Emergency Department Care

Patients presenting with balanitis but without phimosis should receive the following recommendations and treatment^{[5, 23]}:

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.^[24]
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.^[25]

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.^{[26, 27]}
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).^{[28, 29]}
Circumcision is not a preventive treatment of balanitis in those younger than 3 years.

Consult a urologist if a dorsal slit incision or circumcision is contemplated.

Deterrence/prevention of balanitis includes the following measures:

Proper personal hygiene
Control of diabetes and other chronic medical disorders
Weight reduction for patients who are obese

Medical 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

Guidelines

Lisboa C, Ferreira A, Resende C, Rodrigues AG. Infectious balanoposthitis: management, clinical and laboratory features. Int J Dermatol. 2009 Feb. 48(2):121-4. [Medline].
Kuehhas FE, Miernik A, Weibl P, Schoenthaler M, Sevcenco S, Schauer I, et al. Incidence of Balanitis Xerotica Obliterans in Boys Younger than 10 Years Presenting with Phimosis. Urol Int. 2012 Dec 29. [Medline].
Mohammed A, Shegil IS, Christou D, Khan A, Barua JM. Paediatric balanitis xerotica obliterans: an 8-year experience. Arch Ital Urol Androl. 2012 Mar. 84(1):12-6. [Medline].
Boksh K, Patwardhan N. Balanitis xerotica obliterans: has its diagnostic accuracy improved with time?. JRSM Open. 2017 Jun. 8 (6):2054270417692731. [Medline].
[Guideline] Edwards S, Bunker C, Ziller F, van der Meijden WI. 2013 European guideline for the management of balanoposthitis. Int J STD AIDS. 2014 May 14. 25 (9):615-626. [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. 2005 Jul-Aug. 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. 2003 Jan. 96(1):9-11. [Medline].
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Pradhan A, Patel R, Said AJ, Upadhyaya M. 10 Years' Experience in Balanitis Xerotica Obliterans: A Single-Institution Study. Eur J Pediatr Surg. 2018 Aug 21. [Medline].
Charlton OA, Smith SD. Balanitis xerotica obliterans: a review of diagnosis and management. Int J Dermatol. 2018 Oct 12. [Medline].
Kalra S, Chawla A. Diabetes and balanoposthitis. J Pak Med Assoc. 2016 Aug. 66 (8):1039-41. [Medline].
Snodgrass W, Blanquel JS, Bush NC. Recurrence after management of meatal balanitis xerotica obliterans. J Pediatr Urol. 2017 Apr. 13 (2):204.e1-204.e6. [Medline].
Plasma Cell Balanitis (Zoon's Balanitis). American Urological Association. Available at http://www.auanet.org/education/auauniversity/education-products-and-resources/pathology-for-urologists/penis/inflammatory-and-tumor-like-lesions/plasma-cell-balanitis-(zoons-balanitis). Accessed: September 24, 2018.
Johnsson KM, Ptaszynska A, Schmitz B, Sugg J, Parikh SJ, List JF. Vulvovaginitis and balanitis in patients with diabetes treated with dapagliflozin. J Diabetes Complications. 2013 Sep-Oct. 27(5):479-84. [Medline].
Njomnang Soh P, Vidal F, Huyghe E, Gourdy P, Halimi JM, Bouhanick B. Urinary and genital infections in patients with diabetes: How to diagnose and how to treat. Diabetes Metab. 2015 Aug 28. [Medline].
Borelli S, Lautenschlager S. [Differential diagnosis and management of balanitis]. Hautarzt. 2015 Jan. 66 (1):6-11. [Medline].
Celis S, Reed F, Murphy F, Adams S, Gillick J, Abdelhafeez AH, et al. Balanitis xerotica obliterans in children and adolescents: a literature review and clinical series. J Pediatr Urol. 2014 Feb. 10 (1):34-9. [Medline].
Hugh JM, Lesiak K, Greene LA, Pierson JC. Zoon's balanitis. J Drugs Dermatol. 2014 Oct. 13 (10):1290-1. [Medline].
Torchia D, Cappugi P. Photodynamic therapy for Zoon balanitis. Eur J Dermatol. 2014 Nov-Dec. 24 (6):707. [Medline].
Bakkour W, Chularojanamontri L, Motta L, Chalmers RJ. Successful use of dapsone for the management of circinate balanitis. Clin Exp Dermatol. 2014 Apr. 39 (3):333-5. [Medline].
Dayal S, Sahu P. Zoon balanitis: A comprehensive review. Indian J Sex Transm Dis. 2016 Jul-Dec. 37 (2):129-138. [Medline].
Homer L, Buchanan KJ, Nasr B, Losty PD, Corbett HJ. Meatal Stenosis in Boys following Circumcision for Lichen Sclerosus (Balanitis Xerotica Obliterans). J Urol. 2014 Jun 30. [Medline].
[Guideline] Pandya I, Shinojia M, Vadukul D, Marfatia YS. Approach to balanitis/balanoposthitis: Current guidelines. Indian J Sex Transm Dis. 2014 Jul-Dec. 35 (2):155-7. [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].
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. 2009 Jun. 5(3):181-5. [Medline].
Ashfield JE, Nickel KR, Siemens DR, MacNeily AE, Nickel JC. Treatment of phimosis with topical steroids in 194 children. J Urol. 2003 Mar. 169(3):1106-8. [Medline].
Marques TC, Sampaio FJ, Favorito LA. Treatment of phimosis with topical steroids and foreskin anatomy. Int Braz J Urol. 2005 Jul-Aug. 31(4):370-4; discussion 374. [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. 2006 Jun. 26(3):181-94. [Medline].
Van Howe RS. Neonatal circumcision and penile inflammation in young boys. Clin Pediatr (Phila). 2007 May. 46(4):329-33. [Medline].
Philippou P, Shabbir M, Ralph DJ, Malone P, Nigam R, Freeman A, et al. Genital lichen sclerosus/balanitis xerotica obliterans in men with penile carcinoma: a critical analysis. BJU Int. 2013 May. 111(6):970-6. [Medline].
Buechner SA. Common skin disorders of the penis. BJU Int. 2002 Sep. 90(5):498-506. [Medline].
[Guideline] Edwards SK. European guideline for the management of balanoposthitis. Int J STD AIDS. 2001 Oct. 12 Suppl 3:68-72. [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. 2003 Sep. 96(9):449-51. [Medline]. [Full Text].
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Muratov ID. [Bacteriological pattern of acute purulent balanoposthitis in children]. Zh Mikrobiol Epidemiol Immunobiol. 2004 Mar-Apr. 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. 2005 Aug. 16(8):556-9. [Medline].