Redness, Swelling of Head of Penis with White Discharge
Most Likely Diagnosis and First-Line Treatment
This presentation is most consistent with candidal balanitis, and you should start topical clotrimazole 1% cream or miconazole 2% cream applied to the glans 1-3 times daily for 7-14 days. 1
The white discharge strongly suggests a fungal etiology, as Candida albicans is the most frequently isolated organism in infectious balanitis, accounting for the majority of confirmed cases. 2
Initial Assessment: Rule Out Emergencies First
Before treating as simple balanitis, rapidly assess for these red flags that require urgent intervention:
- Fournier gangrene: Check for fever, severe pain disproportionate to exam findings, crepitus on palpation, or rapidly progressive tissue necrosis—these require immediate surgical debridement and broad-spectrum antibiotics. 1
- Penile fracture: Ask about trauma during intercourse, a cracking/snapping sound, immediate loss of erection, and look for penile ecchymosis—this requires urgent surgical exploration. 1
- Ischemic priapism: Assess whether the entire penile shaft is completely rigid and painful—this is a medical emergency requiring intracavernous treatment. 1
Treatment Algorithm
For Candidal Balanitis (Most Common)
- First-line topical therapy: Apply clotrimazole 1% cream or miconazole 2% cream to the glans 1-3 times daily for 7-14 days. 1
- Alternative topical options: Terconazole 0.4% cream for 7 days or tioconazole 6.5% ointment as a single application. 1
- Oral therapy for extensive/recurrent cases: Fluconazole 150 mg as a single oral dose. 1
- Partner treatment: Treat sexual partners if recurrent infections occur, as they may develop symptomatic balanitis. 1
When to Suspect Bacterial Infection Instead
Consider bacterial etiology if the discharge is purulent rather than white/cheesy, or if there are erosive, painful lesions with significant edema. 2, 3
For patients under 35 years (sexually transmitted organisms likely):
- Give ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days. 1
- Obtain cultures before starting antibiotics, including Gram stain of discharge and NAAT testing for N. gonorrhoeae and C. trachomatis. 1
For patients 35 years or older (enteric organisms more likely):
- Give ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days. 1
Mandatory Reassessment
- Reassess at 3 days: If no improvement, consider abscess requiring surgical drainage or atypical organisms. 1
- Abstain from sexual activity until treatment is completed and symptoms fully resolve. 1
Common Pitfalls to Avoid
- Don't use over-the-counter antifungals indefinitely: If symptoms persist beyond 2 months or worsen during treatment, stop empiric therapy and obtain cultures to confirm the diagnosis. 1
- Don't forget partner evaluation: Failure to evaluate and treat sexual partners for sexually transmitted causes leads to reinfection. 1
- Don't delay surgical consultation: If you suspect abscess formation, Fournier gangrene, or penile fracture, immediate surgical evaluation takes precedence over medical management. 1
- Don't assume the clinical appearance predicts the organism: The clinical presentation has little value in distinguishing between fungal and bacterial causes—culture confirmation is essential if initial therapy fails. 2
- Don't miss coexisting STIs: All patients with suspected sexually transmitted balanitis should have serologic testing for syphilis and appropriate cultures for gonorrhea performed at diagnosis. 4
Key Clinical Pearls
- Staphylococci and groups B and D streptococci are the most frequently isolated bacteria when bacterial balanitis occurs. 2
- Severe balanopreputial edema with purulent exudate suggests erosive streptococcal or staphylococcal balanitis requiring systemic antibiotics. 3
- Recurrent balanoposthitis despite appropriate medical therapy may indicate need for circumcision evaluation. 3