Balanitis in Emergency Medicine Treatment & Management

  • Author: Mark J Leber, MD, MPH, FACEP; Chief Editor: Erik D Schraga, MD   more...
 
Updated: Feb 11, 2011
 

Emergency Department Care

  • Patients presenting with balanitis but without phimosis should receive the following recommendations and treatment:
    • Gentle retraction of 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 of antifungals may be attempted; the patient or mother should retract the foreskin gently and apply 0.05% betamethasone twice a day. This applies to children older than 3 years. Success is seen particularly in male children older than 10 years compared with those aged 3-10 years. Success ranges from 65-95%.
    • Topical steroids have had only limited success in patients with moderate-to-severe balanitis xerotica obliterans. These patients are more likely to have distal scarring of the foreskin.
    • In recurrent cases, 1% pimecrolimus cream was used instead of steroids, with a 64% success rate.[2]
    • 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 complicated cases such as those with associated cellulitis, then treat empirically with appropriate antibiotics (typically first-generation cephalosporin).
    • A study of 1185 boys concluded that fluticasone proprionate 0.05% was effective and safe in treating associated phimosis, with successful results in 91.1% of patients.[3]
  • Patients presenting to the ED with phimosis and severe urinary obstruction as a complication of balanitis should receive the following care (recommended that surgical intervention be performed by a urologist, if available):
    • Steroid cream and gentle retraction of the foreskin, if the phimosis is not too tight, may be used before surgery is contemplated.[4, 5]
    • 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).[6, 7]
    • Circumcision is not a preventative treatment of balanitis in those younger than 3 years old.
Next

Consultations

  • Consult a urologist if a dorsal slit incision or circumcision is contemplated.
Previous
Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Mark J Leber, MD, MPH, FACEP  Attending Physician and Faculty, Department of Emergency Medicine and Residency Program, Lincoln Medical and Mental Health Center

Mark J Leber, MD, MPH, FACEP 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.

Specialty Editor Board

Edward Bessman, MD  Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: eMedicine Salary Employment

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.

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  Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

References

  1. Lisboa C, Ferreira A, Resende C, Rodrigues AG. Infectious balanoposthitis: management, clinical and laboratory features. Int J Dermatol. Feb 2009;48(2):121-4. [Medline].

  2. Georgala S, Gregoriou S, Georgala C, et al. Pimecrolimus 1% cream in non-specific inflammatory recurrent balanitis. Dermatology. 2007;215(3):209-12. [Medline].

  3. Zavras N, Christianakis E, Mpourikas D, Ereikat K. Conservative treatment of phimosis with fluticasone proprionate 0.05%: a clinical study in 1185 boys. J Pediatr Urol. Jun 2009;5(3):181-5. [Medline].

  4. 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].

  5. 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].

  6. 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].

  7. Van Howe RS. Neonatal circumcision and penile inflammation in young boys. Clin Pediatr (Phila). May 2007;46(4):329-33. [Medline].

  8. Buechner SA. Common skin disorders of the penis. BJU Int. Sep 2002;90(5):498-506. [Medline].

  9. Edwards S. Balanitis and balanoposthitis: a review. Genitourin Med. Jun 1996;72(3):155-9. [Medline].

  10. [Guideline] Edwards SK. European guideline for the management of balanoposthitis. Int J STD AIDS. Oct 2001;12 Suppl 3:68-72. [Medline].

  11. Harrison BP. Pediatric penile swelling. Acad Emerg Med. Apr 1996;3(4):384, 87, 88. [Medline].

  12. 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].

  13. 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].

  14. 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].

  15. 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].

  16. Muratov ID. [Bacteriological pattern of acute purulent balanoposthitis in children]. Zh Mikrobiol Epidemiol Immunobiol. Mar-Apr 2004;83-5. [Medline].

  17. 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].

  18. 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].

  19. Tanagho EA. Smith's General Urology. 14th ed. New York: McGraw-Hill; 1995:966.

 
Previous
Next
 
Balanitis xerotica obliterans (lichen sclerosus). Courtesy of Wilford Hall Medical Center Slide collection.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.