Emergency Department Care
Patients presenting with balanitis but without phimosis should receive the following recommendations and treatment [5, 23] :
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Gentle retraction of the foreskin daily and soak in warm water to clean penis and foreskin.
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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%.
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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.
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In recurrent cases, 1% pimecrolimus cream was used instead of steroids, with a 64% success rate. [24]
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Apply bacitracin (not Neosporin) for pediatric patients if bacterial infection is suspected.
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Apply topical clotrimazole for adult men with probable candidal balanitis.
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Obtain a culture of discharge in complicated cases such as those with associated cellulitis, then treat empirically with appropriate antibiotics (typically first-generation cephalosporin).
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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):
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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.
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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.
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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:
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Proper personal hygiene
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Control of diabetes and other chronic medical disorders
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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:
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Topical therapy - Bacitracin in children and clotrimazole in adults and possibly a steroid cream
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Education - Improve personal hygiene by retracting the foreskin daily and cleaning the glans penis with water
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Balanitis xerotica obliterans (lichen sclerosus). Courtesy of Wilford Hall Medical Center Slide collection.
