What is balanitis?

Balanitis: Definition, Causes, and Management

Balanitis is inflammation of the glans penis, often involving the prepuce (foreskin), which is then called balanoposthitis. It is a common condition affecting approximately 10.7% of men attending sexually transmitted disease clinics 1.

Etiology and Risk Factors

Balanitis can result from various causes:

• Infectious causes:

  • Fungal (most common): Candida albicans
  • Bacterial: Staphylococcus spp., Groups B and D Streptococci 1
  • Other microorganisms

• Non-infectious causes:

  • Irritative/allergic reactions
  • Traumatic injury
  • Inflammatory conditions
  • Pre-malignant lesions 2

• Major risk factors:

  • Uncircumcised status (all patients in one study were uncircumcised) 1
  • Poor hygiene
  • Phimosis
  • Diabetes mellitus
  • Immunosuppression
  • Chronic inflammation
  • Tobacco use 3

Clinical Presentation

The common symptoms of balanitis include:

• Pruritus (itching sensation)
• Penile discharge
• Penile soreness
• Burning sensation 3

It's important to note that the clinical appearance is often non-specific and has little value in predicting the specific infectious agent 1.

Diagnosis

According to guidelines, diagnosis of balanitis involves:

1. Clinical presentation assessment
2. Patient history
3. Laboratory tests:
   • Examination of discharge characteristics
   • Microscopic examination with saline and 10% potassium hydroxide (KOH) preparations to demonstrate yeast or hyphae
   • Culture for definitive identification in recurrent or severe cases
4. Biopsy in chronic or suspicious lesions 3

Treatment

Treatment should be targeted based on the specific etiology:

For Infectious Balanitis:

• Fungal infections (most common):

  • Topical antifungal agents (clotrimazole, miconazole, or nystatin) applied twice daily for 7-14 days
  • For patients ≥45 kg: Fluconazole 150 mg single dose
  • Combination therapy with oral fluconazole plus topical antifungals for more severe cases 3

• For resistant fungal infections (e.g., C. glabrata):

  • Topical intravaginal boric acid, 600 mg daily for 14 days, or
  • Alternative nystatin intravaginal suppositories, 100,000 units daily for 14 days 3

• For bacterial infections:

  • Appropriate antibiotic therapy based on culture results 3

For Non-infectious Balanitis:

• Improved hygiene measures for non-specific inflammation
• Ultrapotent topical corticosteroid (clobetasol propionate) for lichen sclerosus
• Surgical options including circumcision for cases that fail to respond to medical therapy, particularly for lichen sclerosus 3

Prevention and Follow-up

• Prevention:

  • Good hygiene practices
  • Gentle cleaning with warm water
  • Complete drying after bathing
  • Control of underlying conditions such as diabetes 3

• Follow-up:

  • Reassessment within 1-2 weeks to ensure resolution
  • Consider alternative diagnosis if no improvement after 72 hours of appropriate therapy
  • Lifelong follow-up for patients with lichen sclerosus due to 2-9% risk of developing penile carcinoma 3

Complications

If left untreated, balanitis can lead to serious complications:

• Phimosis
• Urethral stricture
• Sexual dysfunction
• Malignant transformation (especially in cases of lichen sclerosus) 3, 4

Important Clinical Considerations

• Any fixed, chronic, or suspicious lesion should be rapidly assessed by biopsy to rule out pre-malignant or malignant conditions 2
• Recurrence rates of approximately 12.7% have been reported in follow-up studies 1
• Normal variations in the balanopreputial area may cause anxiety in some patients and should be distinguished from pathological conditions 2