Keywords

FormalPara Key Points

  • Balanitis is usually a simple intertrigo with no specific aetiological agent.

  • In most cases, the course will be episodic with recurrences, unless specific care is taken to reverse the predisposing factors.

  • The vast majority of cases respond to simple measures:

    1. (a)

      Retraction of the foreskin

    2. (b)

      Saline baths

    3. (c)

      Simple drying powder

  • Topical antifungal creams give temporary relief only: powders are more effective.

  • Persisting lesions should be biopsied.

Definition and Epidemiology

Balanitis: Inflammation of the glans penis.

Balanoposthitis: Inflammation of the foreskin and surface of the underlying glans penis. Frequently occurs with a tight or not easily retracted foreskin, or phimosis. Usually a more acute and extensive local inflammation than simple balanitis.

Posthitis: inflammation of the preputial mucosa.

The term ‘balanitis’ is frequently used to include all of the above.

The condition is common in infancy when the prepuce is adherent, non-retractable and subject to moisture and contamination from urine and faeces.

It is very common in adulthood. It is not related to poor hygiene, but to intertrigo and accumulation of sub-prepuce secretions. It is equally frequent with overzealous, and even obsessive washing, causing irritation. Candida balanitis is a much less common cause of balanitis and is associated with diabetes mellitus. Sexual transmission is not described in the literature, but most physicians have clinical experience of balanitis occurring postcoitus with a woman who has either candida or bacterial vaginosis. It may be an indicator of sexual risk taking and as such warrants a full STD screen, unless risk is specifically denied.

Essentially, diagnosis is anatomical, but there are multiple causes.

Basic Concepts of Pathogenesis

The blind sub-prepuce sac gives a warm moist environment, with an accumulation of desquamated cells – smegma, an ideal culture medium. The epithelium of the glans penis is protected and covered, so that it remains moist, non-keratinised, thin and sensitive. In many respects, the male preputial sac is the equivalent of the vagina, a closed space, with a polymicrobial ecology and a similar susceptibility to overgrowth of microorganisms normally present to produce symptomatic conditions, and a similar predisposition to recurrence of these conditions.

Most commonly, balanitis is a simple intertrigo with no specific aetiological agent. The majority of cases are mild and may have mechanical or irritant associations. It may present after a recent regretted sexual encounter, where anxiety and increased awareness of genital sensations lead to closer scrutiny of the area. A full STD screening is mandatory in these circumstances.

With infective causes, a more acute inflammatory reaction may be seen, such as with infection/overgrowth of candida or anaerobes. Many dermatological conditions also affect the genital epithelium, where their clinical features may be atypical due to the different morphology of the epithelium.

Sexual transmission has been described with both candidal and anaerobic infections, but it is thought to be infrequent. Partner treatment does not markedly influence the risk of recurrence.

Clinical Presentation

Clinical presentation is variable and is frequently inversely related to guilt and anxiety. The anxious or guilty patient may present with symptoms of non-specific irritation, itching or burning of the glans/prepuce and little or no findings at all. Often there is just a minimal red spotty rash or some macules on the glans. Other patients may present with an obvious red inflamed glans and prepuce, erosive ulcers and an offensive sub-prepuce discharge: an amine odour indicating anaerobic overgrowth. Inguinal adenopathy is rarely present with simple balanitis and its presence should indicate consideration of a wider differential diagnosis, including the need to exclude sexually transmitted infections and carcinoma.

In most cases, the course will be episodic with recurrences, unless specific care is taken to reverse the predisposing factors.

Diagnosis

In simple balanitis, diagnosis is clinical and tested by response to simple measures.

Microscopy of the sub-prepuce secretions may reveal candida or anaerobes, which may point to the same condition in the sexual partner(s). Potassium hydroxide preparation is useful in the identification of candida; Gram stain will be more specific for anaerobes. Culture will identify bacterial causes, although one must be careful not to attribute the causation to commensals.

The presence of ulceration, adenopathy or a positive sexual risk history should prompt a full screen for sexually transmitted infections. Samples from ulcerated lesions should be examined by dark ground microscopy and/or PCR detection to eliminate syphilis, as well as serology. An HSV DNA detection for herpes virus should be taken – HSV culture being less sensitive. Consideration should be given to chancroid, lymphogranuloma venereum and granuloma inguinale. A high degree of suspicion should be maintained for squamous cell carcinoma of the penis and any persisting or suspicious lesions biopsied.

The skin of the glans penis and prepuce may be affected by a wide variety of dermatological conditions, the more important of which are considered in the differential diagnosis which follows. The presentation and appearance of these conditions is modified in the soft non-keratinised skin. In case of persisting lesions, or if in any doubt, do a biopsy.

Differential Diagnosis

As an area of skin, the prepuce and glans penis is subject to abrasion, trauma, infection and the entire gamut of dermatological conditions, including cancer and precancerous lesions (Table 8.1) (Fig. 8.1).

Table 8.1 Balanitis: differential diagnosis of common or important conditions
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Fig. 8.1
figure 1figure 1

Retracted prepuce. Retraction of the prepuce dries out the epithelium, enhances keratinisation and resolves most cases of balanitis

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General Principles of Treatment

The principle is to change the micro-ecosystem of the sub-prepuce sac to one which will not readily become superinfected by candida, anaerobes or other bacteria. Exposure and drying of the skin encourages keratinisation and further enhancement of resistance to infection, abrasion and trauma.

Recommended Therapies

The vast majority of cases respond to simple measures:

  1. (a)

    Retraction of the foreskin

  2. (b)

    Saline baths

  3. (c)

    Simple drying powder

Retraction of the Foreskin

Advising patients to change their habits of a lifetime and maintain retraction of the foreskin requires considerable persuasion. Most find it uncomfortable and oversensitive initially, and it takes about 3–4 weeks for the hypersensitivity to settle down as keratinisation occurs. Once this has been achieved, few wish to revert to their previous mode of wearing the foreskin down.

Some men cannot achieve retraction because of a tight prepuce: application of an emollient cream and stretching over a period of time may allow the desired effect to be achieved. Retraction may not be maintained by others because of a natural tendency of the prepuce to slip down. Use of a thin narrow surgical tape (Micropore® 12.5 mm, 3M®) along the shaft of the penis may retain the prepuce back for a sufficient time for keratinisation to occur.

Patients must be warned to guard against paraphimosis on retraction of the foreskin. This may occur at night, with erotic dreams, when patients may awake with an acute paraphimosis.

Some men have a non-retractile prepuce or phimosis. Use of an ultra-potent topical steroid, combined with gentle stretching over a period of several months, may facilitate retraction to take place. The above warning regarding paraphimosis is particularly pertinent.

On occasions, circumcision is warranted for persisting irritation.

Saline Baths

These appear to help dry out the skin and encourage keratinisation and may have a mild fungistatic/bacteriostatic effect. Essentially, a tablespoon (20 ml) of ordinary domestic table salt in a warm bath of water or more convenient for frequent daily use, use a pinch of salt in a tumbler glass or small jar. The penis and sub-prepuce area should be dried gently, by patting, rather than any rough or abrasive action. Care should be taken not to use too much salt, or the skin will become pickled or irritated, which would be quite counterproductive.

If retraction is not possible initially, one can wash out the sub-prepuce space with warm saline by the use of a small syringe to irrigate the area.

Simple Drying Powder

Application of a simple drying powder to the sub-prepuce space can assist in maintaining dryness. A simple talc may be used or one with a mild antiseptic as commonly used for infants (calcium undecylenate 10 % powder, Caldesene®). Care should be taken to ensure that there is no hypersensitivity to the talc or other constituents.

Some soaps, shower gels and shampoos can be an irritant, as well as contain potential allergens. Again, use of simple non-astringent agents is recommended, with advice against overwashing and abrading with drying. This is particularly important where there is broken skin.

Topical treatments at a glance

Simple measures

Retraction of prepuce

Saline baths

Drying powder

Antifungal powders

Miconazole

Antifungal creams

Not recommended

Topical steroids

Not recommended

Alternative Treatments

Antifungals and Steroids

Antifungal creams (clotrimazole, miconazole, nystatin) are very commonly prescribed, and many patients will present having tried antifungal creams, often obtained OTC. The experience is of relapse with these agents, and they can be only useful in providing short-term symptomatic relief. Recurrence occurs shortly after discontinuation of usage. There is danger of hypersensitivity to these agents and their vehicles, especially clotrimazole. Systemic fluconazole has also been recommended, but as only a small proportion of cases are due to Candida infection (Van der Meijden 2014), and these usually respond to simple measures; its utility is questionable.

Antifungal/antibacterial powders produce better results as they dry out the area. They are particularly useful in acute erosive balanitis, with secondary bacterial infection. Miconazole powder, used three to four times a day, is one such agent.

Local corticosteroid applications should only be used sparingly, and where there is a specific need, as they weaken the skin and may mask an infection. Particularly, steroids may reduce the local immune response and facilitate the expression of a latent HPV infection as genital warts.

Simple measures should be tried initially and given sufficient time for patient compliance to be established and for them to show effect. With persisting balanitis, much stronger consideration must be given to the differential diagnosis, taking special care to exclude a sexually transmitted disease, dermatosis or a precancer/cancer. At this stage biopsy becomes mandatory.

Screening for Sexually Transmitted Diseases

This is mandatory in all cases where a history of potential acquisition has been obtained and is a useful reassurance in the majority of other cases. Many patients who present with balanitis have an underlying anxiety regarding STDs, and this must be definitively addressed.

Circumcision

Recognition of the protective benefit of circumcision on male acquisition of HIV has raised a much greater awareness of the procedure. Current estimates show it to confer a 70 %+ protection after 5 years. It has also been shown to be of some benefit in relation to HPV and HSV acquisition in males (Edwards et al. 2008).

Circumcision is of specific use in lichen sclerosis, after failed topical therapy 3,4, and similarly in lichen planus 5, Zoon’s balanitis(Kulkarni et al. 2009). Circumcision is curative in non-specific balanitis.

Whilst circumcision is usually curative in the above conditions, careful consideration should be given to assiduously try the simple measures outlined previously, as they can usually achieve the same effect without the expense and discomfort of surgery. The challenges are lack of awareness by the physician and difficulty in compliance by the patient.

In relation to prevention, the American Academy of Pediatrics (AAP) task force on circumcision of the male infant (2012) Poter et al. (2001) concluded that ‘the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it. Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction’. More widespread adoption of newborn male circumcision will result in reduction of balanitis in the population. However, there are several vociferous anti-circumcision groups and some very strong-held opinions in relation to this topic. The optimal time for circumcision is the newborn period (Kumar et al. 1995).