What is the treatment for posthitis?

Treatment for Posthitis

The first-line treatment for posthitis is topical antifungal or antiseptic agents, combined with proper hygiene measures and warm water baths. 1, 2

Definition and Clinical Presentation

Posthitis refers to inflammation of the foreskin (prepuce) in uncircumcised males. It often occurs together with balanitis (inflammation of the glans penis) as balanoposthitis. Common symptoms include:

• Pain, tenderness, and itching of the foreskin 1
• Erythema and swelling of the prepuce 1
• Possible discharge or accumulation of debris under the foreskin 1
• In severe cases, phimosis (inability to retract the foreskin) may develop 1, 3

Etiology

Posthitis can be caused by several factors:

• Fungal infections (most commonly Candida species) 1
• Bacterial infections (including Corynebacterium species) 4
• Poor hygiene with accumulation of smegma 1
• Irritant contact dermatitis from soaps or other chemicals 1
• Underlying skin conditions 5

Treatment Algorithm

First-Line Treatment

1. Hygiene measures:

   • Gentle cleansing of the area with warm water (avoid soap) 2
   • Warm water baths 2-3 times daily 2
   • Ensure complete drying after washing 1

2. Topical therapy based on suspected cause:

   • For fungal infection: Antifungal cream (clotrimazole, miconazole) applied 2-3 times daily for 7-10 days 2, 1
   • For bacterial infection: Topical antiseptic solutions or gels 2
   • For mild inflammation: Topical corticosteroid with low potency may be considered 5

Second-Line Treatment

If no improvement after 3-5 days of first-line treatment:

1. Combination therapy:

   • Topical antifungal plus low-potency corticosteroid 5
   • Consider topical antibiotics if bacterial infection is suspected 2

2. Oral therapy:

   • For severe or recurrent fungal infections: Consider oral antifungal therapy 1
   • For bacterial infections not responding to topical treatment: Appropriate oral antibiotics based on culture results 2

Refractory Cases

For cases that don't respond to medical management:

1. Evaluation for underlying causes:

   • Consider diabetes or immunosuppression 1
   • Rule out other dermatological conditions like lichen sclerosus 5

2. Surgical intervention:

   • Circumcision is the definitive treatment for recurrent or chronic posthitis 1, 3
   • For patients who wish to preserve the foreskin, preputial plasty techniques may be considered 6

Special Considerations

In Children

• Baths or local antiseptics are recommended as first-line treatment 2
• Avoid traumatic manipulation of the foreskin 2
• Topical corticosteroids may help with associated phimosis 6
• Circumcision should be considered for recurrent episodes 1

In Adults with Phimosis

• Gentle retraction of the foreskin during treatment if possible 3
• If phimosis prevents proper cleaning or treatment application, surgical options should be discussed 3

Prevention

• Regular gentle cleansing under the foreskin with warm water 1
• Complete drying after washing 1
• Avoiding irritating soaps or chemicals 1
• Circumcision provides definitive prevention of posthitis 1, 3

Follow-up

• Improvement should be seen within 3-5 days of appropriate treatment 2
• If no improvement occurs, reevaluation with possible culture and sensitivity testing is warranted 2
• Consider referral to urology for recurrent cases or if surgical intervention is being considered 3

Common Pitfalls

• Failing to identify and treat the underlying cause (fungal vs. bacterial) 1
• Overuse of topical corticosteroids leading to skin atrophy 5
• Inadequate hygiene measures during and after treatment 1
• Missing other diagnoses such as penile cancer, especially in older adults with persistent symptoms 1