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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
Balanitis is inflammation of the glans penis. If the foreskin is also inflamed, the correct term is balanoposthitis, although balanitis is commonly used to refer to both.
- Balanitis is more common in men than in boys.
- It is present in approximately 11% of attendees at genitourinary medicine (GUM) clinics.
- Balanitis affected 5.9% of uncircumcised boys in one study and 14% in another.
- The most important risk factor is diabetes mellitus.
- Use of oral antibiotics.
- Poor hygiene in uncircumcised males.
- Chemical or physical irritation of glans.
- Many causes seen in practice are a simple intertrigo.
- Infection with candida is the cause in less than 20% of cases. Often, candida is an opportunistic pathogen, signifying an underlying dermatosis.
- Bacterial cases may be polymicrobial.
- Candida spp.
- Staphylococci/streptococci (especially Group B).
- Gardnerella vaginalis.
- Trichomonas spp.
- Entamoeba histolytica (can cause severe oedema and rupture of foreskin).
- Borrelia vincentii.
- Treponema pallidum (syphilis).
- Viral - eg, herpes simplex, human papillomavirus.
- Fixed drug eruption (particularly with sulfonamides and tetracycline).
- Circinate balanitis (may be associated with reactive arthritis).
- Balanitis xerotica obliterans/lichen sclerosus.
- Zoon's balanitis (plasma cell infiltration); a benign, idiopathic condition presenting as a solitary, smooth, shiny, red-orange plaque of the glans and prepuce of a middle-aged to older man.
- Queyrat's erythroplasia (penile Bowen's disease - carcinoma in situ).
- Lichen planus.
- Seborrhoeic dermatitis.
- Irritation or contact dermatitis: wet nappies, poor hygiene, smegma, soap, condoms.
- Trauma: zippers, accidental or inappropriate foreskin retraction by a child/parent.
- Stevens-Johnson syndrome.
- Severe oedema due to right heart failure.
- Morbid obesity.
- Sore, inflamed and swollen glans/foreskin.
- Non-retractile foreskin/phimosis.
- Penile ulceration.
- Penile plaques.
- Satellite lesions.
- May be purulent and/or foul-smelling discharge (most common with streptococcal/anaerobic infection).
- Interference with urinary flow in severe cases.
- Obscuration of glans/external urethral meatus.
- Impotence or pain during coitus.
- Regional lymphadenopathy.
- Blood/urine testing for glucose if diabetes mellitus is possible.
- Swab of discharge for microscopy, Gram staining, culture and sensitivity.
- If syphilis or another sexually transmitted infection (STI) is suspected, refer to a genitourinary medicine (GUM) clinic.
- Daily cleaning with warm water, followed by gentle drying. Saline baths are useful (eg, four tablespoons or so of salt in the bath).
- If an STI is suspected, any partner(s) should be screened. Specialist advice should be sought or the patient referred to a GUM clinic, depending on the expertise of the GP and the clinical scenario.
- If a dermatological cause is suspected then treat the underlying cause with advice from dermatology/GUM/urology. A referral for biopsy may be required.
- In most cases topical treatment is recommended.
- Systemic therapy should be considered if there is severe inflammation affecting the penile shaft, or marked genital oedema.
- If a nonspecific dermatitis or contact dermatitis is suspected:
- Avoid triggers (eg, latex condoms, soaps). Prescribe topical hydrocortisone 1% once daily (and consider adding an imidazole cream), for up to 14 days.
- If symptoms are not improving by seven days: stop topical hydrocortisone and take a sub-preputial swab to exclude or confirm a fungal or bacterial infection - manage according to results.
- If candidal infection is the suspected cause:
- Recommended regimens: clotrimazole cream 1% or miconazole cream 2%; apply twice daily until symptoms have settled.
- Alternative regimens: fluconazole 150 mg stat orally if symptoms are severe.
- Nystatin cream 100,000 units/g - if resistance is suspected or allergy to imidazole.
- Topical imidazole with 1% hydrocortisone if there is marked inflammation.
- There is a high rate of candidal infection in sexual partners, who should be offered screening or empirical anti-candidal treatment.
- If bacterial infection is suspected:
- Take a swab and await the results or consider GUM referral.
- Common bacterial infection can usually be treated with flucloxacillin or erythromycin in penicillin-allergic patients.
- Anaerobic infection:
- Recommended regimen: metronidazole 400 mg twice-daily for one week.
- Alternative regimens: co-amoxiclav 375 mg three times daily for one week; clindamycin cream applied twice-daily until the infection has resolved.
- If there is gross inflammation and the patient is systemically unwell, consider admission to hospital for intravenous antimicrobials.
Surgical referral for consideration of circumcision if balanitis is recurrent or pathological phimosis is present.
This depends on the underlying cause and the presence of any predisposing risk factors. Candidal balanitis resolves rapidly with appropriate treatment but is more likely to recur in men with:
- Diabetes mellitus.
- Poor genital hygiene.
Balanitis due to contact irritants resolves over a period of days with removal of the provoking irritant or allergen. It may recur if exposed again.
Difficulty retracting the foreskin may develop. This is more likely if the balanitis is chronic or recurring.
Further reading and references
Management of balanoposthitis; British Association for Sexual Health and HIV (2008)
Morris BJ, Waskett JH, Banerjee J, et al; A 'snip' in time: what is the best age to circumcise? BMC Pediatr. 2012 Feb 2812:20. doi: 10.1186/1471-2431-12-20.
Achkar JM, Fries BC; Candida infections of the genitourinary tract. Clin Microbiol Rev. 2010 Apr23(2):253-73. doi: 10.1128/CMR.00076-09.
Edwards S, Bunker C, Ziller F, et al; 2013 European guideline for the management of balanoposthitis. Int J STD AIDS. 2014 May 1425(9):615-626.
Delgado L, Brandt HR, Ortolan DG, et al; Zoon's plasma cell balanitis: a report of two cases treated with pimecrolimus. An Bras Dermatol. 2011 Jul-Aug86(4 Suppl 1):S35-8.
Balanitis; NICE CKS, July 2015 (UK access only)
Hayashi Y, Kojima Y, Mizuno K, et al; Prepuce: phimosis, paraphimosis, and circumcision. ScientificWorldJournal. 2011 Feb 311:289-301. doi: 10.1100/tsw.2011.31.