Balanitis is an inflammation of the head of the penis. About 3-11 % are very common among men. Posthitis is an inflammation of the foreskin (prepuce). Balanoposthitis involves both the glans and the foreskin and occurs in about 6% of uncircumcised males. However, balanitis and balanoposthitis often occur together, and the terms are commonly used interchangeably. Balanitis is not a sexually transmitted infection. The actual disease is not transferable from one person to another; however, the transfer of organisms that cause balanitis is possible.
There is a wide range of diseases that affect the male genitalia including inflammatory lesions, infectious etiologies, preneoplastic syndromes, and malignant conditions. Balanitis is most common in uncircumcised males due to poor hygiene and the accumulation of smegma beneath the foreskin. The warm moist environment under the uncircumcised penile foreskin favors the growth of organisms that cause balanitis such as fungi. Smegma is a whitish sebaceous secretion composed of epithelial cells (dead skin) and the sebum (oily secretions) produced by the sebaceous glands of both male and female genitalia. Under normal circumstances, smegma aids in the lubricating movement of the foreskin; without it friction and irritation result. Poor hygiene, a tight foreskin, and a buildup of smegma serve as a nidus for bacterial and fungal overgrowth which can lead to irritation and inflammation. Persistent inflammation and edema may cause scarring and adherence of the foreskin to the glans. Ultimately, this process can evolve into a tightening of the foreskin, known as “phimosis.”
Fungal infections are the most common identifiable etiology with the majority of infections being caused by Candida albicans. This organism is normally present on the skin of the glans and can be considered normal flora. The yeast can cause infection in certain circumstances, especially when the patient has underlying conditions, poor hygiene, overgrowth, or changes in baseline pH. Although yeast infection is the most common cause, there are several other etiologies that exist and must be considered by the provider. These include the following infectious and noninfectious etiologies.
Infectious etiologies:
- Candida species (most commonly associated with diabetes)
- Group B and group A beta-hemolytic streptococci
- Neisseria gonorrhoeae
- Chlamydia species
- Anaerobic infection
- Human papillomavirus
- Gardnerella vaginalis
- Treponema pallidum (syphilis)
- Trichomonas species
- Borrelia vincentii and Borrelia burgdorferi
Noninfectious etiologies:
- Poor personal hygiene (most common)
- Chemical irritants (e.g., spermicides, detergents, perfumed soaps and shower gels, fabric conditioners)
- Edematous conditions, including congestive heart failure (right-sided), cirrhosis, and nephrosis
- Drug allergies (e.g., tetracycline, sulfonamide)
- Morbid obesity
- Allergic reaction (condom latex, contraceptive jelly)
- Fixed-drug eruption (sulfa, tetracycline)
- Plasma cell infiltration (Zoon balanitis)
- Autodigestion by activated pancreatic transplant exocrine enzymes
- Trauma
- Neoplastic conditions
Risk Factors of Balanitis:
- Presence of foreskin
- Morbid obesity
- Poor hygiene
- Diabetes (particularly males with uncontrolled diabetes), probably due to Glucose on the skin, encouraging bacterial and fungal growth
- Nursing home environment
- Condom catheters
- Sensitivity to chemical irritants (i.e., soaps and lubricants)
- Edematous conditions: CHF, nephrosis
- Reactive arthritis
- Sexually transmitted infections
Signs and symptoms usually include:
- Tight, shiny skin on the glans
- Redness around the glans
- Inflammation, soreness, itchiness, or irritation of the glans
- A thick cheesy white discharge under the foreskin (smegma)
- An unpleasant smell
- A tight foreskin cannot retract
- Painful urination
- Swollen glands near the penis
- Sores on the glans
How to evaluate?
Balanitis is a visual diagnosis, the clinical presentation and appearance of the lesions guide the diagnosis. Additional evaluation may be warranted based on the history and physical findings.
Laboratory test to include bacterial culture (in the presence of purulent exudate), herpes simplex virus (HSV) testing (in the presence of vesicular or ulcerative lesions), syphilis testing (in the presence of an ulcer), testing for scabies, and testing for trichomonas and Mycoplasma genitalium (in the presence of urethritis).
Certain features on clinical examination (e.g., white, curd-like exudate) raise suspicion of candidal infection. If available, microscopy can identify budding yeast or pseudohyphae using a potassium hydroxide (KOH) preparation.
How to manage?
The initial aim of diagnosis and management should be to exclude STI, minimize problems with urinary and sexual function, and mitigate the risk of cancer of the penis.
- Proper hygiene with frequent washing and drying off the prepuce is an essential preventive measure, although excessive genital washing with soap may aggravate the condition.
- Topical antifungals. In cases of more severe inflammation, the addition of fluconazole or the combination of a topical imidazole and hydrocortisone often leads to the resolution.
- Treatment with antibiotics is appropriate if there is a concern for concomitant cellulitis.
- Experts recommend circumcision for recurrent and intractable episodes, especially in immunocompromised and diabetic patients and consult urology.
*Data from meta-analyses showed that circumcised males have a 68% lower prevalence of balanitis than uncircumcised males and that balanitis is accompanied by a 3.8-fold increase in the risk of penile cancer.
Differential diagnosis:
- Lichen planus, is a skin pathology with small, itchy, pink, or purple spots on the arms or legs
- Psoriasis, is a dry, scaly skin disorder
- Eczema, is a chronic or long-term dermal condition that can result in itchy, reddened, cracked, and dry skin
- Dermatitis, is an inflammatory skin condition, due to direct contact with an irritant or allergen
Three types of balanitis:
| Zoon’s balanitis | Circinate balanitis | Pseudoepitheliomatous keratotic and micaceous balanitis |
| Inflammation of the glans penis and the foreskin usually affects middle-aged to older uncircumcised men. | associated with reactive arthritis, characterized by small, shallow, painless ulcerative lesions on the glans penis | A condition characterized by scaly, wart-like skin lesions on the head of the penis. |
Complications associated with balanitis include the development of pain, ulcerative lesions of the glans/foreskin, phimosis, paraphimosis, meatal/urethral stricture, and malignant transformation of premalignant lesions.
