Balanitis

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Practice Essentials

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.)



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Balanitis xerotica obliterans (lichen sclerosus). Courtesy of Wilford Hall Medical Center Slide collection.

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.

History

Patients with balanitis usually present with the following complaints:

 

Observe the patient with balanitis for the following signs and symptoms:

Physical

Physical examination findings may include the following:

Causes

Diabetes is the most common underlying condition associated with adult balanitis.[11] In a study of patients with type 2 diabetes mellitus, treatment with dapagliflozin (2.5 mg, 5 mg, or 10 mg once daily) was found to be associated with an increased risk of vulvovaginitis or balanitis, related to the induction of glucosuria. According to the authors, events were generally mild to moderate, were clinically manageable, and rarely led to discontinuation of treatment. For dapagliflozin 2.5 mg, 5 mg, and 10 mg, infections were reported in 4.1%, 5.7%, and 4.8% of patients, respectively, as compared to 0.9% in patients with type 2 diabetes who were given placebo.[14, 15]

Other causes include the following[16] :

Several organisms and viruses cause balanitis, including the following:

Balanitis xerotica obliterans (lichen sclerosus) is a chronic dermatosis identified by whitish plaques involving the glans and foreskin (shown in the image below).[2, 3, 17]



View Image

Balanitis xerotica obliterans (lichen sclerosus). Courtesy of Wilford Hall Medical Center Slide collection.

Zoon balanitis is a reddish velvety lesion on the glans.[18, 19, 20]  It is typically found in older, uncircumcised males. It can be asymptomatic or pruritic or may cause dysuria.[21]

Reiter disease consists of circinate and eroding lesions on the glans.

Complications

Complications of balanitis may include meatal stenosis and possible urethral strictures; urinary retention; and vesicoureteral reflux.

In a study of 250 patients after circumcision for balanitis xerotica obliterans (lichen sclerosus), approximately 20% required a subsequent operation for meatal stenosis. According to the authors, precircumcision topical steroids may help decrease this rate of subsequent meatal pathology. They added that submission of the foreskin for histologic analysis should always be considered, because the prognosis differs for lichen sclerosus and nonlichen sclerosus histology. Those patients with balanitis xerotica obliterans who later underwent meatal procedures rarely underwent a meatal procedure at circumcision and were less likely to have received preoperative topical steroids, as compared to patients who did not need a subsequent meatal procedure.[22]

Laboratory Studies

Laboratory studies for uncomplicated balanitis are not typically necessary but may include the following, when clinically appropriate:

Ultrasonography or bladder scan is used to detect urinary obstruction in severe balanitis.

Emergency Department Care

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

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):

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

Deterrence/prevention of balanitis includes the following measures:

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:

 

Guidelines Summary

European guidelines have been published regarding management of specific balanitides[5] :

 

Medication Summary

The goal of balanitis therapy is to eradicate infection and prevent complications.

Clotrimazole topical (Mycelex, Lotrimin)

Clinical Context:  Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability. For adult use, especially those with a positive history of candidiasis in a sexual partner.

Bacitracin (AK-Tracin)

Clinical Context:  Prevents transfer of mucopeptides into growing cell wall, which inhibits cell wall synthesis and bacterial growth. More commonly used in pediatric patients or patients who are not sexually active.

Class Summary

Therapy must cover all likely pathogens in the context of the clinical setting.

Betamethasone 0.05% (Alphatrex, Diprolene, Maxivate)

Clinical Context:  For treatment of inflammatory dermatoses responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Affects production of lymphokines and has inhibitory effect on Langerhans cells.

Class Summary

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.

Pimecrolimus (Elidel cream)

Clinical Context:  First nonsteroid cream approved in the US for mild-to-moderate atopic dermatitis. Derived from azcomycin, a natural substance produced by fungus Streptomyces hygroscopics var. ascomycetous. Selectively inhibits production and release of inflammatory cytokines from activated T-cells by binding to cytosolic immunophilin receptor macrophilin-12. The resulting complex inhibits phosphatase calcineurin, thus blocking T-cell activation and cytokine release. Cutaneous atrophy was not observed in clinical trials, a potential advantage over topical corticosteroids. Indicated only after other treatment options have failed.

Class Summary

Regulates key factors responsible for the immune response.

What is balanitis?What are predisposing factors for balanitis?How is balanitis treated?What are the signs and symptoms of balanitis?Which physical findings are characteristic of balanitis?What causes balanitis?Which organisms and viruses cause balanitis?How may the presentation of balanitis vary by etiology?What are potential complications of balanitis?What are the differential diagnoses for Balanitis?What is the role of lab studies in the workup of balanitis?What is the role of imaging studies in the workup of balanitis?What is included in emergency department (ED) care of balanitis?How are phimosis and severe urinary obstruction managed in balanitis?Which specialist consultations are helpful in the treatment of balanitis?What are treatment options for balanitis?How is balanitis prevented?What are treatment guidelines for balanitis?What are the goals of medication in the treatment of balanitis?Which medications in the drug class Immunosuppressant agents are used in the treatment of Balanitis?Which medications in the drug class Corticosteroids, topical are used in the treatment of Balanitis?Which medications in the drug class Antimicrobial agents (topical) are used in the treatment of Balanitis?

Author

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

Disclosure: Nothing to disclose.

Coauthor(s)

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

Disclosure: Nothing to disclose.

Specialty Editors

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

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Pfizer Pharmaceutical<br/>Received research grant from: National Institutes Health.

Chief Editor

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

Disclosure: Nothing to disclose.

Additional Contributors

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

Disclosure: Nothing to disclose.

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Balanitis xerotica obliterans (lichen sclerosus). Courtesy of Wilford Hall Medical Center Slide collection.

Balanitis xerotica obliterans (lichen sclerosus). Courtesy of Wilford Hall Medical Center Slide collection.

Balanitis xerotica obliterans (lichen sclerosus). Courtesy of Wilford Hall Medical Center Slide collection.