Balanitis

Balanitis is inflammation of the glans penis (head of the penis). It is a common condition that predominantly affects uncircumcised males, and as such the inflammation frequently involves the foreskin.

This chapter is set out as follows: 

• Uncircumcised men with poor personal hygiene are most affected by balanitis 
   
• Mechanical or chemical irritation 
  • Mechanical irritation in boys, repeatedly playing with their foreskin
  • Chemical irritation from urine, soaps and other irritant substances
     
• Infection
  • Candida, which is more common in people with diabetes or who have recently taken antibiotics
  • Bacterial infection eg streptococci
  • Anaerobic infection 
  • Sexually transmitted infections 

• Inflammatory dermatoses
  • ​Eczema can cause significant inflammation of the glans penis or any part of the genital skin 
  • Psoriasis tends to cause small scaly lesions that can affect any part of the genitalia, as opposed to a true balanitis 
  • Lichen sclerosus - see notes below
  • Classical lichen planus most commonly causes annular lesions on the glans penis, it rarely causes significant inflammation/ulceration in men        

• Symptoms can include itch, pain, swelling, discharge, a tight foreskin ie phimosis, and in more severe cases difficulties with urination or sexual function

General features of balanitis 

• The clinical features vary depending on the cause but can include:
  • Erythema
  • Oedema
  • A white surface coating may be seen in candida
  • Discharge
  • Phimosis (uncommon)
  • Signs of urinary obstruction (rare) - meatal stenosis, ballooning of the foreskin when voiding, bladder distension  

Other conditions to consider where there are persistent and recalcitrant (poor response to treatment) skin / mucosal changes  

• Lichen sclerosus 

• Usually presents with a white, sclerotic ring at the edge of the prepuce or anywhere on the glans itself. Other signs include erythema; sometimes glistening (previously referred to as Zoon's balanitis), telangiectases, and sometimes purpura

• Balanitis xerotica obliterans (BXO) is a term used to describe chronic, often progressive inflammation of the glans penis, which can lead to phimosis and urethral stenosis, affecting both urinary and sexual function. Lichen sclerosus is one of a number of conditions that causes BXO

• For more information refer to the chapter Lichen sclerosus

• Erythroplasia of Queyrat (carcinoma in situ) / squamous cell carcinoma

  • Erythroplasia of Queyrat - single or multiple, non-tender, red, shiny patches or plaques of the ‘mucosal’ penis ie the glans and prepuce of the uncircumcised
  • Squamous cell carcinoma - can cause an irregular nodular and/or ulcerative morphology
  • For more information refer to the chapter Penile intraepethilial neoplasia

• A swab may be required for microscopy and C&S

• For many cases no further investigations are required - symptoms that respond well to topical treatments are generally reassuring, even if they recur

• In persistent and recalcitrant (poor response to treatment) cases a biopsy is usually needed to look for lichen sclerosus, erythroplasia of Queyrat, and squamous cell carcinoma; a confident clinical diagnosis is not always possible or safe

General measures

• The main aims of management are to make the skin more comfortable, minimise urinary and sexual dysfunction, and to exclude premalignant/malignant disease

• Advice should be given as follows:
  • Keep the penis clean by washing it every day with water or with an antiseptic emollient (eg Dermol ® 500 lotion)
  • Soaps and all other irritants should be avoided
  • After washing, the penis should be patted dry

• Candida - treat with a topical antifungal agent eg 1% clotrimazole cream, or miconazole. Occasionally an oral antifungal agent may be required

• Bacterial infections - treatment will depend on the result of the swab

• Sexually transmitted disease (STD) - is best managed, at least in the first instance, by a GUM clinic

• Use an emollient cream if the skin is dry - patient preference is important

• To reduce itch, discomfort or erythema treat with a mild topical steroid BD for several days, and on an intermittent basis, eg 1% hydrocortisone cream, Daktacort ® cream (hydrocortisone with miconazole), or Eumovate ® cream (clobetasone butyrate 0.05%)

• If the inflammation recurs more frequently consider a non-steroid preparation eg Elidel ® (pimecrolimus) cream OD-BD