What is balanitis?

Balanitis: Definition, Causes, and Management

Balanitis is defined as inflammation of the glans penis, often involving the prepuce (foreskin), in which case it is termed balanoposthitis. It is a common inflammatory condition affecting the penis with multiple potential etiologies including infectious, inflammatory, traumatic, and allergic causes that requires prompt diagnosis and appropriate treatment to prevent complications such as phimosis, urethral stenosis, and in some cases, malignancy 1.

Epidemiology and Risk Factors

• Common condition affecting approximately 10.7% of men attending STD clinics 2
• Most frequently affects uncircumcised men
• Risk factors include:
  • Poor hygiene
  • Diabetes
  • Obesity
  • Immunosuppression
  • Exposure to irritants or allergens

Etiology and Classification

Infectious Causes

• Fungal infections: Candida albicans is the most common infectious cause 2
• Bacterial infections: Staphylococcus species and groups B and D Streptococci 2
• Viral infections: HPV, HSV
• Parasitic infections: Trichomonas

Non-infectious Causes

• Inflammatory dermatoses:
  • Psoriasis
  • Lichen planus
  • Contact dermatitis (irritant or allergic)
• Lichen sclerosus (formerly called balanitis xerotica obliterans): A chronic, lymphocyte-mediated skin disease affecting the genital area 3
• Pre-malignant and malignant conditions:
  • Erythroplasia of Queyrat
  • Bowen's disease
  • Squamous cell carcinoma 4

Clinical Presentation

• Redness and inflammation of the glans penis
• Itching or burning sensation
• Pain or discomfort
• Discharge (particularly in infectious causes)
• Swelling
• Difficulty retracting the foreskin (phimosis)
• Fissuring or erosions
• White plaques or patches (in candidal or lichen sclerosus)

Diagnosis

The clinical appearance of balanitis is often non-specific and cannot reliably predict the causative agent 2. Therefore, diagnostic workup may include:

• Detailed history focusing on:

  • Duration and progression of symptoms
  • Previous episodes
  • Sexual history
  • Topical products used
  • Systemic conditions (diabetes, immunosuppression)

• Physical examination of the entire genital area

• Laboratory investigations:

  • Swabs for culture and sensitivity
  • Potassium hydroxide (KOH) preparation for fungal elements
  • Biopsy for persistent, recurrent, or suspicious lesions 4

Management

General Measures

• Maintain proper genital hygiene
• Keep the area clean and dry
• Avoid potential irritants and allergens
• Consider temporary abstinence from sexual activity during acute episodes

Specific Treatment Based on Etiology

Fungal Infections

• First-line: Clotrimazole 1% cream applied twice daily for 7-14 days 5
• For extensive or severe infections: Oral fluconazole 150mg as a single dose 5
• Alternative: Miconazole 2% cream applied twice daily for 7 days 5

Bacterial Infections

• Appropriate antibiotics based on culture and sensitivity results
• Empiric treatment may include broad-spectrum antibiotics while awaiting culture results

Inflammatory Dermatoses

• Low to moderate potency topical corticosteroids
• Avoid combination products containing corticosteroids and antifungals for groin infections as they can cause skin atrophy and potentially worsen the infection 5

Lichen Sclerosus

• Ultrapotent topical corticosteroids (first-line treatment) 3
• Long-term follow-up is essential due to the risk of malignant transformation 3, 4

Recurrent Infections

• Investigate underlying causes such as diabetes or immunosuppression 5
• Consider longer treatment courses (up to 14 days) 5
• Treat sexual partners who may have asymptomatic infection 5

Surgical Management

• Therapeutic circumcision may be considered for chronic, recurrent balanitis resistant to medical therapy 1
• Specialized surgical approaches for specific conditions like lichen sclerosus with urethral involvement 3

Prevention

• Keep the genital area clean and dry
• Wear loose-fitting cotton underwear
• Change underwear and workout clothes promptly after sweating
• Use antifungal powders in skin folds if prone to recurrence 5
• Consider circumcision in cases of recurrent balanitis

Important Considerations and Complications

• Any persistent, non-healing lesion should be biopsied to rule out malignancy 4
• Lichen sclerosus requires long-term follow-up due to its association with squamous cell carcinoma 3
• Treatment should generally be limited to 2 weeks maximum to prevent skin atrophy from prolonged steroid exposure 5
• If symptoms persist after 7 days of treatment, reevaluation is necessary 5

Balanitis, while common, requires careful evaluation to determine the underlying cause and appropriate treatment strategy. Prompt diagnosis and management can prevent complications and improve quality of life.