Balanitis
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Balanitis
Balanitis is inflammation of the glans penis. When it also involves the prepuce (foreskin), it is called balanoposthitis. It is among the most common penile conditions, occurring predominantly in uncircumcised males.
Etiology & Classification
| Type | Causative Agent / Mechanism | Key Features |
|---|---|---|
| Candidal (most common) | Candida albicans | Satellite lesions, white discharge, associated with diabetes/immunosuppression |
| Bacterial | S. aureus, Streptococcus spp. (A, B, D), anaerobes | Purulent discharge, cellulitis |
| Aerobic/Mixed | Polymicrobial | Subpreputial discharge, malodor |
| Circinate balanitis | Reactive arthritis (formerly Reiter's syndrome) | Painless, superficial erosions; associated with urethritis, arthritis, uveitis |
| Plasma cell (Zoon's) | Idiopathic, chronic | Moist, well-demarcated, orange-red patches on glans; older uncircumcised men |
| Lichen sclerosus (BXO) | Autoimmune | White, sclerotic plaques; risk of meatal stenosis and phimosis |
| Lichen planus | Autoimmune | Purple polygonal papules/erosions |
| Psoriatic | Psoriasis | Well-defined erythematous plaques; may lack silvery scale on glans |
| Fixed drug eruption | Drug hypersensitivity (NSAIDs, tetracyclines, sulfonamides) | Recurrent, same site with drug re-exposure |
| Contact/irritant | Soaps, spermicides, latex, antiseptics | History of exposure, resolves on removal |
| Premalignant/Malignant | Erythroplasia of Queyrat, Bowen's disease, SCC | Persistent red velvety plaque; biopsy mandatory |
Risk Factors
- Phimosis (tight foreskin trapping secretions/smegma)
- Diabetes mellitus (promotes candidal and bacterial growth)
- Poor genital hygiene
- Uncircumcised status
- Immunosuppression (HIV, steroids, chemotherapy)
- Obesity
- Sexual transmission (candidal or STI-related)
Clinical Presentation
Symptoms:
- Soreness, itching, burning of the glans
- Dysuria
- Subpreputial discharge
- Difficulty retracting the foreskin
Signs:
- Erythema, oedema of the glans ± prepuce
- Erosions, fissures, or ulceration (depending on type)
- White plaques or exudate (Candida)
- Phimosis (acute or chronic)
Diagnosis
Primarily clinical, supported by:
- Subpreputial swab – culture for Candida, bacteria (Streptococcus spp., S. aureus, anaerobes), and STIs (Trichomonas, gonorrhoea)
- Urinalysis + fasting glucose – screen for diabetes
- STI screen – if sexually transmitted aetiology suspected (HSV, syphilis, gonorrhoea)
- Biopsy – mandatory for persistent, atypical, or non-healing lesions to exclude malignancy or lichen sclerosus
(Management of Balanoposthitis, p. 4)
Management
General Measures (All Types)
- Hygiene advice: gentle retraction and cleaning with water only (avoid soaps)
- Avoid irritants: soaps, lotions, latex
- Glycaemic control in diabetics
Specific Treatment
| Type | Treatment |
|---|---|
| Candidal | Topical clotrimazole 1% cream BD for 7–14 days; sexual partner treatment if symptomatic (STI Guidelines, p. 95) |
| Bacterial | Topical fusidic acid or oral flucloxacillin; metronidazole if anaerobes suspected |
| Mixed/non-specific | Saline soaks, topical antibacterial/antifungal combinations |
| Circinate (reactive) | Topical steroids; treat underlying condition |
| Zoon's plasmacellularis | Topical steroids; circumcision is curative |
| Lichen sclerosus (BXO) | Potent topical steroids (clobetasol propionate); circumcision often required |
| Psoriasis/Lichen planus | Mild-moderate topical corticosteroids |
| Contact/irritant | Remove irritant; mild topical steroid if needed |
| Fixed drug eruption | Identify and withdraw offending drug |
Surgical
- Circumcision – indicated for recurrent balanitis, phimosis, Zoon's balanitis, or BXO; highly effective in reducing recurrence
Complications
- Phimosis (scarring → inability to retract foreskin)
- Paraphimosis (retracted foreskin cannot be returned — urological emergency)
- Meatal stenosis (particularly with BXO)
- Urinary retention
- Penile carcinoma – long-standing chronic inflammation (especially BXO, HPV-related) is a risk factor
Differentials to Exclude
- Erythroplasia of Queyrat / Bowen's disease (carcinoma in situ)
- Penile squamous cell carcinoma
- Herpes simplex (painful vesicles/ulcers)
- Syphilitic chancre (painless ulcer)
- Behçet's disease
Key takeaway: Most acute balanitis responds well to topical antifungals or antibiotics plus improved hygiene. Persistent, atypical, or recurrent cases require biopsy to exclude premalignant/malignant pathology, and circumcision should be considered for recurrent disease.
Phimosis
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Phimosis
Phimosis is the inability to retract the prepuce (foreskin) proximally over the glans penis. It is classified as physiological or pathological, and the distinction determines management.
Classification
1. Physiological Phimosis
- Normal developmental finding in infants and young children
- At birth, ~96% of males have a non-retractile foreskin due to natural adhesions between the glans and inner prepuce
- Spontaneous resolution rates:
- By age 1: ~50% retractile
- By age 10: ~50% fully retractile
- By age 17: ~99% fully retractile
- No treatment required unless symptomatic or associated with urogenital abnormalities (Paediatric Urology, p. 12)
2. Pathological Phimosis
- Results from scarring or fibrosis of the prepuce
- Most common cause: Lichen sclerosus (BXO — Balanitis Xerotica Obliterans)
- Other causes: recurrent balanitis, forcible retraction, trauma, chronic inflammation
- Characterised by a white, scarred, inelastic ring at the preputial tip
- Does not resolve spontaneously — requires intervention
Grading (Kikiros Scale)
| Grade | Description |
|---|---|
| 0 | Full retraction — no phimosis |
| 1 | Full retraction, tight behind glans |
| 2 | Partial exposure of glans |
| 3 | Partial retraction, meatus just visible |
| 4 | Slight retraction, but neither meatus nor glans visible |
| 5 | Absolutely no retraction |
Clinical Features & Presentation
Symptoms:
- Difficulty or inability to retract foreskin
- Ballooning of the foreskin during micturition
- Dysuria or poor urinary stream (in severe cases)
- Painful erections or dyspareunia (in adults)
- Recurrent balanitis or posthitis
Signs:
- Non-retractile foreskin
- White/scarred preputial ring (pathological — suggests BXO)
- Erythema or fissuring at preputial tip
- Meatal stenosis (in BXO)
Diagnosis
Primarily clinical. Investigations where indicated:
- Urinalysis / uroflowmetry — if obstructive voiding symptoms
- Subpreputial swab — if concurrent balanitis
- Biopsy — if BXO/lichen sclerosus suspected (white scarred ring) or to exclude malignancy
- Blood glucose — screen for diabetes in recurrent cases
Management
Conservative (First-Line for Pathological Phimosis)
Topical corticosteroids are the mainstay of non-surgical treatment:
- Agent: Betamethasone 0.05–0.1% cream (Class 4 corticosteroid) applied twice daily for 4–8 weeks
- Technique: apply directly onto the narrow preputial ring under gentle retraction
- Success rate: >80% (Paediatric Urology, p. 12)
- Recurrence rate: up to 17% — prevented by continuing daily foreskin retraction after treatment
- Lower-potency corticosteroids may be nearly as effective
- If BXO suspected, dermatology referral should be considered as response rates are lower
Surgical
| Procedure | Description | Indication |
|---|---|---|
| Circumcision | Complete removal of the prepuce | BXO, failed medical therapy, recurrent balanitis, patient/parent preference |
| Preputioplasty | Foreskin-preserving widening (dorsal slit ± closure) | Mild–moderate pathological phimosis; desire to preserve foreskin |
| Dorsal slit | Longitudinal incision of prepuce | Acute/emergency access; rarely used as definitive procedure |
- Circumcision is curative and eliminates recurrence
- Preputioplasty preserves the foreskin but has a higher recurrence rate than circumcision
Complications of Untreated Phimosis
| Complication | Notes |
|---|---|
| Paraphimosis | Retracted foreskin trapped behind glans — urological emergency; causes glans oedema and potential ischaemia |
| Urinary retention / obstructive uropathy | Severe phimosis with pin-hole meatus |
| Recurrent balanitis | Stagnant secretions under foreskin |
| Sexual dysfunction | Painful erections, inability to have intercourse |
| Penile carcinoma | Chronic inflammation (especially BXO) is a recognised risk factor |
Paraphimosis — Emergency Management
When a tight retracted foreskin cannot be reduced:
- Manual compression of the glans (reduce oedema) + firm traction on prepuce
- Topical hyaluronidase or ice packs to reduce oedema
- Dorsal slit under local anaesthesia if manual reduction fails
- Elective circumcision after the acute episode resolves
Special Considerations
- Forcible retraction in children should be avoided — causes trauma, scarring, and may convert physiological into pathological phimosis
- BXO requires aggressive management (potent steroids + circumcision); has a small association with penile SCC
- In adults, pathological phimosis rarely resolves without intervention
Key takeaway: Physiological phimosis in children requires reassurance only. Pathological phimosis warrants a trial of topical betamethasone (>80% success); surgical options (circumcision or preputioplasty) are reserved for refractory cases, BXO, or patient preference.
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