What is the treatment for an inflamed glans penis?

Treatment of Inflamed Glans Penis (Balanitis)

For acute balanitis, initiate treatment with topical antifungal therapy (miconazole 2% cream twice daily for 7 days) as first-line management, since Candida species are the most common infectious cause. 1, 2

Initial Diagnostic Considerations

Before treating, assess these key clinical features:

• Appearance of lesions: erythematous patches with pruritus suggest candidal infection; erosive, painful lesions with purulent exudate indicate bacterial etiology 1, 3
• Circumcision status: uncircumcised males have significantly higher balanitis rates and different risk profiles 1
• Presence of white, scarred areas or fibrosis: suggests lichen sclerosus (balanitis xerotica obliterans), which requires different management and carries 2-9% malignancy risk 4, 1
• Underlying conditions: diabetes, immunocompromised states, and poor hygiene are major risk factors 1

Treatment Algorithm by Etiology

Candidal Balanitis (Most Common)

First-line options 1:

• Miconazole 2% cream applied twice daily for 7 days
• Tioconazole 6.5% ointment as single application
• Nystatin topical daily for 7-14 days 1

For severe or resistant cases: Fluconazole 150 mg oral tablet as single dose 1

Bacterial Balanitis

When erosive, painful lesions with purulent exudate are present 3, 2:

• Staphylococcal infections (including S. aureus and coagulase-negative staphylococci): oral ciprofloxacin plus topical mupirocin 3
• Streptococcal infections (groups B and D): systemic antibiotic therapy 2
• Culture-guided therapy is essential, as clinical appearance cannot reliably predict the causative organism 2

Lichen Sclerosus (Balanitis Xerotica Obliterans)

This diagnosis requires biopsy confirmation due to malignancy risk 1, 5:

• First-line: Clobetasol propionate 0.05% cream/ointment twice daily for 2-3 months 1, 5
• Maintenance therapy: 30-60g annually for ongoing disease 5
• Surgical management: Circumcision has 96% success rate when disease is limited to glans and foreskin; all removed tissue must undergo pathological examination to exclude squamous cell carcinoma 1, 5

Essential Supportive Measures

All patients require 1:

• Gentle cleansing with warm water only
• Avoidance of strong soaps and irritants
• Keeping area dry after washing
• Evaluation for diabetes in all cases

Follow-Up and Red Flags

Follow-up is mandatory if 1:

• Symptoms persist or recur within 2 months
• Lesions are pigmented, indurated, fixed, or ulcerated (requires biopsy) 1

Obtain cultures and consider biopsy when 1, 2:

• Initial treatment fails
• Recurrent episodes occur
• Clinical appearance is atypical
• Lichen sclerosus is suspected

Critical Pitfalls to Avoid

• Do not assume all inflammation is candidal: bacterial causes (especially staphylococci and streptococci) are the second most common etiology and require different treatment 2
• Do not miss lichen sclerosus: this condition requires long-term surveillance due to malignancy risk and will not respond to antifungal therapy 4, 1
• Do not use combination antifungal-corticosteroid preparations empirically: steroids worsen fungal infections if used without confirmed diagnosis 6
• Do not proceed to circumcision without adequate trial of medical therapy: many patients are unnecessarily referred for surgery when topical steroids would suffice 5

When to Refer

Immediate urology referral is indicated for 1, 5:

• Suspected malignancy (indurated, ulcerated, or fixed lesions)
• Lichen sclerosus with urethral involvement
• Failure of medical management after 1-3 months
• Recurrent episodes despite appropriate treatment