Balanitis

 

Balanitis is inflammation of the glans penis; often inflammation also involves the foreskin.  It can be acute, chronic (lasting for more than a few weeks), or recurrent.  Balanitis affects approximately 4% of pre-pubertal boys, most frequently during the pre-school years.  Balanitis is uncommon in circumcised men.  About one in 10 men attending a genitourinary clinic have balanitis

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Children

Diagnosis

  1. Diagnose balanitis in a child on the basis of clinical findings:
    1. Penile soreness, itch, and odour which usually develop over a few days
    2. Redness of the glans penis (and often the foreskin) with exudate is usual
    3. The glans penis and foreskin may be swollen
  2. Ask about:
    1. Hygiene practices (for example, how often is the nappy changed or penis cleaned?) — lack of hygiene predisposes to non-specific dermatitis
    2. Exposure to irritants — such as bubble bath, detergents, or creams
    3. Trauma — from 'foreskin fiddling'
    4. Other skin conditions (such as eczema)
  3. Look for clinical features and skin conditions which may suggest a specific underlying cause:
    1. Non-specific dermatitis — redness of the glans penis which often extends onto the skin of the shaft of the penis
    2. Contact balanitis — redness of the glans penis with localized swelling. This is most commonly irritant contact dermatitis; allergic contact dermatitis is unusual in children
    3. Candidal balanitis — redness on the undersurface of the glans penis, with sparing around the urethral meatus. Small, eroded papules may be present with a white cheese-like matter, that can be rubbed off easily
    4. Bacterial infection (for example group A beta-haemolytic streptococci or Staphylococcus aureus) — penile redness and pain, often accompanied by a purulent exudate
  4. Take a sub-preputial swab if balanitis is:
    1. Severe (suggesting a secondary infection)
    2. Mild, but persists despite treatment

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Management

  1. Advise the child or the parents or carers to clean the penis with luke warm water and gently dry it.  Do not attempt to retract the foreskin to clean under it, and do not use soap, bubble bath, or baby wipes
  2. For suspected non-specific dermatitis, with or without candidal or bacterial colonization, prescribe topical hydrocortisone 1% once daily and an imidazole cream (clotrimazole 1%, miconazole 2%, or econazole 1%) frequency depending on the preparation used, until symptoms settle, or for up to 14 days
  3. For suspected irritant or allergic contact dermatitis, discontinue any suspected triggers (such as soap or creams) and prescribe a mild topical hydrocortisone 1% cream or ointment once a day until symptoms settle, or for up to 14 days
  4. For suspected or confirmed candidal balanitis, prescribe an imidazole cream (clotrimazole 1%, econazole 1%, ketoconazole 2%, or miconazole 2%), frequency depending on preparation used
  5. For suspected or confirmed bacterial balanitis, prescribe oral flucloxacillin for 7 days.  Oral erythromycin or clarithromycin for 7 days are alternatives for boys who are allergic to penicillin
  6. If symptoms are not improving by day 7 following prescribing for any of the above, advise people to stop treatment with topical hydrocortisone, and take a sub-preputial swab to exclude or confirm a fungal or bacterial infection, and treat accordingly

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Referral

If balanitis is recurrent or chronic, refer to a paediatrician or a dermatologist

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Adults

Diagnosis

  1. Diagnose balanitis in an adult on the basis of clinical findings:
    1. Penile soreness, itch, and odour are common symptoms
    2. Redness on the glans penis (and often the foreskin) with exudate are usual. Swelling of the glans penis and foreskin may be seen
    3. Dysuria and dyspareunia may occur
    4. Balanitis is mostly seen in uncircumcised men and an inability to retract the foreskin is common
  2. Ask about:
    1. Hygiene practices (for example, how often is the penis cleaned?) — lack of hygiene predisposes to non-specific dermatitis
    2. Exposure to irritants — such as soaps or creams
    3. Trauma — for example, during sexual intercourse or vigorous cleaning
    4. Exposure to infections — has the man's partner had bacterial vaginosis, vaginal candidal infection or herpes simplex infection?
    5. A history of diabetes or immunosuppression — which predisposes to infection
  3. Look for clinical features of balanitis and for other skin conditions elsewhere (such as seborrhoeic dermatitis), which suggest a specific underlying cause:
    1. Non-specific dermatitis — redness of the glans penis, which often extends onto the skin of the shaft of the penis
    2. Candidal balanitis — symptoms are generally less acute with redness on the undersurface of the glans penis, with sparing around the urethral meatus. Small, eroded itchy papules may be present with a white cheese-like matter, that can be rubbed off easily
    3. Irritant or allergic contact dermatitis — redness of the glans penis with localized swelling (especially in allergic contact dermatitis)
    4. Gardnerella-associated balanitis — a fishy odour and a sub-preputial mucoid discharge
    5. Streptococcal infection — may present with a rapid onset of symptoms ranging from erythema of the glans to oedema with purulent exudate
  4. Take a sub-preputial swab if balanitis is:
    1. Severe
    2. Recurrent
    3. Mild, but persists despite treatment
  5. Only swab for Gardnerella-associated balanitis if this is suspected clinically. State 'gardnerella' on the laboratory form when requesting the test, as most laboratories will not routinely test for the organism
  6. Check blood glucose levels or urine for glycosuria if balanitis is severe, persistent, or recurrent (especially if candidal balanitis is present)

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Management

  1. Advise daily cleaning under the foreskin with luke warm water, followed by gentle drying.  Soap or other irritants should not be used on the genitalia
  2. For suspected non-specific dermatitis, with or without candidal colonization, prescribe topical hydrocortisone 1% once daily and an imidazole cream (clotrimazole 1%, miconazole 2%, or econazole 1%) frequency depending on preparation used, until symptoms settle, or for up to 14 days
  3. For suspected irritant or allergic contact dermatitis, discontinue any suspected triggers (such as latex condoms, creams, or soaps) and prescribe a mild topical hydrocortisone 1% cream or ointment once a day until symptoms settle, or for up to 14 days
  4. For suspected candidal balanitis, prescribe an imidazole cream (clotrimazole 1%, econazole 1%, ketoconazole 2%, or miconazole 2%), frequency depending on preparation used, until symptoms settle, or oral fluconazole 150 mg as a single dose (licensed for people 16 years of age and older)
  5. For suspected or confirmed Gardnerella-associated balanitis, prescribe oral metronidazole (400 mg twice a day) for 7 days
  6. For suspected or confirmed streptococcal balanitis, prescribe oral flucloxacillin (500 mg four times a day) for 7 days
  7. If symptoms are worsening or have not settled with treatment, review the diagnosis, take a sub-preputial swab (if this has not been done already) and adjust treatment (if indicated), or seek specialist advice

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Recurrent balanitis

  1. Treat as for an acute episode of balanitis
  2. Reinforce advice on personal hygiene
  3. Consider prescribing an emollient (such as emulsifying ointment) as a soap substitute
  4. For irritant or allergic contact dermatitis, advise avoiding potential triggers such as lubricant gels, latex condoms, and topical medications
  5. For candidal, streptococcal or Gardnerella-associated balanitis, advise the man that his partner should be tested for infection and treated if appropriate

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Referral

If penile cancer is suspected, refer urgently to dermatology or urology

If ulceration, urethritis, or inguinal lymphadenopathy are present, refer to genitourinary medicine (GUM)

If balanitis is recurrent and associated with inability to retract the foreskin (phimosis), refer to urology

If balanitis is recurrent and no underlying cause can be identified, or balanitis persists despite treatment, refer to dermatology, urology, or GUM depending on the most likely underlying cause

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Microbiology

Please send sub-preputial swabs to the Microbiology Department at East Kent Hospitals (find details here)

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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