Continuing Education Activity

Balanitis is an inflammation of the glans penis. Men with balanitis often present with penile pain and erythema. This activity explains the risk factors, evaluation, and management of balanitis and highlights the importance of the interprofessional team in enhancing care for affected patients.

Objectives:

• Describe the clinical presentation of balanitis.
• Outline the evaluation of patients with balanitis.
• Explain the treatment strategies for balanitis.
• Employ interprofessional team strategies for improving care coordination and communication to advance the evaluation and management of balanitis and optimize outcomes.

Introduction

Balanitis is an inflammation of the glans penis (head of the penis); it is fairly common and affects approximately 3-11% of males during their lifetime. Posthitis is an inflammation of the foreskin (prepuce). Balanoposthitis involves both the glans and the foreskin and occurs in approximately 6% of uncircumcised males. Balanoposthitis occurs only in uncircumcised males.[1][2]  However, balanitis and balanoposthitis often occur together, and the terms are commonly used interchangeably.  Infectious etiologies of balanitis include certain fungi like yeast and certain bacteria or viruses (including those that cause STDs such as gonorrhea). Balanitis is not a sexually transmitted infection. The actual disease is not transferable from one person to another; however, the transfer of organisms that cause balanitis is possible.  Recurrent episodes of balanoposthitis should raise the concern for occult diabetes. Patients with recurrent episodes should undergo blood glucose screening for diabetes and evaluation by a urologist. 

Etiology

There are a wide range of diseases that affect the male genitalia including inflammatory lesions, infectious etiologies, preneoplastic syndromes, and malignant conditions. However, The most common cause of balanitis is related to inadequate personal hygiene in uncircumcised males leading to infection. The warm moist environment under the uncircumcised penile foreskin favors the growth of organisms that cause balanitis such as Fungi.  

Fungal infections are the most common identifiable etiology with the majority of infections being caused by Candida albicans.[3] This organism is normally present on the skin of the glans and can be a considered normal flora. The yeast can cause infection in certain cicumstances, especially when the patient has underlying conditions, poor hygiene, overgrowth, or changes in basline pH. Although yest infection is the most common cause, there are several other etiologies that exist and must be considered by the provider. These include the following infectious and noninfectious etiologies[4]

Infectious etiologies:

• Candidal species (most commonly associated with diabetes)
• Group B and group A beta-hemolytic streptococci
• Neisseria gonorrhea
• Chlamydia species
• Anaerobic infection
• Human papillomavirus
• Gardnerella vaginalis
• Treponema pallidum (syphilis)
• Trichomonas species
• Borrelia vincentii and Borrelia burgdorferi

Noninfectious etiologies:

• Poor personal hygiene (most common)
• Chemical irritants (e.g.,  spermicides, detergents, perfumed soaps and shower gels, fabric conditioners)
• Edematous conditions, including congestive heart failure (right-sided), cirrhosis, and nephrosis
• Drug allergies (e.g., tetracycline, sulfonamide)
• Morbid obesity
• Allergic reaction (condom latex, contraceptive jelly)
• Fixed-drug eruption (sulfa, tetracycline)
• Plasma cell infiltration (Zoon balanitis)
• Autodigestion by activated pancreatic transplant exocrine enzymes
• Trauma
• Neoplastic conditions

Epidemiology

Balanitis can occur at any age. It affects approximately 1 in every 25 boys and 1 in 30 uncircumcised males during their life. Boys under 4 years of age and uncircumcised men are the highest risk group.  Balanitis is more likely to occur if there is phimosis, a condition where a tight foreskin can’t retract back over the penis. When boys reach approximately the age of 5 years, the foreskin becomes easy to retract, and the risk of balanitis falls. Data from meta-analyses showed that circumcised males have a 68% lower prevalence of balanitis than uncircumcised males and that individuals with balanitis have a 3.8-fold increase in the risk of penile cancer.[5] Although data shows no direct causation, an association exists between nonspecific balanoposthitis and the uncircumcised penis. The data suggest that circumcision prevents or protects against common infective penile dermatoses. 

Risk Factors Balanitis:

• Presence of foreskin
• Morbid obesity
• Poor hygiene
• Diabetes (particularly males with uncontrolled diabetes), probably due to Glucose on the skin, encouraging bacterial and fungal growth
• Nursing home environment
• Condom catheters
• Sensitivity to chemical irritants (i.e., soaps and lubricants)
• Edematous conditions: CHF, nephrosis
• Reactive arthritis
• Sexually transmitted infections

Pathophysiology

Balanitis is most common in uncircumcised males due to poor hygiene and the accumulation of smegma beneath the foreskin. Smegma is a whitish sebaceous secretion composed epithelial cells (dead skin) and the sebum (oily secretions) produced by the sebaceous glands of both male and female genitalia. Under normal circumstances, smegma aids in the lubricating movement of the foreskin; without it friction and irritation results.  Poor hygiene, a tight foreskin, and a buildup of smegma serve as a nidus for bacterial and fungal overgrowth which can lead to irritation and inflammation. Fungal infections are usually responsible, most commonly involving the yeast Candida albicans.  History and physical examination findings sometimes point to other etiologies that have management implications.

Sometimes a dermatologic cause (e.g., psoriasis or lichen planus)  allergic reaction, or (less likely) premalignant condition may be responsible.  It may warrant specialty referral to a dermatologist for a biopsy or urologist.  

Localized edema may develop if someone allows balanitis to progress without treatment. The combination of inflammation and edema can cause adherence of the foreskin to the glans. 

Symptoms include pain, redness and a foul-smelling discharge from under the foreskin. Balanitis has a more fulminant clinical presentation in diabetic and immunocompromised patients.[5]

Histopathology

• Under microscopic examination, nonspecific inflammatory changes are visible with lymphocytes, plasma cells, and macrophages
• The causative organism is usually not discernable by routine examination
• Epithelial changes such as squamous hyperplasia and ulceration have an association with inflammation
• Fungal hyphae may be present

History and Physical

History should assess the risk for sexually transmitted infections (STIs), and any underlying dermatologic (e.g., eczema, psoriasis) or systemic (e.g., reactive arthritis) diseases. Along with inspection of the glans and foreskin, the physical examination should also include an assessment of the urethral meatus for inflammation and discharge, and any extragenital manifestations such as a generalized rash, oral ulcers, inguinal lymphadenopathy, and arthritis. Persistent inflammation and edema may cause scarring and adherence of the foreskin to the glans. Ultimately, this process can evolve into a tightening of the foreskin, known as “phimosis.” Phimosis is an abnormal constriction of the opening in the foreskin that prevents retraction over the glans. Paraphimosis refers to trapping of the foreskin behind the glans penis and requires urgent reduction.[6]

Signs and symptoms usually include:

• Tight, shiny skin on the glans
• Redness around the glans
• Inflammation, soreness, itchiness, or irritation of the glans
• A thick cheesy white discharge under the foreskin (smegma)
• An unpleasant smell
• Tight foreskin cannot retract
• Painful urination
• Swollen glands near the penis
• Sores on the glans

Evaluation

Balanitis is a visual diagnosis, the clinical presentation and appearance of the lesions guide the diagnosis. Additional evaluation may be warranted based upon the history and physical findings. This might include bacterial culture (in the presence of purulent exudate), herpes simplex virus (HSV) testing (in the presence of vesicular or ulcerative lesions), syphilis testing (in the present of an ulcer), testing for scabies, and testing for trichomonas and Mycoplasma genitalium (in the presence of urethritis).

Men with suspected balanitis often complain of penile pain and redness.

Physical examination revealing an inflamed and erythematous glans confirms the diagnosis of balanitis. For men who are uncircumcised, the mobility of the foreskin should be assessed to exclude the complications of phimosis and paraphimosis.  Paraphimosis requires urgent urologic consultation.  

Certain features on clinical examination (e.g., white, curd-like exudate) raise suspicion for candidal infection. If available, microscopy can identify budding yeast or pseudohyphae using a potassium hydroxide (KOH) preparation.

Treatment / Management

The initial aim of diagnosis and management should be to exclude STI, minimize problems with urinary and sexual function, and mitigate the risk of cancer of the penis. 

Proper hygiene with frequent washing and drying off the prepuce is an essential preventive measure although excessive genital washing with soap may aggravate the condition.

Topical antifungals usually for one to three weeks is the treatment of choice for most patients with balanoposthitis. Imidazoles such as clotrimazole 1% twice daily (bid), and miconazole 1% bid are the first line therapy choice. Nystatin cream is an alternative in patients allergic to imidazoles.

In cases of more severe inflammation, the addition of fluconazole 150 mg stat orally or the combination of a topical imidazole and a low potency topical steroids such as hydrocortisone 0.5% bid often lead to the resolution.

Treatment with a first-generation cephalosporin is appropriate if there is a concern for concomitant cellulitis.

Experts recommend circumcision for recurrent and intractable episodes especially in immunocompromised and diabetic patients, consult urology. Data from meta-analyses showed that circumcised males have a 68% lower prevalence of balanitis than uncircumcised males and that balanitis is accompanied by a 3.8-fold increase in the risk of penile cancer.[7]

Female sexual partners of men with balanitis should be offered testing for candida or empiric treatment to reduce the reservoir of infection in the couple.[8]

Differential Diagnosis

Balanitis is a descriptive diagnostic term for a heterogeneous class of inflammatory or infectious dermatoses which require differentiation from potentially malignant conditions. Causes of balanitis include Candida spp. and bacterial infections, including anaerobic bacteria, viral infections, parasites and other sexually transmitted infections (STI) also must be considered.[9][10]

Skin conditions may also trigger the condition.

Examples can include:

• Lichen planus, a skin pathology with small, itchy, pink, or purple spots on the arms or legs
• Psoriasis, a dry, scaly skin disorder
• Eczema, a chronic or long-term dermal condition that can result in itchy, reddened, cracked, and dry skin
• Dermatitis, an inflammatory skin condition, due to direct contact with an irritant or allergen

In very rare cases, balanitis has been linked to skin cancer.

There are three types of balanitis:

Zoon's balanitis: inflammation of the glans penis and the foreskin. Usually affects middle-aged to older uncircumcised men.

Circinate balanitis: associated with reactive arthritis, characterized by small, shallow, painless ulcerative lesions on the glans penis.   A biopsy can show pustules in the upper epidermis, similar in appearance to pustular psoriasis.  There may also be a serpiginous annular dermatitis that often has a grayish white granular appearance with a "geographical" white margin.[8] This lesion can be mistaken for psoriasis on physical examination, and histological evaluation cannot reliably distinguish between the two disorders. The distinction between circinate balanitis and psoriasis is generally made clinically (history of reactive arthritis or psoriasis).  If circinate balanitis is suspected clinically in a patient without known reactive arthritis, screening for STIs and testing for human leukocyte antigen (HLA)-B27 is advised.

Pseudoepitheliomatous keratotic and micaceous balanitis: A condition characterized by scaly, wart-like skin lesions on the head of the penis.

Complications

Complications associated with balanitis include the development of pain, ulcerative lesions of the glans/foreskin, phimosis, paraphimosis, meatal/urethral stricture, and malignant transformation of premalignant lesions. 

Phimosis is an abnormal constriction of the opening in the foreskin that precludes retraction over the glans penis, results from chronic inflammation and edema of the foreskin. Development of phimosis often complicates sexual function, voiding, and hygiene. If the patient or medical staff forcibly retract the foreskin, paraphimosis (trapping of the foreskin) can occur. 

Phimosis is treatable in the emergent setting by dilation using a surgical clamp and pain medication. In the event this is not successful, a dorsal slit circumcision can be performed by a urologist to temporize the problem. Definitive treatment, under elective circumstances, is complete circumcision.

Paraphimosis refers to the trapping of the foreskin behind the glans penis and is a urologic emergency. The constricting foreskin has become located proximal to the glans penis. Under these circumstances, the constricting band will limit the venous and lymphatic outflow while allowing continued arterial inflow. Over the course of minutes to hours, the glans will increase in size and become exquisitely painful and must undergo treatment by a urologist with reduction of the paraphimosis. 

Genital yeast infection (termed “candidiasis” or “thrush”) is uncommon in healthy individuals, but in immunocompromised individuals, such as those with HIV infection, in diabetic and cancer patients C. albicans can also cause bloodstream infection with serious consequences.

Enhancing Healthcare Team Outcomes

 Healthcare workers and nurse practitioners should be aware of skin disorders that affect the penis.

1. The most common cause of balanitis is related to inadequate personal hygiene in uncircumcised males. Of cases with identifiable causes, candidal infection is the most common. Various other infectious agents, dermatologic conditions, and premalignant conditions have associations with balanitis. 
2. Balanitis may present as pain, tenderness, or pruritus associated with erythematous lesions on the glans and/or the foreskin; an exudate may also be present. If balanitis is a manifestation of reactive arthritis, it may present with associated joint inflammation, mouth sores, and/or generalized symptoms. 
3. Physical examination should include inspection of the glans and foreskin and the urethral meatus for inflammation/discharge. Careful inspection for possible paraphimosis is necessary.
4. History and physical examination findings sometimes point to specific etiologies that have management implications.
5. Management of balanitis without an identifiable cause initially focuses on the implementation of local hygiene measures. In addition, it warrants empiric treatment for candidal infection and/or noninfectious dermatitis in some patients.
6. Retraction of the foreskin with thorough genital cleansing can be both preventive and therapeutic. The suggestion is twice-daily bathing of the affected area with a saline solution. In uncircumcised males, nonspecific balanitis may respond to saline solution bathing  by itself.
7. If other specific etiologies are identifiable, directed therapy is warranted. Management generally consists of topical antibiotics for bacterial infections, topical steroid creams for dermatologic conditions, and potential ablation or excision of premalignant lesions. 

 If there is any doubt, referral to a urologist is a prudent option.