What are the causes of balanitis?

Causes of Balanitis

Balanitis is primarily caused by fungal infections (particularly Candida species), bacterial infections (including Staphylococcus and Streptococcus species), and inflammatory conditions, with uncircumcised status and poor hygiene being the most significant risk factors. 1

Common Causes of Balanitis

Infectious Causes

• Fungal infections:

  • Candida albicans (most common infectious cause) 1, 2
  • Other Candida species

• Bacterial infections:

  • Staphylococcus species 1, 2
  • Streptococcus groups B and D 2, 3
  • Anaerobic bacteria 4
  • Coagulase-negative staphylococci (including Staphylococcus haemolyticus) 3

• Other infectious agents:

  • Viral infections 4
  • Parasitic infestations 4, 5
  • Sexually transmitted infections 4

Non-Infectious Inflammatory Causes

• Lichen sclerosus (balanitis xerotica obliterans) 1, 6
• Lichen planus 4
• Psoriasis 4
• Contact dermatitis 4
• Irritant reactions 6, 5
• Allergic reactions 6
• Trauma 6, 5

Risk Factors for Balanitis

The American Academy of Dermatology identifies several high-evidence risk factors 1:

• Uncircumcised status (all men in one study were uncircumcised) 2
• Poor hygiene
• Phimosis (tight foreskin)
• Diabetes mellitus
• Immunosuppression
• Chronic inflammation
• Tobacco use (moderate evidence level) 1

Clinical Considerations and Pitfalls

1. Diagnostic challenges: The clinical presentation of balanitis is often non-specific, making it difficult to determine the causative agent based on appearance alone 2. This highlights the importance of appropriate laboratory testing for accurate diagnosis.

2. Pre-malignant potential: Any fixed, chronic, or suspicious lesion should be biopsied to rule out malignancy 1, 6. This is particularly important with lichen sclerosus, which carries a 2-9% risk of developing into penile carcinoma 1.

3. Recurrence risk: Balanitis can be recurrent, especially in uncircumcised men with predisposing factors. In one study, recurrence was observed in 12.7% of patients during follow-up 2. Circumcision may be indicated for recurrent cases 1, 3.

4. Treatment resistance: Some cases of balanitis may not respond to empiric treatment, necessitating culture and sensitivity testing to guide appropriate antimicrobial therapy, as demonstrated in the case of Staphylococcus haemolyticus causing erosive balanitis even in a circumcised patient 3.

5. Lifelong monitoring: Patients with lichen sclerosus require lifelong follow-up due to the risk of malignant transformation 1.

The European Association of Urology and National Institute for Health and Care Excellence guidelines emphasize that diagnosis should be based on clinical presentation, patient history, and appropriate laboratory tests, with biopsy for chronic or suspicious lesions 1.