Balanoposthitis, defined as inflammation of the foreskin and glans in uncircumcised males, occurs over a wide age range and may have any of multiple bacterial or fungal origins or may be caused by contact dermatitides.[1] Complex infections have been well documented, often from a poorly retractile foreskin and poor hygiene that leads to colonization and overgrowth. Balanoposthitis should not be confused with balanitis, which is inflammation of the glans penis or the clitoris.
Treatment focuses on clearing the acute infection and preventing recurrent inflammation or infection through improved hygiene. Circumcision, though not as necessary as in the past, may be considered for refractory or recurrent balanoposthitis. Consensus-based recommendations for care have been published.[2, 3] (See Guidelines.)
Although multiple organisms have been incriminated in the pathogenesis of balanoposthitis, most patients are treated empirically, without confirmation of a specific causative organism. The multicausal origin of balanoposthitis was emphasized in a study that identified infectious, mechanical/traumatic, or contact dermatitides in 34 of 51 (67%) patients with mild balanoposthitis[4] ; in the remaining 17, no specific cause could be established even after clinical examination and microbiologic and serologic tests had been performed.
Candidal infection appears to be the most common cause of balanoposthitis.[5] In older men, other etiologic factors are often present, including intertrigo, irritant dermatitides, or other fungal infections. Organisms that have been identified include Bacteroides, Gardnerella,[6, 7] and Candida species, as well as beta-hemolytic streptococci.[8] Balanoposthitis may also occur as a manifestation of syphilis.[9, 10]
Although, in general, fungal infections of the penis are rare, it has been suggested that candidal balanitis/balanoposthitis is the most common mycotic infection of the penis.[11] In one series, Candida species accounted for 30% of the causative organisms, with beta-hemolytic streptococci accounting for 13%. In another study, Candida species were identified as the causative pathogen in 50% of patients and Streptococcus species in 25%; no growth was noted in 13% (12% were not tested).[12]
Rare causes include Streptococcus pyogenes,[13, 14] Prevotella melaninogenica, Cordylobia anthropophaga,[15] Pasteurella bettyae,[16] Providencia stuartii, and Pseudomonas aeruginosa,[17] the last two in individuals who are immunocompromised. Reports of an association between human papillomavirus (HPV) infection and longstanding balanoposthitis have been published, but this association may be a noncausal one.[18, 19, 20] Associations with ulcerative colitis[21] and Crohn disease[22] have also been noted. Granulomatous balanoposthitis after intravesical bacille Calmette-Guérin (BCG) vaccine instillation has been described.[23]
In a study by Alsterholm et al, patients with balanoposthitis had a significantly higher frequency of positive cultures than control subjects did (59% vs 35%).[24] In the balanoposthitis group, Staphylococcus aureus was found in 19% of patients, group B streptococci in 9%, Candida albicans in 18%, and Malassezia in 23%. In the control group, S aureus was not found at all, whereas C albicans was found in 7.7% of patients and Malassezia in 23%. Different causative organisms did not correspond with distinct clinical manifestations.
Although a direct causal relation has not been established, an association is known to exist between nonspecific balanoposthitis and the uncircumcised penis. Several authors have proposed that circumcision may protect against balanoposthitis and common penile infections.[25, 26]
Less common causes of balanoposthitis include external irritants or allergens (eg, contact-induced balanoposthitis caused by the application of celandine juice from the plant Chelidonium majus). An association with preputial smegma stones has been described, a correlation that most likely reflects the hygiene of the affected population.[27] Granulomatous balanoposthitis has occurred after intravesical BCG treatment of urothelial cancer.[28] Fixed drug eruption–induced balanoposthitis has been reported.[29]
To date, no studies of the incidence of balanoposthitis have been performed in the United States.
In a Japanese study, balanoposthitis was found in nine (1.5%) of 603 uncircumcised Japanese boys aged 0-15 years.[30] In a study from Hong Kong, only one of 2149 elementary schoolchildren had balanoposthitis.[31] In a British study, Candida species were identified as the cause of balanoposthitis in 35% of 450 men examined.[32] An Italian study found balanoposthitis in 51 (16%) of 321 patients with genital dermatoses.[4] A long-term Japanese study revealed an incidence of 3-7% per annum.[33]
Although balanoposthitis is known to occur over a wide age range, most studies have centered on the juvenile population (0-5 y) or on sexually active adult males.
By definition, balanoposthitis occurs only in males.
Although balanoposthitis, because of its heterogenous etiology, has been described in individuals of many races and ethnic backgrounds, no breakdowns of frequency on the basis of such categories have been performed.
The therapeutic outcome is often favorable, with treatment failures frequently leading to further clinical examination and tailoring of the treatment to the particular offending agent. Aside from the associated irritant symptoms, morbidity is limited.
Lack of response in the setting of appropriate treatment should raise the suspicion of malignancy.[34] Biopsy is then necessary to rule out both primary malignancies and secondary malignancies involving the penis. The most common malignancy that mimics balanoposthitis is erythroplasia of Queyrat, though Bowen disease may have some clinical overlap. A case report has described the presentation of acute promyelocytic leukemia as an ulcerating balanoposthitis.[35]
Mondor phlebitis of the penis following recurrent candidal balanoposthitis has been reported.[36]
In a patient who is immunocompromised, the presence of a systemic fungal infection can lead to involvement of the penis and often arises as a more deeply involved ulcerating lesion. Treatment of this disease, which can be caused by any number of fungal agents, involves clearing the systemic infection and immunodepression. Mortality is present only in patients who are immunocompromised and develop balanoposthitis secondary to fungal bloodstream infection.
In adults, a detailed clinical history focusing on topical irritants and home remedies assists in making the correct diagnosis and in detecting possible contact dermatitides.
Patients with balanoposthitis may report varying degrees and types of sexual dysfunction.[37]
Examination of the glans and the prepuce often reveals a red, moist macular lesion. Associated erythema is noted, and areas of yellow-to-black discoloration have been described.[38] The presence of lichenification, irregular borders, or acetowhite changes with 5% acetic acid treatment suggest a human papillomavirus (HPV) infection, which can be seen in association with balanoposthitis.
A superimposed balanoposthitis on a flat condyloma has been described. Such coexisting lesions may be diagnosed on the basis of the clinical history and a culture of fungus or bacteria from the ulcer.
Ulceration and deep erosion have been seen in patients with advanced disease, often in association with fungal infections and in individuals who are immunocompromised.
Potassium hydroxide (KOH) slide preparation allows rapid visualization of the candidal hyphae, and culture for Candida species often isolates candidal species and helps to direct proper treatment.
Rarely, serologic tests for candidal species may be indicated, particularly in unclear cases and for academic interest.
Biopsy is performed in doubtful cases and when antifungal treatment fails to produce a favorable response. Biopsy is especially warranted if premalignant or malignant lesions, such as erythroplasia of Queyrat or Bowen disease, are suspected and must be excluded.
The histologic findings are nonspecific and eczematous in nature. Dermis contains lymphoplasmacytic infiltrates (see the image below). Special stains for fungi, such as the periodic acid–Schiff (PAS) stain, may exhibit fungal elements characteristic of candidal organisms.
 View Image | Balanoposthitis. Dermis with lymphoplasmacytic infiltrates and dilated blood vessels. |
The primary goals in the treatment of balanoposthitis are elimination of various pathogenic organisms and control of inflammation. Topical antibiotics (eg, metronidazole cream) and antifungals (eg, clotrimazole cream) or low-potency steroid creams for contact dermatitides often lead to clearing of the lesion.[43, 44, 45]
Proper hygiene with frequent washing and drying of the prepuce is an essential preventive measure.
Topical application of "water of the three sulfates" (copper sulfate, zinc sulfate, and alum) has been reported to be effective.[46]
Consensus-based guidelines and recommendations for care have been published.[2, 3] (See Guidelines.)
Circumcision or preputioplasty may be advocated in recurrent and recalcitrant cases.[47]
Prevention has centered on improved hygiene of the prepuce. Although circumcision has been advocated for refractory or recurrent cases, it is now primarily used when improved drying and hygiene are not effective. Several authors have proposed that circumcision may protect against balanoposthitis and common penile infections.[25, 26]
In 2023, a European group published updated guidelines for the management of various forms of balanoposthitis.[2]
Regimens for the management of balanoposthitis caused by Candida included the following:
Regimens for the management of balanoposthitis caused by anaerobic infection included the following:
Regimens for the management of balanoposthitis caused by aerobic infection included the following:
Regimens for the management of irritant/allergic balanoposthitis included the following:
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Balanoposthitis. Dermis with lymphoplasmacytic infiltrates and dilated blood vessels.
Balanoposthitis. Dermis with lymphoplasmacytic infiltrates and dilated blood vessels.
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