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Balanitis, Causes, Symptoms, Diagnosis, Treatment

Balanitis is inflammation of the glans penis. When the foreskin is also affected, it is termed balanoposthitis.^[rx]Balanitis on boys still in diapers must be distinguished from redness caused by ammoniacal dermatitis.^[rx]

Balanitis is common in uncircumcised men as a result of poorer hygiene and aeration or because of irritation by smegma and in many cases preputial dysfunction is a causal or contributing factor. Balanitis may be more severe in the presence of some underlying medical conditions. It has been reported as a source of fever and bacteremia in neutropenic men and candidal balanitis may be especially severe in patients with diabetes mellitus.[rx]

Balanitis is an inflammation of the glans penis (head of the penis); it is fairly common and affects approximately 3-11% of males during their lifetime. Posthitis is an inflammation of the foreskin (prepuce). Balanoposthitis involves both the glans and the foreskin and occurs in approximately 6% of uncircumcised males. Balanoposthitis occurs only in uncircumcised males.[rx][rx] However, balanitis and balanoposthitis often occur together, and the terms are commonly used interchangeably. Infectious etiologies of balanitis include certain fungi like yeast and certain bacteria or viruses (including those that cause STDs such as gonorrhea). Balanitis is not a sexually transmitted disease. The actual disease is not transferable from one person to another; however, the transfer of organisms that cause balanitis is possible. Recurrent episodes of balanoposthitis should raise the concern for occult diabetes. Patients with recurrent episodes should undergo blood glucose screening for diabetes.

Balanitis

Types of Balanitis

The Types of balanitis are

Zoon’s balanitis – also known as Balanitis Circumscripta Plasmacellularis or plasma cell balanitis (PCB) is an idiopathic, rare, benign penile dermatosis^[rx] for which circumcision is often the preferred treatment.^[rx]^[rx]^[rx] Zoon’s balanitis has been successfully treated with the carbon dioxide laser^[rx] and more recently Albertini and colleagues report the avoidance of circumcision and successful treatment of Zoon’s balanitis with an Er:YAG laser.^[11] Another study, by Retamar and colleagues, found that 40 percent of those treated with CO₂ laser relapsed.^[rx]
Circinate balanitis – Circinate balantitis (also known as balanitis circinata) is a serpiginous annular dermatitis associated with reactive arthritis. Associated with reactive arthritis, characterized by small, shallow, painless ulcerative lesions on the glans penis. A biopsy can show pustules in the upper epidermis, similar in appearance to pustular psoriasis. There may also be a serpiginous annular dermatitis that often has a grayish white granular appearance with a “geographical” white margin.[rx] This lesion can be mistaken for psoriasis on physical examination, and histological evaluation cannot reliably distinguish between the two disorders. The distinction between circinate balanitis and psoriasis is generally made clinically (history of reactive arthritis or psoriasis). If circinate balanitis is suspected clinically in a patient without known reactive arthritis, screening for STIs and testing for human leukocyte antigen (HLA)-B27 is advised.
Pseudoepitheliomatous keratotic and micaceous balanitis – A condition characterized by scaly, wart-like skin lesions on the head of the penis.

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Pathophysiology

Balanitis is most common in uncircumcised males due to poor hygiene and the accumulation of smegma beneath the foreskin. Smegma is a whitish sebaceous secretion composed 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 results. 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. Fungal infections are usually responsible, most commonly involving the yeast Candida albicans. History and physical examination findings sometimes point to other etiologies that have management implications.

Sometimes a dermatologic cause (e.g., psoriasis or lichen planus) allergic reaction, or (less likely) premalignant condition may be responsible. It may warrant specialty referral to a dermatologist for a biopsy or urologist.

Localized edema may develop if someone allows balanitis to progress without treatment. The combination of inflammation and edema can cause adherence of the foreskin to the glans.

Symptoms include pain, redness and a foul-smelling discharge from under the foreskin. Balanitis has a more fulminant clinical presentation in diabetic and immunocompromised patients.[rx]

Causes of Balanitis

Balanitis

Fungal infections are the most common identifiable infectious etiology, especially the yeast Candida albicans.[rx] This organism is normally present on the skin of the glans. Under the right conditions (an imbalance between the normally present yeast and the baseline pH) excessive growth of bacteria or yeast occurs. However, a host of other potential causes exist. These include the following infectious and noninfectious etiologies[rx]

Infectious etiologies

Candidal species (most commonly associated with diabetes)
Group B and group A beta-hemolytic streptococci
Neisseria gonorrhea
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

Overall Causes

poor hygiene, leading to a build-up of smegma
irritation under the foreskin caused by pee
soaps, shower gels, and other skin irritants
thrush
a bacterial infection
a sexually transmitted infection (STI)
skin conditions, such as eczema, psoriasis, and lichen sclerosus
children fiddling with their foreskin

Symptoms of Balanitis

Symptoms can include

First signs – small red erosions on the glans
Redness of the foreskin
Redness of the penis
Other rashes on the head of the penis
Foul smelling discharge
Painful foreskin and penis

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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
Tight foreskin cannot retract
Painful urination
Swollen glands near the penis
Sores on the glans

Diagnosis of Balanitis

Under microscopic examination, nonspecific inflammatory changes are visible with lymphocytes, plasma cells, and macrophages
The causative organism is usually not discernable by routine examination
Epithelial changes such as squamous hyperplasia and ulceration have an association with inflammation
Fungal hyphae may be present

History and Physical

History should assess the risk for sexually transmitted infections (STIs), and any underlying dermatologic (e.g., eczema, psoriasis) or systemic (e.g., reactive arthritis) diseases. Along with inspection of the glans and foreskin, the physical examination should also include an assessment of the urethral meatus for inflammation and discharge, and any extragenital manifestations such as a generalized rash, oral ulcers, inguinal lymphadenopathy, and arthritis. 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.” Phimosis is an abnormal constriction of the opening in the foreskin that prevents retraction over the glans. Paraphimosis refers to trapping of the foreskin behind the glans penis and requires urgent reduction.[rx]

In most cases, your doctor can diagnose balanitis based on the symptoms you describe to him. He may run these tests to be sure, such as:

Serum glucose test (to screen for diabetes)
Lab tests of any discharge
Tests to see if you have a sexually transmitted disease (STD)
Tests for the medical conditions that cause balanitis

Treatment of Balanitis

The objectives of management are

To minimize sexual dysfunction
To minimize urinary dysfunction
To exclude penile cancer
To treat premalignant disease
To diagnose and treat sexually transmitted disease.

All persistent/undiagnosed genital lesions regardless of appearance must be evaluated for herpes

Your treatment will depend on what set off the balanitis. The prescription usually comes as a cream or ointment. Your doctor might prescribe:

Antibiotics for bacterial balanitis. It comes as a pill or a cream.
Antifungal cream if the condition was from candida yeast.
Steroid creams can relieve balanitis caused by skin disease.

It you don’t get it treated, you might have complications such as:

Narrowing of the opening through which urine leaves the body called urethral strictures
Urinary retention
A backflow of urine toward the kidneys known as vesicoureteral reflux

Take home message

Predisposing factors include poor hygiene and over washing, over-the-counter (OTC) medications, as well as nonretraction of the foreskin
Many cases of balanitis seen in practice are a simple intertrigo; that is, inflammation between two layers of skin with bacterial or fungal overgrowth
Rapid resolution can be achieved most frequently in practice by advising the patient to keep his foreskin retracted if possible, having advised him of the risk of paraphimosis
Saline baths are also useful and medicated OTC talcum powders are helpful in drying the area. This advice is simple, but compliance may be challenging
Many patients will present having tried antifungal creams, often obtained OTC. Such cases usually come with relapse. The simple measures have a more durable effect
HIV should be ruled out in every case not responding to therapy/having atypical presentation.

Home Advices

Healthcare workers and nurse practitioners should be aware of skin disorders that affect the penis.

The most common cause of balanitis is related to inadequate personal hygiene in uncircumcised males. Of cases with identifiable causes, candidal infection is the most common. Various other infectious agents, dermatologic conditions, and premalignant conditions have associations with balanitis.
Balanitis may present as pain, tenderness, or pruritus associated with erythematous lesions on the glans and/or the foreskin; an exudate may also be present. If balanitis is a manifestation of reactive arthritis, it may present with associated joint inflammation, mouth sores, and/or generalized symptoms.
Physical examination should include inspection of the glans and foreskin and the urethral meatus for inflammation/discharge. Careful inspection for possible paraphimosis is necessary.
History and physical examination findings sometimes point to specific etiologies that have management implications.
Management of balanitis without an identifiable cause initially focuses on the implementation of local hygiene measures. In addition, it warrants empiric treatment for candidal infection and/or noninfectious dermatitis in some patients.
Retraction of the foreskin with thorough genital cleansing can be both preventive and therapeutic. The suggestion is twice-daily bathing of the affected area with a saline solution. In uncircumcised males, nonspecific balanitis may respond to saline solution bathing by itself.
If other specific etiologies are identifiable, directed therapy is warranted. Management generally consists of topical antibiotics for bacterial infections, topical steroid creams for dermatologic conditions, and potential ablation or excision of premalignant lesions.

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