Balanoposthitis

Balanoposthitis is inflammation of both the glans penis and the prepuce (foreskin). It occurs in uncircumcised males, affecting about 3 to 11 percent of uncircumcised men and boys. The peak is at ages 2 to 5 years in boys, and in adult men with diabetes or poor hygiene.

The warm, moist environment under the prepuce, with retained smegma and urine, supports microbial overgrowth and irritation.

Causes:

• Infection: Candida albicans (the commonest in adults), Staphylococcus aureus, group A and B streptococci, anaerobes such as Bacteroides and Fusobacterium, Gardnerella vaginalis, Trichomonas vaginalis, herpes simplex virus, human papillomavirus, Treponema pallidum, Chlamydia and gonorrhoea.
• Non-infectious causes: irritant or allergic contact dermatitis from soaps, detergents, latex or spermicide; atopic dermatitis; psoriasis; seborrhoeic dermatitis; lichen sclerosus; lichen planus; reactive arthritis; Zoon balanitis; fixed drug eruption.
• Premalignant disease.

Risk factors: diabetes mellitus, immunosuppression, obesity, phimosis, poor hygiene, excessive washing and sexual contact with an infected partner.

Complications: phimosis, paraphimosis, recurrent infection, lymphangitis, balanitis xerotica obliterans, meatal stenosis, and urinary retention in children.

• Erythema, oedema and tenderness of the glans and foreskin, with itch, burning, pain on retraction, and dysuria.
• Subpreputial discharge: creamy white (candidal or smegma), purulent with a foul odour (bacterial and anaerobic), thin and watery (trichomonal), and vesicles or ulcers (herpes).
• Superficial erosions, fissures and a tight, swollen prepuce that cannot be retracted (acquired phimosis).
• Satellite papules or pustules (candidal), white plaques, and macerated or peeling skin.
• Inguinal lymphadenopathy and fever in severe bacterial infection.
• In boys: irritability, penile pain, crying on voiding, and purulent discharge at the tip of the foreskin.
• Scarring and ballooning of the foreskin with voiding in chronic disease.

• Clinical examination, with gentle retraction of the foreskin, evaluation of the glans, sulcus and meatus, and inguinal nodes.
• Swabs from under the foreskin for bacteria (Gram stain and culture), yeast (potassium hydroxide microscopy and culture), and viral polymerase chain reaction; nucleic acid amplification tests for chlamydia, gonorrhoea, and Trichomonas; syphilis and HIV serology when risk is present.
• Fasting glucose or HbA1c for adults with recurrent or candidal infection; urinalysis for glucose.
• Patch testing for suspected contact allergy.
• Biopsy for chronic, persistent, ulcerated, indurated or atypical lesions to exclude lichen sclerosus, penile intraepithelial neoplasia and squamous carcinoma.
• Ultrasound if abscess is suspected.

• Hygiene: daily gentle retraction (if possible), rinsing with warm water or saline (a bath with salt water for 10 minutes, twice daily), thorough drying, avoiding soaps, perfumes and irritants, and using a soap substitute.
• Candidal infection: clotrimazole 1 percent cream (or miconazole 2 percent, econazole 1 percent) applied two to three times daily for 7 to 14 days, with hydrocortisone 1 percent cream briefly for inflammation.
• For resistant candidal disease, give oral fluconazole 150 mg single dose (a repeat dose at 1 week may be needed). Treat the partner if symptomatic and optimise glycaemic control.
• Bacterial infection: fusidic acid 2 percent cream twice daily for 7 days (or mupirocin 2 percent), oral flucloxacillin 500 mg four times daily for 7 days (children 12.5 to 25 mg/kg four times daily), or clarithromycin 500 mg twice daily if penicillin allergic.
• For anaerobic infection, give metronidazole 400 mg twice daily for 7 days (children 7.5 mg/kg three times daily). For streptococcal infection, give penicillin V.
• In paediatric infection, topical antibiotics with warm bathing are usually sufficient.
• Combined creams (hydrocortisone, clotrimazole and fusidic acid, or clotrimazole with betamethasone) are suitable for mixed or unclear cases (for 7 to 14 days).
• Dermatitis and psoriasis: low to moderate potency topical corticosteroid (hydrocortisone 1 percent, clobetasone butyrate 0.05 percent) twice daily for 1 to 2 weeks, with emollients; topical tacrolimus 0.1 percent for steroid sparing.
• Lichen sclerosus: clobetasol propionate 0.05 percent for 12 weeks, then maintenance, and circumcision.
• Sexually transmitted infections: treat according to pathogen and notify partners.
• Herpes: aciclovir 400 mg three times daily for 5 to 7 days. Trichomoniasis: metronidazole 400 mg twice daily for 5 to 7 days or tinidazole 2 g stat. Syphilis: benzathine benzylpenicillin 2.4 million units intramuscularly.
• Severe oedema and paraphimosis: reduction (compression, ice, hand compression, osmotic agents), dorsal slit.
• Circumcision is indicated for recurrent episodes, phimosis not responding to topical steroid (betamethasone 0.05 percent twice daily for 4 to 8 weeks), lichen sclerosus, premalignant change, and balanitis xerotica obliterans.
• In adult men circumcision is curative in most. In boys, defer if possible, and consider for recurrent episodes (over 3 to 4 per year).
• Follow up in 1 to 2 weeks. Investigate recurrence for diabetes, immunosuppression, and sexually transmitted infection. Biopsy persistent lesions.