eMedicine Specialties > Emergency Medicine > Genitourinary
Balanitis: Treatment & Medication
Updated: Nov 5, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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.
Adult
Apply sparingly over affected area tid
Pediatric
<3 years: Not established
>3 years: Apply as in adults
None reported
Documented hypersensitivity
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.
Adult
Apply sparingly over affected area tid
Pediatric
Apply as in adults
None reported
Documented hypersensitivity
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.
Adult
Apply as thin film bid
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; paronychia; cellulitis; impetigo; angular cheilitis; erythrasma; erysipelas; rosacea; perioral dermatitis; acne
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.
Adult
Apply topically to penis bid; short-term and intermittent use only
Pediatric
Not established
None reported
Documented hypersensitivity
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
More on Balanitis |
| Overview: Balanitis |
| Differential Diagnoses & Workup: Balanitis |
 Treatment & Medication: Balanitis |
| Follow-up: Balanitis |
| References |
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References
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Further Reading
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
