What is balanitis?

Balanitis: Definition, Diagnosis, and Management

Balanitis is inflammation of the glans penis, often involving the prepuce (balanoposthitis) in uncircumcised males, caused by various infectious and non-infectious etiologies. 1, 2

Epidemiology and Risk Factors

• Balanitis is a common condition, affecting approximately 10.7% of men attending sexually transmitted disease clinics 3
• Risk factors include poor hygiene, phimosis, diabetes, immunocompromised states, and being uncircumcised 4, 5
• Balanitis is associated with a 2-9% risk of developing penile carcinoma in cases of chronic inflammation, particularly with lichen sclerosus (balanitis xerotica obliterans) 4, 1

Etiology

• Infectious causes (most common):
  • Fungal: Candida species (most frequent infectious cause) 1, 3
  • Bacterial: Staphylococcus species, Streptococcus groups B and D 3, 6
  • Viral and other sexually transmitted infections 2
• Non-infectious causes:
  • Dermatological conditions: Lichen sclerosus, psoriasis, lichen planus 2, 7
  • Contact dermatitis from irritants or allergens 2
  • Medication-related: SGLT2 inhibitors like Jardiance can increase risk due to glycosuria 8

Clinical Presentation

• Erythematous areas on the glans penis 1, 8
• Pruritus or irritation 1, 8
• Possible pain, tenderness, and edema 6
• In severe cases: erosions, exudate, and ulcerations 6

Diagnosis

• Clinical examination often reveals non-specific inflammatory changes 3
• Diagnostic workup may include:
  • Culture studies to identify infectious agents 3
  • Biopsy for persistent, suspicious, or pigmented lesions to rule out malignancy 1
  • STI screening in appropriate cases 1

Treatment Algorithm

1. First-line treatment for candidal balanitis:

   • Topical antifungal agents: miconazole 2% cream twice daily for 7 days or tioconazole 6.5% ointment as a single application 1, 8
   • For severe or resistant cases: oral fluconazole 150 mg as a single dose 1, 8

2. For bacterial balanitis:

   • Appropriate antibiotics based on culture and sensitivity 6

3. For lichen sclerosus (balanitis xerotica obliterans):

   • Topical clobetasol propionate 0.05% cream twice daily for 2-3 months 1
   • Long-term follow-up due to risk of progression to squamous cell carcinoma 1

4. General measures for all types:

   • Proper genital hygiene: gentle cleansing with warm water, avoiding strong soaps 1, 9
   • Keeping the area dry after washing 9
   • Evaluation for underlying conditions such as diabetes 1, 9

5. For recurrent or resistant cases:

   • Consider circumcision as definitive treatment, especially in uncircumcised males with recurrent episodes 2, 5
   • Evaluation and potential treatment of sexual partners for candidal infections 1

Follow-up

• Recommended if symptoms persist or recur within 2 months 1, 8
• More aggressive evaluation for immunocompromised patients 1
• Regular monitoring for patients with lichen sclerosus due to malignancy risk 1

Complications and Prognosis

• If untreated, complications may include phimosis, urethral stenosis, sexual dysfunction, and malignancy 7
• Circumcision reduces balanitis risk by 68% and is associated with lower risk of penile cancer 5

Common Pitfalls

• Assuming all cases are candidal without appropriate testing 9
• Using combination antifungal-corticosteroid preparations without a clear diagnosis 9
• Neglecting to evaluate for underlying conditions in recurrent cases 1