Balanitis

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Balanitis is inflammation of the glans penis ^[1]  and is a common condition affecting an estimated 3-11% of males. Balanitis can occur in males at any age. Morbidity is associated with the complications of phimosis. ^{[2, 3, 4]} Balanitis involving the foreskin and prepuce is termed balanoposthitis. According to European guidelines outlining the current management of balanoposthitis, the aims of management are to minimize sexual dysfunction and  urinary dysfunction, exclude penile cancer, treat premalignant disease, and diagnose and treat STIs.

Predisposing factors include poor hygiene and overwashing, use of over-the-counter medications, and nonretraction of the foreskin. ^[5]  Though uncommon, a complication of balanitis (usually only in recurrent cases) is constricting phimosis, or inability to retract the foreskin from the glans penis. Other complications of balanitis may include meatal stenosis and possible urethral strictures; urinary retention; and vesicoureteral reflux.

Balanitis xerotica obliterans (BXO), or penile lichen sclerosus, is a progressive sclerosing inflammatory dermatosis of the glans penis and foreskin. BXO is uncommon in children. ^{[2, 3, 4, 6, 7, 8, 9, 10]}

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. Though uncommon, complications of balanitis include phimosis and cellulitis. Meatal stenosis with urinary retention may rarely accompany balanitis. In very few cases, balanitis may contribute to the “buried penis syndrome.” Diabetes is the most common underlying condition associated with adult balanitis. ^{[11, 12, 13]}  Older age has been identified as a risk factor for candidal balanitis. Zoon’s balanitis is a disease of older men who are uncircumcised. ^[5]

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.

Bacitracin should be used for children, and clotrimazole in adults, and possibly a steroid cream.

(See the image below of balanitis xerotica obliterans.)

For additional information, see Medscape’s Urology Resource Center.

For excellent patient education resources, visit eMedicineHealth’s Men’s Health Center. Also, see eMedicineHealth’s patient education articles Foreskin Problems and Circumcision.

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].

Pugliese JM, Morey AF, Peterson AC. Lichen sclerosus: review of the literature and current recommendations for management. J Urol. 2007 Dec. 178(6):2268-76. [Medline].

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].

McGregor TB, Pike JG, Leonard MP. Pathologic and physiologic phimosis: approach to the phimotic foreskin. Can Fam Physician. 2007 Mar. 53(3):445-8. [Medline].

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].

Mark J Leber, MD, MPH Assistant Professor of Emergency Medicine in Clinical Medicine, Weill Cornell Medical College; Attending Physician, Lincoln Medical and Mental Health Center

Mark J Leber, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Anuritha Tirumani, MD Research Coordinator, Department of Emergency Medicine, Brooklyn Hospital Center

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: Received salary from Medscape for employment. for: Medscape.

Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

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

Edward Bessman, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Balanitis

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