AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Balanitis is inflammation of the glans penis. Balanitis involving the foreskin and prepuce is termed balanoposthitis. The most common complication of balanitis is 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. Adherence of the foreskin to the inflamed and edematous glans penis causes phimosis, which is the major presenting complication of balanitis seen in the ED. Meatal stenosis with urinary retention may accompany balanitis. In rare cases, balanitis may contribute to the "buried penis syndrome."

Frequency

United States

Balanitis is a common condition affecting 11% of adult men seen in urology clinics and 3% of children.

International

Balanitis may occur in up to 3% of uncircumcised males worldwide.

Mortality/Morbidity

No mortality is associated with balanitis. Morbidity is associated with the complications of phimosis.

Race

Among adult patients seen at Veterans Administration Hospital clinics, balanitis is seen twice as often in Blacks and Hispanics. This may be related to different circumcision rates.

Age

Males at any age can get balanitis. Etiologies vary depending on age.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Patients usually present with the following complaints:

• Penile discharge
• Inability to retract foreskin
• Impotence
• Difficulty urinating or controlling urine stream (in very severe cases)
• Inability to insert a Foley catheter
• Tenderness of the glans penis
• Itching

Physical

• Erythema and edema of glans penis or foreskin
• Inability to visualize glans penis or urethral meatus
• Discharge
• Ulceration and/or plaques
• Phimosis
• Meatal stenosis
• Bladder distension
• Ballooning of the foreskin when voiding
• Lymph node involvement

Causes

• Diabetes is the most common underlying condition associated in 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)
  • Anaerobic infection
  • Human papilloma virus
  • Gardnerella vaginalis
  • Treponema pallidum (syphilis)
  • Trichomonal species
  • Group B and group A streptococci
  • Borrelia vincenti and Borrelia burgdorferi
• Penile cancer
• Balanitis xerotica obliterans (lichen sclerosus) - This is a chronic dermatosis identified by whitish plaques involving the glans and foreskin.
• Zoon balanitis - Reddish velvety lesion on the glans
• Reiter disease - Circinate and eroding lesions on the glans

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Leukoplakia
Balanitis xerotica obliterans (lichen sclerosis)
Reiter syndrome
Zoon balanitis

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Serum glucose test - As part of a comprehensive diabetes workup
• Culture of discharge
• Syphilis serology test
• Wet mount
• KOH looking for Candida
• HIV and HPV titers in selected cases

Imaging Studies

• Ultrasonography to detect urinary obstruction in severe balanitis

Other Tests

• Referral to urologist for biopsy in chronic cases

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Emergency Department Care

• Patients presenting with balanitis but without phimosis should receive the following recommendations and treatment:
• • Retract the foreskin daily and soak in warm water to clean penis and foreskin.
  • In pediatric patients and patients diagnosed with balanitis xerotica, a 2-month trial may be attempted, having the patient or the mother retract the foreskin gently and applying 0.05% betamethasone twice a day.
  • 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 unusual cases, then treat the infection with appropriate antibiotics.
• Patients presenting to the ED with phimosis as a complication of balanitis should receive the following care:
• • 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).

Consultations

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

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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

Drug Category: Antimicrobial agents (topical)

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

Drug Category: Corticosteroids, topical

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

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Observe patient for the following signs and symptoms:
• • Signs of sepsis
  • Uncontrolled diabetes
  • Inability to retract foreskin
• Inability to urinate

Further Outpatient Care

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

Deterrence/Prevention

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

Complications

• Meatal stenosis and possible urethral strictures
• • Urinary retention

Patient Education

• For excellent patient education resources, visit eMedicine's Men's Health Center. Also, see eMedicine's patient education articles Foreskin Problems and Circumcision.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to consider diabetes as the most common underlying condition for balanitis
• Failure to correct phimosis
• Failure to consider carcinoma in elderly patients
• Failure to consider that balanitis may involve the meatus

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Ashfield JE. Treatment of phimosis with topical steroids in 194 children. J Urol. 2003;169:1106-1108. [Medline].
• Buechner SA. Common skin disorders of the penis. BJU Int. Sep 2002;90(5):498-506. [Medline].
• Edwards S. Balanitis and balanoposthitis: a review. Genitourin Med. Jun 1996;72(3):155-9. [Medline].
• Edwards SK. European guideline for the management of balanoposthitis. Int J STD AIDS. Oct 2001;12 Suppl 3:68-72. [Medline].
• Harrison BP. Pediatric penile swelling. Acad Emerg Med. Apr 1996;3(4):384, 87, 88. [Medline].
• Huntlley JS. Troubles with the foreskin: one hundred consecutive referrals to pediatric surgeons. J R Soc Med. 2003;96:449-451. [Medline].
• Kiss A., Kiraly L, Kutasy B. High Incidence of balanitis xerotica obliterans in boys with phimosis: prospective 10 year study. Pediatr Dermatol. 2005;22:305-308. [Medline].
• Kizer WS. Balanitis xerotica obliterans: epidemiologic distribution in an equal access health care. South Med J. 2003;96:9-11. [Medline].
• Marques TC, Sampaio FJ, Favorto LA. Treatment of phimosis with topcal steroids and foreskin anatomy. Braz J Urol. 2005;31:370-374. [Medline].
• Muratov ID. [Bacteriological pattern of acute purulent balanoposthitis in children]. Zh Mikrobiol Epidemiol Immunobiol. Mar-Apr 2004;83-5. [Medline].
• O'Farrell N, Quigley M, Fox P. Association between the intact foreskin and inferior standards of male genital hygiene behaviour: a cross-sectional study. Int J STD AIDS. Aug 2005;16(8):556-9. [Medline].
• Tanagho EA. Smith's General Urology. 14th ed. New York: McGraw-Hill;1995:966.

Article Last Updated: Jun 8, 2006