Balanitis

Overview

Balanitis is the inflammation of the glans penis. Posthitis is the inflammation of the prepuce (foreskin). Both areas are often affected and this is described as balanoposthitis.

Epidemiology

• Balanitis affects up to 4% of people aged 2-5 years and becomes les common with age as the foreskin matures
• Balanitis is uncommon in people who are circumcised

Presentation and Causes

Presentation

The causes of balanitis can have different features, however, general features of balanitis include:

• Penile soreness and itching
• Foreskin bleeding or odour
• Penile redness and swelling
• Tightening of the foreskin – suggests lichen sclerosus
• Phimosis may be present

Causes

There are many causes of balanitis which can present similarly or co-exist:

• Non-specific dermatitis is the most common cause – usually acute:
  • In younger children, the foreskin is less retractable (physiological phimosis) which can lead to poor hygiene, irritation, and colonisation of organisms including Candida albicans
  • Features include:
    • Erythema of the glans penis which may extend to the shaft of the penis
    • Itchy papules that may have associated white, curd-like discharge on the glans, shaft of the penis, and scrotal skin
  • Secondary infection with Streptococcus pyogenes and Staphylococcus aureus can occur, leading to painful redness, oedema, erosions, and purulent foul–smelling exudate.
• Other infectious causes – usually acute:
  • Gardnerella species – associated with a fishy discharge
  • Sexually-transmitted infections – Chlamydia, gonorrhoea, Trichomonas vaginalis, syphilis, and herpes simplex
• Irritant or allergic contact dermatitis – usually acute:
  • Using soap, fragrances, lubricants, latex condoms, or topical medications may lead to a red, scaly rash on the glans penis that may have associated burning (irritant) or itching (allergic contact dermatitis)
  • No other parts of the body are usually affected
• Seborrhoeic dermatitis – often chronic:
  • Greasy, scaly lesions that may be red and itchy
  • Lesions are also found in other typical areas such as the nasolabial folds, scalp, and eyebrows
• Psoriasis – acute or chronic:
  • Well–demarcated, red, scaly plaques on the glans penis
  • Lesions may be found in surrounding areas (e.g. the buttocks) or on other parts of the body
• Lichen sclerosus (balanitis xerotica obliterans) – usually chronic:
  • Itchy, painful, atrophic white patches or plaques on the glans penis that can cause white, firm, scarring with repeated chronic inflammation which can cause foreskin tightening
• Lichen planus – usually chronic:
  • Purplish, well–demarcated plaques on the glans penis and shaft of the penis
  • There may be Wickham striae in the oral mucosa
• Circinate balanitis – acute or chronic:
  • Associated with reactive arthritis and appears with well–demarcated red/grey plaques on the glans penis with ragged borders
  • These may coalesce to form ‘geographical areas’ with white borders

Investigations and Referral

Overview

Most cases of balanitis are diagnosed clinically, however in some cases, tests may be considered:

• Sub-preputial swabformicroscopy and culture:
  • Not routinely performed but can be used if symptoms are severe, suggesting a secondary infection
• Sexually transmitted infection (STI) screen:
  • If STIs are suspected
• HbA1c:
  • Diabetes mellitus can predispose to recurrent/severe candidal balanitis
• HIV testing (if appropriate):
  • HIV can predispose to recurrent/severe candidal balanitis

Referral

Some indications for a referral to secondary care based on clinical judgement are as follows:

• Uncertain diagnosis
• Recurrent balanitis with no known underlying cause
• Persistent/recurrent balanitis that is unresponsive to primary care management
• Suspected STI – refer to a sexual health clinic
• Suspected lichen sclerosis and/or persistent phimosis
• Suspected allergic contact dermatitis
• Penile masses, ulcerated lesions, significant damage and STIs are unlikely

Management

Overview

In all cases managed in primary care, management involves cleaning under the foreskin with water daily. Topical hydrocortisone may be considered if inflammation cause significant discomfort.

Some more specific treatment options may include:

• Non-specific dermatitis – topical hydrocortisone and imidazole cream
• Irritant/contact dermatitis – topical hydrocortisone, emollients, and avoid triggers
• Candidal balanitis – topical imidazole or oral fluconazole
• Bacterial balanitis – oral flucloxacillin or clarithromycin if allergic
• Gardnerella – oral metronidazole

Complications

• Complications due to lichen sclerosus include:
  • Phimosis
  • Meatal stenosis and urethral stricture which can cause urinary retention
  • Penile squamous cell carcinoma – <5% risk with progressive lichen sclerosus
• Cellulitis of the penis due to bacteria
• Sexual dysfunction – due to dyspareunia, erectile dysfunction, painful erections, or emotional problems