What are the diagnosis and treatment options for balanitis?

Diagnosis and Treatment of Balanitis

Balanitis, inflammation of the glans penis, should be treated with topical antifungal agents for symptomatic cases, with identification and management of underlying causes to prevent recurrence. 1

Diagnosis

Clinical Presentation

• Erythematous areas on the glans penis
• Pruritus or irritation
• Inflammation may involve the prepuce (balanoposthitis)

Etiology

Balanitis can be caused by various factors:

1. Infectious causes 2, 3:

   • Candida albicans (most common infectious cause)
   • Bacterial infections (Staphylococcus spp., Streptococci groups B and D)
   • Viral infections
   • Parasites
   • Sexually transmitted infections

2. Non-infectious causes 2, 4:

   • Irritative dermatitis
   • Allergic contact dermatitis
   • Traumatic injury
   • Inflammatory skin conditions:
     • Lichen planus
     • Psoriasis
     • Lichen sclerosus

3. Predisposing factors 1, 5:

   • Poor hygiene
   • Phimosis (inability to retract foreskin)
   • Uncircumcised status (all patients in one study were uncircumcised) 3
   • Uncontrolled diabetes mellitus
   • Immunosuppression

Diagnostic Approach

1. Clinical examination:

   • Inspect for erythema, erosions, ulcerations
   • Assess for presence of discharge
   • Evaluate foreskin retractability

2. Laboratory testing:

   • Swab for culture and sensitivity (to identify causative organism)
   • Consider glucose testing (balanitis may be first presentation of diabetes) 5

3. Biopsy:

   • Required for any fixed, chronic, or suspicious lesion to rule out malignancy 4
   • Essential for persistent or recurrent cases

Treatment

Infectious Balanitis

1. Candidal balanitis 1:

   • First-line treatment: Topical antifungal agents
     • Clotrimazole 1% cream applied twice daily for 7-14 days
     • Miconazole 2% cream applied twice daily for 7 days
     • Other azole creams (butoconazole, terconazole) are also effective

2. Bacterial balanitis:

   • Topical antibacterial agents based on culture results
   • Systemic antibiotics for severe cases 3

Non-infectious Balanitis

• Identify and remove irritants/allergens
• Topical corticosteroids for inflammatory conditions
• Disease-specific treatments for psoriasis, lichen planus, etc.

General Measures for All Types

1. Maintain proper genital hygiene 2:

   • Gentle cleansing with warm water
   • Avoid soap and other potential irritants
   • Keep the area dry

2. For recurrent cases:

   • Treat underlying conditions (e.g., diabetes control) 5
   • Consider maintenance therapy for recurrent candidal infections

3. Surgical intervention:

   • Circumcision may be considered for chronic, recurrent balanitis unresponsive to medical therapy 2

Management of Sexual Partners

• Partners with symptomatic balanitis or penile dermatitis should be treated with appropriate topical agents 1
• Routine treatment of asymptomatic partners is generally unnecessary 1

Follow-Up

• Patients should return for follow-up only if symptoms persist or recur within 2 months 1
• Any fixed, chronic, or suspicious lesion requires biopsy and lifelong follow-up due to risk of malignant transformation, particularly with lichen sclerosus 4

Common Pitfalls and Caveats

1. Misdiagnosis: Clinical appearance alone is often insufficient to determine the causative agent 3

2. Missed underlying conditions: Always consider and test for diabetes in patients with recurrent balanitis 5

3. Delayed diagnosis of malignancy: Any persistent or atypical lesion requires biopsy to rule out premalignant or malignant conditions 4

4. Inadequate treatment duration: Short courses of therapy may lead to recurrence; ensure adequate treatment duration

5. Neglecting hygiene education: Patient education about proper genital hygiene is essential for prevention of recurrence