eMedicine Specialties > Emergency Medicine > Genitourinary
Balanitis
Updated: Nov 5, 2008
Introduction
Background
Balanitis is inflammation of the glans penis. Balanitis involving the foreskin and prepuce is termed balanoposthitis. The most common complication of balanitis is phimosis, or inability to retract the foreskin from the glans penis.
For additional information, see Medscape's Urology Resource Center.
Pathophysiology
Uncircumcised men with poor personal hygiene are most affected by balanitis. Lack of aeration and irritation because of smegma and discharge surrounding the glans penis causes inflammation and edema. Adherence of the foreskin to the inflamed and edematous glans penis causes phimosis, which is the major presenting complication of balanitis seen in the ED. Meatal stenosis with urinary retention may accompany balanitis. In rare cases, balanitis may contribute to the "buried penis syndrome."
Frequency
United States
Balanitis is a common condition affecting 11% of adult men seen in urology clinics and 3% of children. Phimosis, an occasional complication of balanitis, can be seen in a majority of children younger than 3 years.
International
Balanitis may occur in up to 3% of uncircumcised males worldwide.
Mortality/Morbidity
No mortality is associated with balanitis. Morbidity is associated with the complications of phimosis.
Race
Among adult patients seen at Veterans Administration Hospital clinics, balanitis is seen twice as often in blacks and Hispanics. This may be related to different circumcision rates.
Age
Balanitis can occur in males at any age. Etiologies vary depending on age.
Clinical
History
Patients with balanitis usually present with the following complaints:
- Penile discharge
- Inability to retract foreskin
- Impotence
- Difficulty urinating or controlling urine stream (in very severe cases)
- Inability to insert a Foley catheter
- Tenderness of the glans penis
- Itching
- Recurrent UTIs in male children
Physical
Physical examination findings may include the following:
- Erythema and edema of glans penis or foreskin
- Inability to visualize glans penis or urethral meatus
- Discharge
- Ulceration and/or plaques
- Phimosis
- Meatal stenosis
- Bladder distension
- Ballooning of the foreskin when voiding
- Lymph node involvement
Causes
- Diabetes is the most common underlying condition associated with adult balanitis.
- Other causes include the following:
- Poor personal hygiene
- Chemical irritants (eg, soap, petroleum jelly)
- Edematous conditions, such as congestive heart failure (right-sided), cirrhosis, and nephrosis
- Drug allergies (eg, tetracycline, sulfonamide)
- Morbid obesity
- Several organisms and viruses cause balanitis, including the following:
- Candidal species (most commonly associated with diabetes)
- Anaerobic infection
- Human papilloma virus
- Gardnerella vaginalis
- Treponema pallidum (syphilis)
- Trichomonal species
- Group B and group A streptococci
- Borrelia vincentii and Borrelia burgdorferi
- Penile cancer
- Balanitis xerotica obliterans (lichen sclerosus) - This is a chronic dermatosis identified by whitish plaques involving the glans and foreskin.
- Zoon balanitis - Reddish velvety lesion on the glans
- Reiter disease - Circinate and eroding lesions on the glans
Differential Diagnoses
Candidiasis
Psoriasis
Other Problems to Be Considered
Leukoplakia
Balanitis xerotica obliterans (lichen sclerosis)
Reiter syndrome
Zoon balanitis
Workup
Laboratory Studies
Laboratory studies for balanitis may include the following:
- Serum glucose test - As part of a comprehensive diabetes workup
- Culture of discharge
- Syphilis serology test
- Wet mount
- KOH looking for Candida
- HIV and HPV titers in selected cases
Imaging Studies
- Ultrasonography to detect urinary obstruction in severe balanitis
Other Tests
- Referral to a urologist for biopsy in chronic cases
Treatment
Emergency Department Care
- Patients presenting with balanitis but without phimosis should receive the following recommendations and treatment:
- Retract the foreskin daily and soak in warm water to clean penis and foreskin.
- In pediatric patients and patients with mild balanitis xerotica, a 2-month trial may be attempted, having the patient or the mother retract the foreskin gently and applying 0.05% betamethasone twice a day. This applies to children older than 3 years. Success was seen particularly in male children older than 10 years compared with those aged 3-10 years. Success ranged from 65-95%.
- Topical steroids had only limited success in patients with moderate-to-severe balanitis xerotica obliterans. These patients have distal scarring of the foreskin.
- In recurrent cases, 1% pimecrolimus cream was used instead of steroids with a 64% success rate.
- Apply bacitracin (not Neosporin) for pediatric patients if bacterial infection is suspected.
- Apply topical clotrimazole for adult men with probable candidal balanitis.
- Obtain a culture of discharge in unusual cases, then treat the infection with appropriate antibiotics.
- Patients presenting to the ED with phimosis as a complication of balanitis should receive the following care:
- Steroid cream and gentle retraction of the foreskin, if the phimosis is not too tight, may be used before surgery is contemplated.
- Without damaging the glans penis, dilate the foreskin using a clamp. If the glans penis is adherent to the foreskin, the procedure may be contraindicated. Local anesthesia, analgesia, and/or sedation may be required.
- Perform a dorsal slit incision by cutting the foreskin over the dorsal shaft of the penis to enlarge the foreskin opening. This procedure requires local anesthesia and, possibly, sedation.
- Perform a formal circumcision (preferably in the operating room).
- Circumcision is not a preventative treatment of balanitis in those younger than 3 years old.
Consultations
Consult a urologist if a dorsal slit incision or circumcision is contemplated.
Medication
The goal of therapy is to eradicate infection and prevent complications.
Antimicrobial agents (topical)
Therapy must cover all likely pathogens in the context of the clinical setting.
Clotrimazole (Mycelex, Lotrimin)
Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability. For adult use, especially those with a positive history of candidiasis in a sexual partner.
Dosing
Adult
Apply sparingly over affected area tid
Pediatric
<3 years: Not established
>3 years: Apply as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
For external use only; avoid contact with eyes; if irritation or sensitivity develops, discontinue use and institute appropriate therapy
Bacitracin (AK-Tracin)
Prevents transfer of mucopeptides into growing cell wall, which inhibits cell wall synthesis and bacterial growth. More commonly used in pediatric patients or patients who are not sexually active.
Dosing
Adult
Apply sparingly over affected area tid
Pediatric
Apply as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Prolonged use may result in overgrowth of nonsusceptible organisms
Corticosteroids, topical
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
Betamethasone 0.05% (Alphatrex, Diprolene, Maxivate)
For treatment of inflammatory dermatoses responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Affects production of lymphokines and has inhibitory effect on Langerhans cells.
Dosing
Adult
Apply as thin film bid
Pediatric
Apply as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity; paronychia; cellulitis; impetigo; angular cheilitis; erythrasma; erysipelas; rosacea; perioral dermatitis; acne
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use in skin with decreased circulation; can cause atrophy of groin, face, and axillae; may cause striae distensae, rosacealike eruption; may increase skin fragility; rarely may suppress HPA axis; if infection develops and is not responsive to antibiotic treatment, discontinue until infection is under control; do not use monotherapy to treat widespread plaque psoriasis
Treatment must be monitored by physician with expertise in treating balanitis
Immunosuppressant agents
Regulates key factors responsible for the immune response.
Pimecrolimus (Elidel cream)
First nonsteroid cream approved in the US for mild-to-moderate atopic dermatitis. Derived from ascomycin, a natural substance produced by fungus Streptomyces hygroscopicus var. ascomyceticus. Selectively inhibits production and release of inflammatory cytokines from activated T-cells by binding to cytosolic immunophilin receptor macrophilin-12. The resulting complex inhibits phosphatase calcineurin, thus blocking T-cell activation and cytokine release. Cutaneous atrophy was not observed in clinical trials, a potential advantage over topical corticosteroids. Indicated only after other treatment options have failed.
Dosing
Adult
Apply topically to penis bid; short-term and intermittent use only
Pediatric
Not established
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Potential exacerbation of existing infection at site of application; may cause burning and irritation; caution with conditions that suppress the immune system (eg, AIDS, cancer); possible risk of lymph node or skin cancer based on animal studies and a small number of patients; may increase risk of viral infections; other adverse effects include headache, sore throat, flulike symptoms, fever, and cough
Follow-up
Further Inpatient Care
- Observe the patient with balanitis for the following signs and symptoms:
- Signs of sepsis
- Uncontrolled diabetes
- Inability to retract foreskin
- Inability to urinate
Further Outpatient Care
- If the patient is able to retract the foreskin and does not have uncontrolled diabetes, he may be discharged to follow up with a urologist.
- Circumcision should only be suggested, if the patient fails outpatient conservative therapy, particularly in children.
- Patients should receive the following instructions:
- Topical therapy - Bacitracin in children and clotrimazole in adults and possibly a steroid cream
- Education - Improve personal hygiene by retracting the foreskin daily and cleaning the glans penis with water
Deterrence/Prevention
Deterrence/prevention of balanitis include the following measures:
- Proper personal hygiene
- Control of diabetes and other chronic medical disorders
- Weight reduction for patients who are obese
Complications
Complications of balanitis may include the following:
- Meatal stenosis and possible urethral strictures
- Urinary retention
- Vesico-ureteral reflux
Patient Education
- For excellent patient education resources, visit eMedicine's Men's Health Center. Also, see eMedicine's patient education articles Foreskin Problems and Circumcision.
Miscellaneous
Medicolegal Pitfalls
- Failure to consider diabetes as the most common underlying condition for balanitis
- Failure to correct phimosis
- Failure to consider carcinoma in elderly patients
- Failure to refer to urologist for recurrent balanitis
- Failure to consider that balanitis may involve the meatus
References
Ashfield JE, Nickel KR, Siemens DR, MacNeily AE, Nickel JC. Treatment of phimosis with topical steroids in 194 children. J Urol. Mar 2003;169(3):1106-8. [Medline].
Buechner SA. Common skin disorders of the penis. BJU Int. Sep 2002;90(5):498-506. [Medline].
Edwards S. Balanitis and balanoposthitis: a review. Genitourin Med. Jun 1996;72(3):155-9. [Medline].
Edwards SK. European guideline for the management of balanoposthitis. Int J STD AIDS. Oct 2001;12 Suppl 3:68-72. [Medline].
Georgala S, Gregoriou S, Georgala C, et al. Pimecrolimus 1% cream in non-specific inflammatory recurrent balanitis. Dermatology. 2007;215(3):209-12. [Medline].
Harrison BP. Pediatric penile swelling. Acad Emerg Med. Apr 1996;3(4):384, 87, 88. [Medline].
Huntley JS, Bourne MC, Munro FD, Wilson-Storey D. Troubles with the foreskin: one hundred consecutive referrals to paediatric surgeons. J R Soc Med. Sep 2003;96(9):449-51. [Medline].
Kiss A, Király L, Kutasy B, Merksz M. High incidence of balanitis xerotica obliterans in boys with phimosis: prospective 10-year study. Pediatr Dermatol. Jul-Aug 2005;22(4):305-8. [Medline].
Kizer WS, Prarie T, Morey AF. Balanitis xerotica obliterans: epidemiologic distribution in an equal access health care system. South Med J. Jan 2003;96(1):9-11. [Medline].
Marques TC, Sampaio FJ, Favorito LA. Treatment of phimosis with topical steroids and foreskin anatomy. Int Braz J Urol. Jul-Aug 2005;31(4):370-4; discussion 374. [Medline].
McGregor TB, Pike JG, Leonard MP. Pathologic and physiologic phimosis: approach to the phimotic foreskin. Can Fam Physician. Mar 2007;53(3):445-8. [Medline].
Muratov ID. [Bacteriological pattern of acute purulent balanoposthitis in children]. Zh Mikrobiol Epidemiol Immunobiol. Mar-Apr 2004;83-5. [Medline].
O'Farrell N, Quigley M, Fox P. Association between the intact foreskin and inferior standards of male genital hygiene behaviour: a cross-sectional study. Int J STD AIDS. Aug 2005;16(8):556-9. [Medline].
Pugliese JM, Morey AF, Peterson AC. Lichen sclerosus: review of the literature and current recommendations for management. J Urol. Dec 2007;178(6):2268-76. [Medline].
Steadman B, Ellsworth P. To circ or not to circ: indications, risks, and alternatives to circumcision in the pediatric population with phimosis. Urol Nurs. Jun 2006;26(3):181-94. [Medline].
Tanagho EA. Smith's General Urology. 14th ed. New York: McGraw-Hill; 1995:966.
Van Howe RS. Neonatal circumcision and penile inflammation in young boys. Clin Pediatr (Phila). May 2007;46(4):329-33. [Medline].
Keywords
balanitis, glans penis inflammation, inflammation of the glans penis, balanoposthitis, phimosis, penile discharge, inability to retract foreskin, impotence, tenderness of glans penis, diabetes, cirrhosis, nephrosis, candidal infection, anaerobic infection, human papilloma virus infection, Gardnerella vaginalis, Treponema pallidum, syphilis, trichomonal infection, group Bstreptococci, Borrelia vincentii
Contributor Information and Disclosures
Author
Mark J Leber, MD, MPH, Clinical Assistant Professor of Emergency Medicine, Weill Medical College of Cornell University; Consulting Staff, Department of Emergency Medicine, Brooklyn Hospital Medical Center
Mark J Leber, MD, MPH is a member of the following medical societies: American College of Emergency Physicians and American College of Physicians
Disclosure: Nothing to disclose.
Coauthor(s)
Anuritha Tirumani, MD, Research Coordinator, Department of Emergency Medicine, Brooklyn Hospital Center
Disclosure: Nothing to disclose.
Medical Editor
Edward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University
Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Pharmacy Editor
Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment
Managing Editor
Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
CME Editor
John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Chief Editor
Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.
© 1994-
by Medscape.
All Rights Reserved
(http://www.medscape.com/public/copyright)