H. Henry Lai, MD, FACS
Gerald L. Andriole, MD, FACS
BASICS
DESCRIPTION
• Balanitis: Inflammation of the glans penis.
• Balanoposthitis: Inflammation of the foreskin and glans penis (affects uncircumcised men).
EPIDEMIOLOGY
Incidence
• Can occur at any age.
• No incidence studies of balanoposthitis have been reported in US.
– 1.5% of uncircumcised boys ages 0–15 were affected in a Japanese cohort.
Prevalence
• Common, the exact prevalence is unknown.
– Balanitis affects 11% of adult men and 3% of boys seen in urology clinics.
RISK FACTORS (1)
• Presence of a foreskin (uncircumcised)
• Tight foreskin (phimosis)
• Poor genital hygiene
• Intertrigo (see below)
• Sexual contact (with or without infection)
• Poorly controlled diabetes mellitus
• Immunocompromised host
• Coexisting penile cancer
Genetics
N/A
PATHOPHYSIOLOGY (2)
• The pathophysiology is usually different in young boys compared to adult men:
– Boys: From bacterial invasion of tissue
– Men: Combination of poor genital hygiene, intertrigo, irritant dermatitis, maceration injury, and bacterial, or candidal overgrowth
– Candida is the most common infectious cause
• Intertrigo refers to a condition in which damp, moist body areas are predisposed to inflammation:
– Involves genitals, inner thighs, underbelly
– Risk factors: Grossly overweight, diabetes, bed rest, diaper use, poor personal hygiene
– Skin dampness predisposes to secondary opportunistic bacterial or fungal overgrowth
• Balanitis xerotica obliterans (BXO) is a specific form of balanitis:
– Chronic, progressive, fibrotic disease (a form of lichen sclerosis isolated to the penis)
– Elastin is replaced by collagen
– The skin around the meatus becomes white, featureless, contracted, causing meatal stricture
– BXO may spread to the foreskin and coronal sulcus. In extreme cases, the entire end of the penis is replaced by fibrotic tissue, becomes thickened and nonretractile, causing sexual and voiding issues (eg, weak stream, obstruction)
ASSOCIATED CONDITIONS
Diabetes mellitus
GENERAL PREVENTION
• Maintain good genital hygiene
• Retraction of foreskin to clean the glans
• Keep the glans and foreskin dry
• Circumcision
• Safe sexual contact
• Manage risk factors (eg, glycemic control)
DIAGNOSIS
HISTORY
• Symptoms may include: Pain, discharge, irritation, voiding symptom (dysuria, weak stream)
• Prior episodes and treatment
• Uncircumcised
• Foreskin retractability
• Genital hygiene habits
• Sexual contacts, sexually transmitted diseases
• Other systemic risk factors (eg, diabetes)
PHYSICAL EXAM
• Inspection (ulcers, mass, genital pus, edema)
• Palpation (tenderness, induration, mass)
• Inguinal lymph nodes should be nonpalpable
DIAGNOSTIC TESTS & INTERPRETATION
Lab
Swab of glans/foreskin for viral, bacterial, and fungal culture
Imaging
N/A
Diagnostic Procedures/Surgery
• Potassium hydroxide and Tzanck preparation for men
– Potassium hydroxide smear evaluates for fungus
– Tzanck preparation for herpes virus
Pathologic Findings
• Biopsy is indicated for:
– Balanitis that persists and in which the cause remains unclear warrants biopsy to rule out coexisting neoplasm or premalignant lesions
– For definitive diagnosis of BXO
DIFFERENTIAL DIAGNOSIS
• Fixed drug eruption (allergy)
• Contact dermatitis
• Squamous cell carcinoma of the penis
• Carcinoma in situ of the penis
• Zoon (plasma cell) balanitis
• Psoriasis
• Reiter syndrome (Reactive arthritis/reactive arthritis triad) (with circinate balanitis)
• Human papilloma virus
TREATMENT
GENERAL MEASURES
• Meticulous genital hygiene
• Keep the glans and foreskin clean and dry
• Expose the glans to air as often as possible
• Avoid excessive dampness in the genitals
• Avoid soaps while inflammation is present
• Cleaning with soap and water routinely
• Manage risk factors (eg, glycemic control)
MEDICATION
Treatment depends on the underlying cause (infectious vs. inflammatory) and organisms
First Line
• Candidal infection: The most common cause of infectious balanitis
– Clotrimazole cream 1%
– Miconazole cream 2%
– Apply BID until symptoms resolve
– Oral fluconazole if symptoms are severe
– Nystatin cream if allergic to imidazole
– Imidazole with hydrocortisone if inflammation
• Anaerobic infection:
– Metronidazole 400 BID for 1 wk
– Optimal dosage schedule is unknown
– Alternatively, amoxicillin/clavulanic acid PO or clindamycin topically
• Aerobic infection:
– Group A streptococci, Staphylococcus aureus, Gardnerella vaginalis are all reported cases of balanitis.
– Treatment based on sensitivity of the culture (topical antibiotics, occasionally oral antibiotics)
• BXO:
– Topical steroids (clobetasol propionate or betamethasone valerate) offers limited efficacy
• Zoon (plasma cell) balanitis:
– Topical steroids with or without antibacterial cream
• Circinate balanitis (Reiter syndrome):
– Hydrocortisone cream 1% apply BID
– Treatment of associated infection
• Irritant, allergic balanitis:
– Avoid exposure to irritants especially soaps
– Emollients aqueous cream: Apply PRN and used as a soap substitute while inflammation is present
– Hydrocortisone 1% apply QD or BID until symptoms resolve
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Circumcision is reserved for recurrent balanitis, balanoposthitis, or phimosis that have failed conservative treatments.
• Occasionally dorsal slit may be performed.
• For BXO that does not respond to steroid:
– Periodical self-dilation with tapered dilators
– Dilation by urologists
– Formal surgical reconstructive repair
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
N/A
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Can be recurrent or persistent
• 10% recurrence rate
• Some patients may require circumcision to prevent recurrence and ensure resolution.
COMPLICATIONS
• Abscess formation
• Penile cellulitis
• Progression to Fournier gangrene
• Scarring and subsequent phimosis
FOLLOW-UP
Patient Monitoring
• After an acute episode and treatment is implemented, patients should be seen again to ensure resolution of symptoms and infection.
– Progression to cellulitis or gangrene may occur in diabetic patients with genital infection.
• Follow closely with genital dysplasia among those men with condyloma with a history of balanoposthitis than those with no such history.
Patient Resources
N/A
REFERENCES
1. Vohra S, Badlani G. Balanitis and balanoposthitis. Urol Clin North Am. 1992;19(1):143–147.
2. Edwards S. Balanitis and balanoposthitis: A review. Genitourin Med. 1996;72(3):155–159.
ADDITIONAL READING
Wikström A, Hedblad MA, Syrjänen S. Human papillomavirus-associated balanoposthitis–a marker for penile intraepithelial neoplasia? Int J STD AIDS. 2013;24(12):938–943.
See Also (Topic, Algorithm, Media)
• Balanitis and balanoposthitis Image 
• Balanitis Xerotica Obliterans
• Balanitis, Zoon (Plasma Cell Balanitis)
• Lichen Sclerosis Et Atrophicus
• Penis, Lesion
CODES
ICD9
• 605 Redundant prepuce and phimosis
• 607.1 Balanoposthitis
• 607.81 Balanitis xerotica obliterans
ICD10
• N47.1 Phimosis
• N47.6 Balanoposthitis
• N48.1 Balanitis
CLINICAL/SURGICAL PEARLS
• Maintaining good genital hygiene is a key preventive strategy (keep the foreskin and glans clean and dry).
• Underlying risk factors should also be managed (eg, glycemic control in diabetes).
• Treatment depends on the underlying cause (infectious vs. inflammatory) and organisms.
• Circumcision is reserved for recurrent balanitis, balanoposthitis, or phimosis that have failed conservative treatments.
• Balanitis that persists and if the cause remains unclear warrants biopsy to rule out coexisting neoplasm or premalignant lesions.