What is balanitis and how is it treated?

Balanitis: Diagnosis and Treatment

Balanitis is an inflammation of the glans penis, often involving the prepuce (balanoposthitis), that requires specific treatment based on the underlying cause, with topical antifungal agents being first-line for fungal infections and topical corticosteroids for inflammatory conditions. 1

Definition and Etiology

Balanitis refers to inflammation of the glans penis, which may extend to involve the prepuce (foreskin), in which case it is termed balanoposthitis. It can result from various causes:

• Infectious causes: Fungal (most commonly Candida albicans), bacterial (Staphylococcus spp., Streptococci), viral, or parasitic infections 1, 2
• Non-infectious causes: Irritant contact dermatitis, allergic reactions, trauma, inflammatory skin conditions (psoriasis, lichen planus), and lichen sclerosus 1, 3
• Pre-malignant conditions: Particularly lichen sclerosus, which carries a 2-9% risk of developing into penile carcinoma 1, 4

Clinical Presentation

Common symptoms include:

• Pruritus (itching)
• Penile discharge
• Penile soreness or pain
• Burning sensation
• Redness and inflammation of the glans penis 1

Diagnosis

Diagnosis is primarily clinical, based on:

1. Patient history (including sexual history, hygiene practices)
2. Physical examination of the genital area
3. Laboratory tests when needed:
   • Microscopic examination with saline and 10% KOH preparations
   • Culture for recurrent or resistant cases
   • Biopsy for chronic, suspicious, or pre-malignant lesions 1, 4

Treatment Algorithm

1. Fungal Balanitis (Candida)

• First-line: Topical clotrimazole cream applied twice daily for 7-14 days 1
• For severe/extensive infections: Oral fluconazole 150 mg every 72 hours for 2-3 doses plus topical clotrimazole cream twice daily for 14 days 1
• Alternative: Itraconazole 200 mg daily for 7 days for non-responsive cases 1

2. Bacterial Balanitis

• Appropriate antibiotics based on culture and sensitivity
• Keep the area clean and dry 1, 3

3. Inflammatory Balanitis (including Lichen Sclerosus)

• First-line: Ultrapotent topical corticosteroid (clobetasol propionate) 1
• For lichen sclerosus that fails to respond to topical steroids, referral to a urologist for consideration of circumcision or other surgical options 5

4. Irritant or Allergic Balanitis

• Remove irritant/allergen
• Mild topical corticosteroids
• Emollients 3

Prevention and Risk Factors

Risk factors include:

• Uncircumcised status
• Poor hygiene
• Phimosis
• Diabetes mellitus
• Immunosuppression
• Chronic inflammation
• Tobacco use 1

Preventive measures:

• Good genital hygiene with gentle cleaning using warm water
• Complete drying after bathing
• Control of underlying conditions such as diabetes 1

Complications and Follow-up

Potential complications:

• Phimosis (inability to retract the foreskin)
• Urethral stricture
• Sexual dysfunction
• Malignant transformation, especially with lichen sclerosus 1, 6

Follow-up recommendations:

• Reassessment within 1-2 weeks to ensure resolution of symptoms
• Consider alternative diagnosis if no improvement after 72 hours of appropriate therapy
• Lifelong follow-up for patients with lichen sclerosus due to the 2-9% risk of malignancy 1

Special Considerations

• Any fixed, chronic, or suspicious lesion must be rapidly assessed by biopsy to rule out pre-malignant or malignant conditions 4
• Therapeutic circumcision can be considered for most forms of chronic balanitis that are resistant to medical treatment 3
• The clinical appearance alone is often insufficient to determine the specific infectious agent, making laboratory confirmation important in persistent cases 2