Balanitis

What is balanitis?

Balanitis is an inflammatory condition of the glans penis (head of the penis).

Inflammation often involves the foreskin, or prepuce, which is more appropriately known as balanoposthitis. Many urologic clinic visits are due to balanitis, which may be caused by infection, trauma, irritation to the glans penis, and allergic dermatitis. Untreated balanitis can have a wide range of complications, such as urethral stenosis, phimosis, and malignancy.

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Who gets balanitis?

Balanitis is present in up to 6% of young men and has an approximate overall prevalence of 3-11%.

• Uncircumcised men are at greater risk (approximately 68% increased lifetime incidence) as microorganisms, epithelial debris, and secretions may accumulate between the glans penis and overlying prepuce.
  • Difficult to distinguish inflammation of the glans penis versus prepuce involvement in uncircumcised men; therefore more frequently diagnosed with balanoposthitis.

Other risk factors include:

• Morbid obesity
• Condom catheter use
• Uncontrolled diabetes mellitus
• Poverty
• Poor hygiene
• Certain drugs e.g. trimethoprim/sulfamethoxazole
• Autoinflammatory conditions e.g. genital lichen planus and psoriasis.

What causes balanitis?

Balanitis can be best categorised as infectious versus non-infectious aetiologies.

Infectious aetiologies include, but are not limited to:

• Fungal infection (most common overall cause)
  • Candida
  • Dermatophytosis
• Bacterial infection (second most common overall cause)
  • Haemolytic streptococci
  • Staphylococci epidermidis/aureus
• Viral infection
  • Herpes simplex virus (HSV)
  • Varicella zoster virus (VZV)
  • Human papillomavirus (HPV)
  • Monkeypox
• Protozoal
  • Trichomonas vaginalis
• Parasitic
  • Sarcoptes scabiei var. hominis (scabies)
  • Pediculosis (lice).

Non-infectious aetiologies include, but are not limited to:

• Inflammatory conditions
  • Circinate balanitis (reactive arthritis)
  • Genital lichen planus
  • Zoon’s balanitis
  • Psoriasis
  • Lichen sclerosus (balanitis xerotica obliterans, BXO)
  • Pseudoepitheliomatous, keratotic and micaceous balanitis
• Premalignant conditions
  • Erythroplasia of Queyrat
  • Bowenoid papulosis
  • Bowen’s disease
• Malignant conditions
  • Squamous cell carcinoma (SCC)
• Miscellaneous
  • Trauma
  • Poor genital hygiene
  • Fixed drug eruption
  • Chemotherapy-induced e.g. fluorouracil (5FU)
  • Contact dermatitis (irritant and allergic).

What are the clinical features of balanitis?

Clinical features of balanitis vary depending on the specific aetiology.

In general, clinical features include, but are not limited to:

• Penile soreness
• Dysuria
• Itchiness, bleeding, and erythema of the glans penis.

Specific clinical features can be characterised by the following examples.

• Candida balanitis — blotchy erythema with small red “satellite” papules or dry dull red areas.
• Anaerobic infection — foul-smelling and malodorous inflammation with or without discharge; may be accompanied by tender inguinal lymph nodes.
• Aerobic infection — may see uniform erythema and local oedema.
• Trichomonas vaginalis — superficial erosions may lead to phimosis (retraction of penile foreskin in uncircumcised persons).
• HSV — grouped vesicles on an erythematous base which may rupture, unveiling painful shallow, grey ulcers.
• HPV — multiple flesh-coloured and/or erythematous circinate lesions that become acetowhite after 5% acetic acid is applied.
• Circinate balanitis — grey-white annular papules that coalesce to form “geographic” areas surrounded by a white-erythematous margin on the glans penis. Often accompanied by other features of reactive arthritis (such as conjunctivitis and arthritis).
• Zoon’s balanitis — symmetric “cayenne pepper spots” and orange-glazed erythema on the glans penis due to microvascular haemorrhage and hemosiderin deposition.
• Genital lichen planus — violaceous annular papules and patches over the glans penis and scrotum; sometimes accompanied by linear white “Wickham striae” with hyperpigmented centres.
• BXO — otherwise known as penile lichen sclerosus; hyperkeratosis of the squamous mucosa and peri-meatal glans appearing as white confluent papules or ivory-white papular lesions.
• Pseudoepitheliomatous hyperkeratotic and micaceous balanitis — thick well circumscribed mica like scaling over the glans
• Drug-induced balanitis — clearly demarcated erythema, oedema, and/or blistering of the glans penis; may be violaceous; history of provocative drug use before onset.

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How do clinical features vary in differing types of skin?

Erythema and inflammation may appear more violaceous/dark blue as opposed to red in patients of darker Fitzpatrick skin types.

What are the complications of balanitis?

• Pain and ulceration.
• Inflammation extension to involve the prepuce (balanoposthitis).
• Adhesions between the glans and prepuce.
• Phimosis — constriction of the opening of the prepuce that prevents retraction beyond the glans penis.
  • Due to chronic prepuce inflammation and oedema.
  • Can result in difficulty urinating and sexual dysfunction.
  • Forcible retraction can lead to paraphimosis; a urologic emergency.
• Paraphimosis — trapping of the foreskin proximal to the glans penis limiting blood flow. Increased size and pain over minutes to hours once trapping has occurred; it is a urologic emergency requiring release of the constriction (by a dorsal slit operation).
• Recurrent genital infections (such as yeast) is uncommon in healthy individuals and may warrant screening for immunocompromised conditions (HIV, diabetes, cancer).

How is balanitis diagnosed?

• Diagnosed clinically, proper history (including sexual history, autoimmunity) and a physical exam are essential.
• Swabs for microbiology (bacteria, yeasts, fungi, and viruses).
• Dermoscopy and biopsy to further evaluate balanitis refractory to treatment and/or exclude malignancy.

What is the differential diagnosis for balanitis?

• Infectious balanitis (Candida, HSV)
• Balanoposthitis
• Lichen planus
• Psoriasis
• Eczema
• Pre-malignancy (Erythroplasia of Queyrat, Bowenoid papulosis, Bowen’s disease)
• Malignancy (SCC)
• Zoon’s balanitis
• Circinate balanitis
• Fixed drug eruption.

What is the treatment for balanitis?

General measures

• Regularly retract the prepuce and gently clean with lukewarm water, and if desired with a light emollient.
• Thoroughly dry the entire glans penis and prepuce.
• Saline baths, dilute potassium permanganate soaks, or Burow’s solution are helpful in drying the glans in weepy exudative conditions.
• Many patients will try over-the-counter antifungal creams and may present with refractory balanitis if the initial cause was not fungal or yeast (Candida).

Specific measures

Sexually transmitted infections should be excluded, especially in sexually active persons. HIV should be ruled out in cases not responding to therapy and/or non-typical presentations.

Fungal cause:

• Topical antifungals (e.g. clotrimazole, miconazole, nystatin)

Non-infectious eczematous cause:

• Topical mild-moderate strength steroid cream.

For more severe inflammatory causes of balanitis (such as Zoon’s balanitis, genital lichen planus, BXO):

• Stronger topical corticosteroids (clobetasol 0.05%) and/or
• Topical calcineurin inhibitors (pimecrolimus 1% ointment).

Psoriatic balanitis:

• Topical moderate strength corticosteroids
• Topical Vitamin D3 analogues (calcipotriol ointment) and/or
• Topical calcineurin inhibitors (tacrolimus ointment).

Drug-induced balanitis:

• Topical moderate-high strength corticosteroids are recommended
• Discontinuation of the offending drug.

Pre-malignant causes of balanitis (such as erythroplaisa of Queyrat):

• Topical 5-fluorouracil 5% and/or
• Topical imiquimod 5% creams

How do you prevent balanitis?

• Maintaining proper hygiene is essential, especially in children; frequent diaper changes are recommended.
• Avoid frequent washing of the penis and prepuce with soaps; use a light emollient and properly dry the area before putting on clothing.
• In patients who are uncircumcised, pull back the prepuce to expose the glans fully during urinating and washing (lukewarm) to prevent collection of fluids in between the prepuce and glans.
• In those who are sexually active, safe sex practice (e.g. condom use) is important.

What is the outcome for balanitis?

Most individuals with balanitis recover without complications with appropriate treatment and genital hygiene measures. In those who are uncircumcised, it is not uncommon for balanitis to recur.

Phimosis and paraphimosis are emergent complications of balanitis and must be evaluated by a urologist.

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