seborrhoeic dermatitis
• Pemphigus
• Pemphigoid

Miscellaneous

• Irritation or contact dermatitis: wet nappies, poor hygiene, smegma, soap, condoms
• Trauma: zippers, accidental or inappropriate foreskin retraction by child/parent
• Stevens-Johnson syndrome
• Severe oedema due to right heart failure
• Morbid obesity

Presentation

• Sore, inflamed and swollen glans/foreskin
• Non-retractile foreskin/phimosis
• Penile ulceration
• Penile plaques
• Satellite lesions
• May be purulent and/or foul-smelling discharge (most common with streptococcal/anaerobic infection)
• Dysuria
• Interference with urinary flow in severe cases
• Obscuration of glans/external urethral meatus
• Impotence or pain during coitus
• Regional lymphadenopathy

Investigations

• Blood/urine testing for glucose if diabetes mellitus possible.
• Swab of discharge for microscopy, Gram staining, culture and sensitivity.
• If syphilis or other STD suspected, refer to GUM clinic.

Management⁵

• Local hygiene.
• Warm bath with dilute saline (4 tablespoons or so in bath) - dry penis well afterwards. Will improve symptoms regardless of cause until therapy works.
• If STD suspected, partner(s) should be screened and patient referred to/advice taken from GUM clinic.
• If dermatological cause suspected then treat underlying cause with advice from dermatology/GUM/urology.

Drug

• In most cases topical treatment is recommended with ointments (preferred as more adherent and effective) or creams.⁶
• Systemic therapy should be considered if there is severe inflammation affecting penile shaft, or marked genital oedema.
• If candida is the suspected cause:¹
  • Recommended regimens: clotrimazole cream 1% or miconazole cream 2%; apply twice daily until symptoms have settled.
  • Alternative regimens: fluconazole 150 mg stat. orally if symptoms are severe.
  • Topical imidazole with 1% hydrocortisone if there is marked inflammation
  • There is a high rate of candidal infection in sexual partners, who should be offered screening.
• If bacterial infection is suspected:
  • Take swab and await results or consider GUM referral.
  • Common bacterial infection can usually be treated with flucloxacillin or erythromycin in penicillin-allergic patients.
  • Anaerobic infection:¹
    • Recommended regimen: metronidazole 400 mg twice-daily for 1 week.
    • Alternative regimens: co-amoxiclav 375 mg three times daily for 1 week; clindamycin cream applied twice-daily until resolved.
• If gross inflammation/systemically unwell, consider admission to hospital for IV antimicrobials.

Surgery

Surgical referral for consideration of circumcision if balanitis is recurrent or pathological phimosis is present.⁷

Prognosis

This depends on the underlying cause and the presence of any predisposing risk factors.⁸ Candidal balanitis resolves rapidly with appropriate treatment but is more likely to recur in men with:

• Diabetes mellitus
• Poor genital hygiene
• Phimosis

Balanitis due to contact irritants resolves over a period of days with removal of the provoking irritant or allergen. It may recur if exposed again.

Complications

Difficulty retracting the foreskin may develop. This is more likely if the balanitis is chronic or recurring.

Document references

1. National Guideline on the Management of Balanoposthitis, Clinical Effectiveness Group British Association for Sexual Health and HIV (2008)
2. Leber M; Balanitis. eMedicine, (2008).
3. O'Farrell N, Quigley M, Fox P; Association between the intact foreskin and inferior standards of male genital hygiene behaviour: a cross Int J STD AIDS. 2005 Aug;16(8):556 [abstract]
4. Buechner SA; Common skin disorders of the penis. BJU Int. 2002 Sep;90(5):498 [abstract]
5. Balanitis, Clinical Knowledge Summaries (June 2009)
6. Vohra S, Badlani G; Balanitis and balanoposthitis. Urol Clin North Am. 1992 Feb;19(1):143 [abstract]
7. Clark C, Huntley JS, Munro FD, et al; Managing the paediatric foreskin. Practitioner. 2004 Dec;248(1665):888, 891
8. English JC 3rd, Laws RA, Keough GC, et al; Dermatoses of the glans penis and prepuce. J Am Acad Dermatol. 1997 Jul;37(1):1 [abstract]

Acknowledgements