Balanitis

Balanitis is inflammation of the glans penis.¹ Balanitis involving the foreskin and prepuce is termed balanoposthitis. Though uncommon, a complication of balanitis (usually only in recurrent cases) is constricting phimosis, or inability to retract the foreskin from the glans penis.

Pathophysiology

Uncircumcised men with poor personal hygiene are most affected by balanitis. Lack of aeration and irritation because of smegma and discharge surrounding the glans penis causes inflammation and edema. Though uncommon, complications of balanitis include phimosis and cellulitis. Meatal stenosis with urinary retention may rarely accompany balanitis. In very few cases, balanitis may contribute to the “buried penis syndrome

History

Patients with balanitis usually present with the following complaints:

• Penile discharge
• Pain or difficulty with retraction of foreskin
• Impotence
• Difficulty urinating or controlling urine stream (in very severe cases)
• Inability to insert a Foley catheter
• Tenderness and erythema of the glans penis
• Itching
• Systemic symptoms such as fever and nausea are uncommon

Physical

Physical examination findings may include the following:

• Erythema and edema of glans penis or foreskin
• Discharge
• Ulceration and/or plaques
• Phimosis (uncommon)
• Signs of urinary obstruction (rare)
  • Meatal stenosis
  • Bladder distension
  • Ballooning of the foreskin when voiding
• Lymphadenopathy

Causes

• Diabetes is the most common underlying condition associated with adult balanitis.
• Other causes include the following:
  • Poor personal hygiene
  • Chemical irritants (eg, soap, petroleum jelly)
  • Edematous conditions, such as congestive heart failure (right-sided), cirrhosis, and nephrosis
  • Drug allergies (eg, tetracycline, sulfonamide)
  • Morbid obesity
• Several organisms and viruses cause balanitis, including the following:
  • Candidal species (most commonly associated with diabetes)
  • Group B and group A beta-hemolytic streptococci
  • Neisseria gonorrhoeae
  • Chlamydia species
  • Anaerobic infection
  • Human papilloma virus
  • Gardnerella vaginalis
  • Treponema pallidum (syphilis)
  • Trichomonal species
  • Borrelia vincentii and Borrelia burgdorferi
• Penile cancer
• Balanitis xerotica obliterans (lichen sclerosus): This is a chronic dermatosis identified by whitish plaques involving the glans and foreskin (shown in the image below)

Laboratory studies for uncomplicated balanitis are not typically necessary but may include the following, when clinically appropriate:

• Serum glucose test (as part diabetes screening)
• Culture of discharge
• Syphilis serology test
• Wet mount
• Potassium hydroxide (for Candida)
• HIV and human papilloma virus titers in selected cases

Imaging Studies

• Ultrasonography or bladder scan to detect urinary obstruction in severe balanitis

Other Tests

• Referral to a urologist for biopsy in chronic cases

• .

Emergency Department Care

• Patients presenting with balanitis but without phimosis should receive the following recommendations and treatment:
  • Gentle retraction of the foreskin daily and soak in warm water to clean penis and foreskin.
  • In pediatric patients and patients with mild balanitis xerotica, a 2-month trial of antifungals may be attempted; the patient or mother should retract the foreskin gently and apply 0.05% betamethasone twice a day. This applies to children older than 3 years. Success is seen particularly in male children older than 10 years compared with those aged 3-10 years. Success ranges from 65-95%.
  • Topical steroids have had only limited success in patients with moderate-to-severe balanitis xerotica obliterans. These patients are more likely to have distal scarring of the foreskin.
  • In recurrent cases, 1% pimecrolimus cream was used instead of steroids, with a 64% success rate.²
  • Apply bacitracin (not Neosporin) for pediatric patients if bacterial infection is suspected.
  • Apply topical clotrimazole for adult men with probable candidal balanitis.
  • Obtain a culture of discharge in complicated cases such as those with associated cellulitis, then treat empirically with appropriate antibiotics (typically first-generation cephalosporin).
  • A study of 1185 boys concluded that fluticasone proprionate 0.05% was effective and safe in treating associated phimosis, with successful results in 91.1% of patients.³
• Patients presenting to the ED with phimosis and severe urinary obstruction as a complication of balanitis should receive the following care (recommended that surgical intervention be performed by a urologist, if available):
  • Steroid cream and gentle retraction of the foreskin, if the phimosis is not too tight, may be used before surgery is contemplated.^4,5
  • Without damaging the glans penis, dilate the foreskin using a clamp. If the glans penis is adherent to the foreskin, the procedure may be contraindicated. Local anesthesia, analgesia, and/or sedation may be required.
  • Perform a dorsal slit incision by cutting the foreskin over the dorsal shaft of the penis to enlarge the foreskin opening. This procedure requires local anesthesia and, possibly, sedation.
  • Perform a formal circumcision (preferably in the operating room).^6,7
  • Circumcision is not a preventative treatment of balanitis in those younger than 3 years old.

Consultations

• Consult a urologist if a dorsal slit incision or circumcision is contemplated.

Medication

The goal of balanitis therapy is to eradicate infection and prevent complications.

Antimicrobial agents (topical)

Therapy must cover all likely pathogens in the context of the clinical setting.

Clotrimazole (Mycelex, Lotrimin)

Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability. For adult use, especially those with a positive history of candidiasis in a sexual partner.