Balanitis

Practice Essentials

Balanitis is inflammation of the glans penis and is a common condition that affects an estimated 3-11% of males.^[1] Balanitis can occur in males at any age. Morbidity is associated with the complications of phimosis.^{[2, 3, 4]} Balanitis involving the foreskin and prepuce is termed balanoposthitis. According to European guidelines outlining the current management of balanoposthitis, the aims of management are to minimize sexual dysfunction and  urinary dysfunction, exclude penile cancer, treat premalignant disease, and diagnose and treat sexually transmitted infections.^[5]

Predisposing factors include poor hygiene and overwashing, use of over-the-counter medications, and nonretraction of the foreskin.^[5] Though uncommon, a complication of balanitis (usually only in recurrent cases) is constricting phimosis, or inability to retract the foreskin from the glans penis. Other complications of balanitis may include meatal stenosis and possible urethral strictures, urinary retention, and vesicoureteral reflux.

Balanitis xerotica obliterans (BXO), or penile lichen sclerosus, is a progressive sclerosing inflammatory dermatosis of the glans penis and foreskin (see the image below). BXO is uncommon in children.^{[2, 3, 4, 6, 7, 8]}

View Image

Balanitis xerotica obliterans (lichen sclerosus). Courtesy of Wilford Hall Medical Center Slide collection.

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." Diabetes is the most common underlying condition associated with adult balanitis.^{[9, 10, 11]}  Older age has been identified as a risk factor for candidal balanitis. 

Zoon balanitis (balanitis circumscripta plasmacellularis) is an inflammatory condition that is thought to result from chronic irritation and that presents as a well-demarcated shiny erythematous patch or plaque over the genital mucosa.^[11]  It typically occurs in middle-aged and older men who are uncircumcised. Because Zoon balanitis often complicates other dermatoses — especially lichen sclerosus, but also precancerous lesions and cancer— its frequency, and even its existence as an independent entity, has been called into question.^{[5, 12]}

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Etiology

Diabetes mellitus is the most common underlying condition associated with balanitis in adults.^[9] In a study of patients with type 2 diabetes mellitus, treatment with dapagliflozin (a selective sodium-glucose transporter–2 [SGLT2] inhibitor that increases urinary glucose excretion) was found to be associated with an increased risk of vulvovaginitis or balanitis, related to the induction of glucosuria. According to the authors, events were generally mild to moderate, were clinically manageable, and rarely led to discontinuation of treatment. For dapagliflozin 5 mg and 10 mg daily, infections were reported in 5.7% and 4.8% of patients, respectively, as compared to 0.9% in patients with type 2 diabetes who were given placebo.^{[13, 14]}

Other causes include the following^[15] :

• 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

Pathogens that can cause balanitis include the following:

• Candidal species (most commonly associated with diabetes)
• Group B and group A beta-hemolytic streptococci
• Neisseria gonorrhoeae
• Chlamydia species
• Anaerobes (eg, Bacteroides)
• Human papillomavirus
• Gardnerella vaginalis
• Treponema pallidum (syphilis)
• Trichomonal species
• Borrelia vincentii and Borrelia burgdorferi

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History

Patients with balanitis usually present with the following complaints:

• Penile discharge
• Pain or difficulty with retraction of foreskin
• Erectile dysfunction
• 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

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Physical Examination

Physical examination findings may include the following:

• Erythema and edema of glans penis or foreskin
• Foul odor
• Discharge
• Ulceration and/or plaque
• Phimosis (uncommon)
• Signs of urinary obstruction (rare) – Meatal stenosis, bladder distension, ballooning of the foreskin when voiding
• Lymphadenopathy
• Signs of sepsis

Findings in specific disorders include the following:

• Balanitis xerotica obliterans (penile lichen sclerosus) is a chronic dermatosis identified by whitish plaques involving the glans and foreskin.^{[2, 3, 8]}
• Zoon balanitis is a reddish velvety lesion on the glans.^{[16, 17, 18]}  It is typically found in older, uncircumcised males. It can be asymptomatic or pruritic or may cause dysuria.^[19]
• Reactive arthritis consists of circinate and eroding lesions on the glans.
• Candidal balanitis may present as a white curd-like exudate and penile discharge. It is most common in patients with diabetes.

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Complications

Complications of balanitis may include meatal stenosis and possible urethral strictures; urinary retention; and vesicoureteral reflux.

In a study of 250 patients who had undergone circumcision for balanitis xerotica obliterans (penile lichen sclerosus), approximately 20% required a subsequent operation for meatal stenosis. According to the authors, precircumcision topical steroids may help decrease this rate of subsequent meatal pathology. They added that submission of the foreskin for histologic analysis should always be considered, because the prognosis differs for lichen sclerosus and nonlichen sclerosus histology. Those patients with balanitis xerotica obliterans who later underwent meatal procedures rarely underwent a meatal procedure at circumcision and were less likely to have received preoperative topical steroids, as compared to patients who did not need a subsequent meatal procedure.^[20]

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Laboratory Studies

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 papillomavirus titers in selected cases

Ultrasonography or bladder scan is used to detect urinary obstruction in severe balanitis.

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Emergency Department Care

Patients presenting with balanitis but without phimosis should receive the following recommendations and treatment^{[5, 21]} :

• Gentle retraction of the foreskin daily and soaking in warm water to clean penis and foreskin.
• In pediatric patients and patients with mild balanitis xerotica, a 2-month trial of topical corticosteroid therapy 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 boys older than 10 years compared with those aged 3-10 years. Success rates range 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.^[22]
• In pediatric patients with suspected bacterial infection, apply bacitracin (not Neosporin [neomycin sulfate, bacitracin zinc, and polymyxin B sulfate]) 
• 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 a 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.^[23]

Patients presenting to the ED with phimosis and severe urinary obstruction as a complication of balanitis should receive the following care (surgical intervention should 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.^{[24, 25]}
• 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 (see Dorsal Slit of the Foreskin for procedural details).
• Perform a formal circumcision (preferably in the operating room).^{[26, 27]}
• Circumcision is not a preventive treatment of balanitis in those younger than 3 years.

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

Deterrence/prevention of balanitis includes the following measures:

• Proper personal hygiene
• Control of diabetes and other chronic medical disorders
• Weight reduction for patients who are obese

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Medical Care

If the patient is able to retract the foreskin and does not have uncontrolled diabetes, he may be discharged to follow up with a urologist.

Circumcision should be suggested only if outpatient conservative therapy fails, particularly in children.

Patients should receive the following instructions:

• Topical therapy - Bacitracin in children and clotrimazole in adults and possibly a steroid cream
• Education - Improve personal hygiene by retracting the foreskin daily and cleaning the glans penis with water

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Guidelines Summary

European guidelines have been published regarding management of specific balanitides^[5] :

• Candidal balanitis: clotrimazole cream 1%; miconazole cream, 2%; apply twice daily until symptoms resolve.
• Anaerobic infection: metronidazole 400-500 mg twice daily for 1 wk.
• Aerobic infection: trimovate cream applied once daily; erythromycin 500 mg qds for 1 wk; co-amoxiclav 375 mg 3 times daily for 1 wk.
• Lichen sclerosus: ultrapotent topical steroids such as clobetasol proprionate applied once daily until remission, then gradually reduced.
• Lichen planus: moderate to ultrapotent topical steroids depending on severity.
• Zoon balanitis: circumcision; topical steroids with or without antibacterials applied once or twice weekly.
• Psoriasis: moderate-potency topical steroids with or without antibiotic and antifungal.
• Eczema: hydrocortisone 1% applied once or twice daily until resolution of symptoms.
• Seborrheic dermatitis: antifungal cream with a mild to moderate steroid.
• Bowenoid papulosis: imiquimod 5% cream; laser resection.
• Premalignant conditions: surgical excision.
• Nonspecific balanoposthitis: circumcision is curative.

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Medication Summary

The goal of balanitis therapy is to eradicate infection, reduce inflammation, and prevent complications. Topical antimicrobials, corticosteroids, and immunosuppressants are used.

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Clotrimazole topical (Gyne Lotrimin, Lotrimin, Lotrimin AF)

• Dosing, Interactions, etc.

Clinical Context:  Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability. For use in adults, especially those with candidiasis in a sexual partner.

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Bacitracin topical (Baciguent)

• Dosing, Interactions, etc.

Clinical Context:  Prevents transfer of mucopeptides into growing cell wall, which inhibits cell wall synthesis and bacterial growth. More commonly used in pediatric patients or patients who are not sexually active.

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Class Summary

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

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Betamethasone topical (Alphatrex, BetaVal, Dermabet)

• Dosing, Interactions, etc.

Clinical Context:  For treatment of inflammatory dermatoses responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Affects production of lymphokines and has inhibitory effect on Langerhans cells.

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Class Summary

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.

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Pimecrolimus (Elidel)

• Dosing, Interactions, etc.

Clinical Context:  First nonsteroid cream approved in the US for mild-to-moderate atopic dermatitis. Derived from azcomycin, a natural substance produced by fungus Streptomyces hygroscopics var. ascomycetous. Selectively inhibits production and release of inflammatory cytokines from activated T-cells by binding to cytosolic immunophilin receptor macrophilin-12. The resulting complex inhibits phosphatase calcineurin, thus blocking T-cell activation and cytokine release. Cutaneous atrophy was not observed in clinical trials, a potential advantage over topical corticosteroids. Indicated only after other treatment options have failed.

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Class Summary

Regulates key factors responsible for the immune response.

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