Balanitis

Balanitis is inflammation of the glans penis, which may occur in association with inflammation of the foreskin (balanoposthitis). It occurs in about 3 to 11 percent of men, and 3 to 4 percent of uncircumcised boys. It is related to poor hygiene, moisture, trapped smegma and irritation under the foreskin.

Causes:

• Infection: Candida albicans (about 30 to 40 percent of cases in men attending sexual health clinics, with higher rates in diabetes), anaerobic bacteria, streptococcus group A and B, Staphylococcus aureus, Gardnerella.
• Sexually transmitted infections such as Trichomonas, herpes simplex virus, syphilis, chlamydia, gonorrhoea and human papillomavirus.
• Non-infectious inflammatory dermatoses: irritant and allergic contact dermatitis to soaps, detergents, condoms, spermicides and lubricants; atopic eczema, seborrhoeic dermatitis, psoriasis, lichen planus; lichen sclerosus (balanitis xerotica obliterans).
• Circinate balanitis in reactive arthritis, and plasma cell balanitis of Zoon in older uncircumcised men.
• Fixed drug eruption.
• Premalignant lesions (erythroplasia of Queyrat and squamous cell carcinoma in situ, which may appear as persistent erythematous patches).

Risk factors: diabetes, obesity, immunosuppression, phimosis, poor hygiene, and antibiotic use.

Complications: phimosis, paraphimosis, meatal stenosis, scarring, and psychological distress.

• Erythema, swelling and tenderness of the glans, burning, itching, soreness and pain, and a subpreputial discharge (white, curd like in candidal infection; foul smelling purulent discharge with bacterial infection).
• Candidal balanitis: erythematous patches with satellite pustules or papules, and white plaques or curdy material.
• Bacterial balanitis: well demarcated, glistening erythema and oedema with foul odour, and fissuring.
• Dermatitis: erythema with scaling and itch.
• Lichen sclerosus: whitish atrophic plaques, hypopigmentation and phimosis; lichen planus: violaceous annular papules (Wickham striae); circinate balanitis: painless shallow erosions with a white rim.
• Persistent solitary red velvety plaque (erythroplasia) or non-healing ulcer: suspect neoplasia.
• Dysuria, a painful or non-retractile foreskin, and inguinal lymphadenopathy in severe infection.

• Clinical examination of the glans, prepuce, meatus and inguinal nodes.
• Swabs for bacterial culture and fungal culture or microscopy (potassium hydroxide), with testing for sexually transmitted infections if indicated (nucleic acid amplification tests for chlamydia, gonorrhoea; herpes simplex virus PCR; syphilis serology; and HIV).
• Blood glucose or HbA1c in all patients with recurrent candidal balanitis.
• Patch testing for suspected allergic contact dermatitis.
• Biopsy for persistent lesions (over 4 to 6 weeks of treatment), suspicious plaques (erythroplasia of Queyrat, lichen sclerosus with atypia, penile intraepithelial neoplasia), and uncertain diagnosis.
• Urinalysis for glycosuria.

• General measures: gentle hygiene (retract the foreskin and rinse with warm water once or twice daily, dry thoroughly). Avoid soaps, shower gels, perfumed products, and irritants, and use a soap substitute (emollient such as aqueous cream or emulsifying ointment). Avoid occlusion.
• Use condoms if allergic to latex or lubricants (switch to polyurethane condoms). Weight loss, and management of diabetes.
• Candidal balanitis: topical clotrimazole 1 percent cream applied two to three times daily for 7 to 14 days (or miconazole 2 percent, econazole 1 percent, or nystatin cream). Add hydrocortisone 1 percent cream for 5 to 7 days when severely inflamed.
• Oral fluconazole 150 mg single dose (repeat after 7 days) for severe or recurrent candidal infection; treat the partner if symptomatic.
• Bacterial balanitis: topical fusidic acid 2 percent cream twice daily for 7 days, or mupirocin 2 percent, or clindamycin 1 percent.
• Oral flucloxacillin 500 mg four times daily for 7 days for severe infection, and metronidazole 400 mg twice daily for 7 days in anaerobic balanitis.
• Phenoxymethylpenicillin 500 mg four times daily for 10 days for group A and B streptococcal balanitis.
• Combination therapy (for non-specific balanitis): hydrocortisone 1 percent with clotrimazole 1 percent and fusidic acid (a triple combination cream) applied twice daily for up to 2 to 4 weeks.
• Irritant or allergic dermatitis, psoriasis, seborrhoeic dermatitis: topical corticosteroid, mild to moderate potency (hydrocortisone 1 percent or clobetasone butyrate 0.05 percent twice daily for 1 to 2 weeks), emollient and trigger avoidance. Topical calcineurin inhibitors (tacrolimus 0.1 percent twice daily) are steroid sparing agents.
• Lichen sclerosus: ultrapotent corticosteroid (clobetasol propionate 0.05 percent ointment daily for 4 to 12 weeks, then tapered to twice weekly as maintenance). Circumcision for refractory disease or phimosis is curative in over 90 percent. Long term follow up for squamous cell carcinoma.
• Sexually transmitted infections: specific treatment and partner notification:
  • Chlamydia: doxycycline 100 mg twice daily for 7 days.
  • Gonorrhoea: ceftriaxone 1 g intramuscularly single dose.
  • Herpes: aciclovir 400 mg three times daily for 5 to 10 days or valaciclovir 500 mg twice daily for 3 to 5 days.
  • Syphilis: benzathine benzylpenicillin 2.4 million units intramuscularly.
• Premalignant lesions (erythroplasia of Queyrat, penile intraepithelial neoplasia): topical fluorouracil 5 percent cream twice daily for 4 to 6 weeks, or imiquimod 5 percent three times weekly for up to 16 weeks, or laser ablation, local excision or glans resurfacing; circumcision.
• Circumcision is indicated for recurrent balanitis (more than 3 to 4 episodes per year) in uncircumcised men, phimosis, lichen sclerosus, and failed medical therapy.
• Follow up: review at 2 weeks if not improving; refer to dermatology or urology for refractory or recurrent episodes; biopsy persistent lesions.