Balanitis

Balanitis — inflammation of the glans. Posthitis — inflammation of the foreskin. Balanoposthitis — inflammation of both.

Demographics: ~6% of uncircumcised males, ~3% of circumcised males.

Causes:

• Dermatitis from trapped urine converting to ammonia.
• Irritation from environmental substances (soaps) or sexual trauma.
• Primary or secondary bacterial/fungal infection.
• Inflammatory dermatoses — psoriasis, lichen sclerosus, lichen planus, Zoon’s balanitis (see the guideline-update note below).
• Pre-malignant conditions — Bowen disease, bowenoid papulosis, erythroplasia of Queyrat.

Consider predisposing factors such as HIV and diabetes.

History

Depends on the underlying cause:

• Candidal (men): itchy, red, scaly maculopapular rash on the glans.
• Bacterial (children): painful, red, weeping, raw glans with painful urination.

Management

Treatment depends on the suspected cause and the patient’s age.

Boys: most often irritant dermatitis from not retracting the foreskin to wash, or from phimosis. Treat with hydrocortisone 1% (Murtagh) or Advantan 0.1% daily for ~7 days (eTG). Uncommonly caused by Streptococcus pyogenes — much more severe, with a red-raw weeping glans and painful urination; treat with phenoxymethylpenicillin 500mg (or 15mg/kg) BD for 10 days (as for strep throat).

Men, uncircumcised: usually contact dermatitis with superimposed candidal infection (rarely S. pyogenes); poor hygiene may still contribute. Take a swab to confirm. Treat with hydrocortisone + clotrimazole 1% (or miconazole 2%) BD for two weeks after the skin clears.

Special situations: if topical therapy is intolerable and the swab is candida-positive, use oral fluconazole 150mg once. Glycosuria (poorly controlled diabetes, or possibly SGLT2 inhibitors) may be a contributing factor — refer for expert advice; circumcision may be needed. Candida sensitivity: some men develop an itchy red rash after sex with a partner who has candidal vulvovaginitis, from irritation rather than transfer of infection — treatment relies on treating the female partner, with Hydrozole to ease the male partner’s symptoms in the meantime.

Failure to respond: consider non-infectious causes, trial reducing skin irritants; if severe or persisting, refer for expert advice — skin biopsy may be required.

Zoon’s balanitis (plasma cell balanitis) — a benign, idiopathic, chronic inflammatory condition of the glans in uncircumcised men, presenting as well-demarcated orange-red, moist patches; often mistaken for infective balanitis but doesn’t respond to antimicrobials — diagnosis is clinical ± biopsy if atypical, and circumcision is curative if topical steroids/tacrolimus fail. Any balanitis not responding to standard treatment needs explicit red-flag recognition for neoplastic change (persistent, non-healing, indurated, or ulcerated lesions — see Penile Cancer).