Epidemiology

• Balanitis is more common in men than in boys.
• It is present in approximately 11% of attendees at genitourinary medicine (GUM) clinics.^[1]
• Balanitis affected 5.9% of uncircumcised boys in one study and 14% in another.^[2] 

Risk factors^[3] 

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

Aetiology^[1]  

• 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 - eg, herpes simplex, human papillomavirus

Dermatological

• Fixed drug eruption (particularly with sulfonamides 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 man
• Queyrat's erythroplasia (penile Bowen's disease - carcinoma in situ)^[4] 
• Psoriasis
• Lichen planus
• Leukoplakia
• Seborrhoeic dermatitis
• Pemphigus
• Pemphigoid

Miscellaneous

• Irritation or contact dermatitis: wet nappies, poor hygiene, smegma, soap, condoms
• Trauma: zippers, accidental or inappropriate foreskin retraction by a 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 is possible.
• Swab of discharge for microscopy, Gram staining, culture and sensitivity.
• If syphilis or another STI is suspected, refer to a GUM clinic.

Management^[5]

• Local hygiene.
• Warm bath with dilute saline (four tablespoons or so in a bath) - dry penis well afterwards.This will improve symptoms regardless of cause until therapy works.
• If an STI is suspected, any partner(s) should be screened. Specialist advice should be sought or the patient referred to a GUM clinic, depending on the expertise of the GP and the clinical scenario.  
• If a dermatological cause is suspected then treat the underlying cause with advice from dermatology/GUM/urology.

Drug

• In most cases topical treatment is recommended.
• Systemic therapy should be considered if there is severe inflammation affecting the penile shaft, or marked genital oedema.
• If candidal infection 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 a swab and await the 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 one week.
    • Alternative regimens: co-amoxiclav 375 mg three times daily for one week; clindamycin cream applied twice-daily until the infection has resolved.
• If there is gross inflammation and the patient is 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.^[6] 

Prognosis^[5] 

This depends on the underlying cause and the presence of any predisposing risk factors. 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.