Balanitis

This 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.

It is more common in men than boys.
Present in approximately 11% of attendees at genito-urinary medicine (GUM) clinics.¹ Affects about 3% of boys at some time.²

Risk factors

Most important is diabetes mellitus, which should be checked for with capillary glucose/urinalysis (if cause unknown), in all cases.

• Use of oral antibiotics
• Poor hygiene in uncircumcised males³
• Immunosuppression
• Chemical or physical irritation of glans

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

Infection

• Candida spp.
• Staphylococci/streptococci (esp. 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, HPV

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
• Erythroplasia of Queyrat (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

• Sore, inflamed and swollen glans/foreskin
• Non-retractile foreskin/phimosis
• Penile ulceration
• Penile plaques
• Satellite lesions
• May be purulent and/or foul-smelling discharge (commonest 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

• 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

General points

• 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 use imidazole derivatives e.g. clotrimazole.⁷ There is no evidence of any difference in the efficacy of the various agents. Topical ketoconazole is not available for NHS use for this indication.
• Second-line therapy with combined imidazole/1% hydrocortisone is useful if severe inflammation/itching.
• An alternative anti-fungal agent is terbinafine. NB It is not licensed for use in patients <16 years old.⁸ They are useful if there is suspected irritation/allergy due to imidazoles. They can also be combined with 1% hydrocortisone where irritation is a problem.
• Oral fluconazole should be used where candidal balanitis is not responding to topical therapy. This is also not licensed for patients who are <16 years old.
• If bacterial infection is suspected then take swab and await results or consider GUM referral. Common bacterial infection can usually be treated with flucloxacillin or erythromycin in penicillin-allergic patients.
• 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.⁹

This depends on the underlying cause and the presence of any predisposing risk factors.¹⁰ Candidal balanitis resolves rapidly with appropriate treatment but is more likely to recur in men with:

• Diabetes
• Poor genital hygiene
• A 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.

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