Balanitis

Etiology

Many diseases, infections, and disorders affect the male genitalia, including inflammatory lesions, infectious processes, preneoplastic syndromes, and malignant conditions. However, the most common cause of balanitis is poor or inadequate personal hygiene in uncircumcised males, leading to candidal infection.

The warm, moist environment under the uncircumcised penile foreskin, lack of aeration, sequestration of urine and urethral discharge or seepage, and the accumulation of irritating smegma promote the growth of organisms, most commonly Candida, that cause balanitis, leading to erythema, irritation, edema, inflammation, and discomfort of the glans penis.[3] Fungal infections, particularly those caused by Candida albicans, are the most common identifiable infectious causes of balanitis and balanoposthitis.[4] C albicans is normally present on the skin of the glans and can be considered part of the normal flora. However, colonization can progress to an outright infection under certain conditions, particularly in individuals with underlying medical conditions; poor hygiene; uncircumcised men, especially those with phimosis; or changes in baseline pH. The risk of infection is also higher in men whose sexual partners have recurrent vaginal candidal infections.[5][6] Diabetes is the most commonly identified underlying contributing disorder.[3][7]

Data from meta-analyses show that circumcised males have a substantially lower prevalence of balanitis (68%) compared to uncircumcised males and that balanitis is associated with a 3.8-fold increase in the risk of penile cancer.[8][9] Up to 45% of patients with penile cancer report a history of balanitis.[10][11][12][13] Although the 2 entities share some common risk factors, such as the presence of a foreskin and poor genital hygiene, these data suggest that chronic inflammation or infection (balanitis) is an etiological factor for penile carcinoma.[10][11][12][13] Please see StatPearls' companion resource, "Penile Cancer and Penile Intraepithelial Neoplasia," for more information.

Although yeast infection is the most commonly identified cause of balanitis, numerous other potential causes must be considered, including both infectious and noninfectious agents: [14][15][16]

Infectious etiologies of balanitis include:

• Anaerobic and aerobic bacteria such as Bacteroides, Streptococcus, and Staphylococcus
• Borrelia vincentii and Borrelia burgdorferi
• Candida species (most commonly associated with diabetes)
• Chlamydia species
• Gardnerella vaginalis
• Group B and group A beta-hemolytic streptococci
• Human herpesvirus 1 and 2
• Human papillomaviruses
• Neisseria gonorrhoeae
• Scabies
• Treponema pallidum, the etiologic agent of syphilis
• Trichomonas species.

Noninfectious etiologies of balanitis include:

• Allergic reactions to condom latex and contraceptive jelly
• Autodigestion by activated pancreatic transplant exocrine enzymes
• Chemical irritants, such as spermicides, detergents, perfumed soaps and shower gels, fabric conditioners, and petroleum jelly
• Cirrhosis
• Drug allergies, such as tetracycline, sulfonamide, phenacetin, spermicides, and personal lubricants
• Eczema
• Edematous conditions, including right-sided heart failure, cirrhosis, anasarca, and nephrotic syndrome
• Fixed-drug eruptions, such as those due to sulfa and tetracycline
• Morbid obesity
• Neoplastic conditions
• Penile intraepithelial neoplasia
• Plasma cell infiltration (Zoon balanitis)
• Overwashing
• Poor personal hygiene (most common)
• Trauma.

Epidemiology

Balanitis can occur at any age, affecting approximately 1 in every 25 boys and 1 in 30 uncircumcised men during their lifetime. Boys younger than 4 years and uncircumcised men are the highest-risk groups. Balanitis accounts for approximately 11% of all male patients treated by urologists in the United States. Globally, about 3% of all uncircumcised men are affected.

Balanitis is more likely to occur if there is phimosis, a condition where a tight foreskin cannot retract back over the glans penis. When boys reach approximately 5, the foreskin becomes easy to retract, and the risk of balanitis decreases.

Data from meta-analyses show that circumcised men have a 68% lower prevalence of balanitis compared to uncircumcised males and that individuals with balanitis have a 3.8-fold increase in the risk of penile cancer.[17] Diabetes is the most common underlying condition predisposing adult males to balanitis.[7] Overall, balanitis affects about 16% of men with diabetes compared to just 5.8% of men without diabetes.[18]

An association exists between nonspecific balanoposthitis and an uncircumcised penis, especially with phimosis. The data strongly suggest that circumcision prevents or protects against common infective penile dermatoses, although there may not be a direct causation.[10][19]

Risk factors for balanitis include:

• Use of condom catheters
• Contact allergic responses
• Diabetes, particularly when undiagnosed or poorly controlled, likely due to high skin glucose levels that promote bacterial and fungal growth [3]
• Edematous conditions, such as heart failure, nephrosis, anasarca, and cirrhosis
• Failing to retract the foreskin
• Use of glycosuric drugs in diabetes [20]
• Immunocompromised state
• Morbid obesity
• Nursing home environment
• Overwashing
• Penile trauma
• Phimosis
• Poor personal hygiene
• Reactive arthritis
• Sensitivity to common chemicals, such as soaps and lubricants
• STIs
• Unauthorized application of topical treatments to the glans
• Uncircumcised state
• Use of glycosuric agents, such as canagliflozin, dapagliflozin, and empagliflozin

Pathophysiology

Balanitis is most common in uncircumcised males due to poor hygiene and the accumulation of smegma beneath the foreskin. Smegma is a soft, thick, cheesy, whitish substance composed of shed skin cells, sweat, and sebaceous oils (sebum), which typically collects under the foreskin in uncircumcised males. Although smegma has an unpleasant odor, it is usually harmless if regularly cleaned from the glans; however, it can become infected in cases of balanitis.

Under normal conditions, smegma helps lubricate the movement of the foreskin; without it, localized trauma from friction and irritation results. Although smegma was once believed to be a risk factor for penile carcinoma, recent reviews suggest that it is harmless and not a cancer threat.[10][21]

Typical symptoms of balanitis include pain, redness, and a foul-smelling discharge from under the foreskin. The condition has a more fulminant clinical presentation in diabetic and immunocompromised patients.[17] Localized edema may develop if balanitis is allowed to progress without treatment. The combination of inflammation and edema can cause the foreskin to adhere to the glans and may also progress to penile cellulitis and adhesions.

Poor hygiene, a tight foreskin, and the accumulation of smegma, which serves as a nidus for bacterial and fungal overgrowth, can lead to localized irritation, infection, and inflammation of the glans and the foreskin. Fungal infections are typically responsible, most commonly involving C albicans. Please see StatPearls' companion resource, "Candidiasis," for more information.

In some cases, dermatologic conditions, such as psoriasis, lichen planus, or lichen sclerosus; allergic reactions; or, less likely, premalignant conditions may be responsible. Suspicion of an underlying malignancy warrants a diagnostic or excisional biopsy. Clinical findings on physical examination may point to other etiologies that can have management implications.

Histopathology

The causative organism is typically not discernable through routine microscopic examination, although fungal hyphae may be present.

Microscopically, the appearance is typically nonspecific inflammation with increased lymphocytes, plasma cells, and macrophages. Epithelial changes associated with inflammation, such as squamous hyperplasia and ulcerations, may also be found. Histological signs of malignancy are not present.

Characteristics of squamous cell carcinoma include basal and paranasal cell atypia, differentiated penile intraepithelial neoplasia, squamous hyperplasia, and a variable lymphoplasmacytic infiltrate, and there may be clear glycogenated cells. Many cancers show keratinization and foreign body-type giant cells. The degree of cytological atypia, keratinization, lack of intracellular bridging, mitotic activity, and demarcation of the tumor margins determine the grade of the malignancy. Please see StatPearls' companion resource, "Penile Cancer and Penile Intraepithelial Neoplasia," for more information.

History and Physical

The patient's history should include an assessment of the risk for an STI and any underlying dermatologic conditions, such as eczema or psoriasis, or systemic diseases, such as reactive arthritis or diabetes.

Along with a careful inspection of the glans and foreskin, the physical examination should also include an assessment of the urethral meatus for inflammation, discoloration, stenosis, and discharge, and any extragenital manifestations such as a generalized rash, oral ulcers, inguinal lymphadenopathy, skin infections, edema, and arthritis.

The use of glycosuric diabetic agents that increase urinary glucose excretion, including canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance), has been linked to an increased risk of balanitis.[22][23][24][25]

Symptoms typically include itching, tenderness, burning, or discomfort of the glans penis. There may be soreness, pruritus, irritation, edema, ulcers, dysuria, sores, or other signs of inflammation affecting the head of the penis and the foreskin. These symptoms often worsen after sexual intercourse.

A physical examination revealing an inflamed and erythematous glans essentially confirms the diagnosis of balanitis. Small papules with patchy erythema, tight skin on the glans that appears glazed or shiny, and whitish patches may also be present. The glans may be tender to palpation, and the patient may experience erectile dysfunction, an inability to retract the foreskin, or pain when doing so. Smegma is typically present and may be infected. There may be inguinal lymphadenopathy. Balanitis may also less commonly appear as an ulcer, mimicking an STI. Systemic symptoms are unlikely.

Certain features on clinical examination, such as white curd-like exudate and penile discharge, raise suspicion for candidal infection. Any discharge should be cultured. If available, microscopy can identify budding yeast or pseudohyphae using a potassium hydroxide (KOH) preparation. Please see StatPearls' companion resource, "Candidiasis," for more information.

For uncircumcised men, the mobility and tightness of the foreskin should be assessed to exclude complications such as phimosis and paraphimosis.

Persistent inflammation and edema may cause scarring and adherence of the foreskin to the glans. Ultimately, this process can progress into a tightening of the foreskin or phimosis. Phimosis is an abnormal constriction of the opening in the foreskin that prevents retraction over the glans. If the phimosis is sufficiently tight, the patient may notice difficulty in urination or dysuria. Initial treatment often involves topical steroids, but a dorsal slit or circumcision may be required in severe or refractory cases. Please see StatPearls' companion resources, "Phimosis," and "Balanoposthitis," for more information.

Paraphimosis refers to the trapping of a tight foreskin behind the glans penis, which becomes stuck and cannot be easily replaced manually. Such a situation is considered a surgical emergency and requires urgent manual reduction or immediate surgery.[26] Please see StatPearls' companion resource, "Paraphimosis," for more information.

Balanitis may also present as a manifestation of reactive arthritis or Reiter's disease. In these cases, it manifests as circinate balanitis, often associated with joint inflammation, mouth sores, and other generalized symptoms.[27] Please see StatPearls' companion resource, "Reactive Arthritis," for more information.

Evaluation

Balanitis is typically diagnosed through visual examination, as the clinical presentation and appearance of the lesions are sufficient. However, further evaluation may be necessary based on the patient's history and physical findings. These evaluations may include a bacterial culture (such as in the presence of purulent exudate), herpes simplex virus (HSV) testing (in the presence of vesicular or ulcerative lesions), syphilis testing (in the presence of an ulcer), checking for scabies, trichomonas and Mycoplasma genitalium (in the presence of urethritis). Please see StatPearls' companion resource, "Urethritis," for more information.

Men with suspected balanitis often complain of penile pain, itchiness, redness, and difficulty retracting the foreskin. There may be dysuria or difficulty with voiding, a foul odor, ulcerations, plaques, meatal stenosis, inguinal lymphadenopathy, or ballooning of the foreskin during micturition, indicating phimosis.

One of the primary goals in the evaluation and management of balanitis is to exclude STIs, minimize problems with urinary and sexual function, and exclude cancer of the penis. All patients presenting with balanitis should be considered for STI screening, including blood tests for syphilis, HIV, and HPV, and screening for diabetes. Any discharge should be cultured. A potassium hydroxide test can be performed to identify Candida.

The presence of penile ulcers or vesicles does not rule out balanitis, although these findings suggest HSV or syphilis, respectively.

There are some similarities between balanitis and squamous carcinoma of the penis. Both conditions are more likely to appear in older, uncircumcised males who exhibit poor genital hygiene and have a foul-smelling discharge, phimosis, and a rash or color change on the glans or foreskin. However, penile cancer is typically characterized by painless bleeding, a specific growth or distinct ulcer on the genitalia, and a lack of response to topical balanitis treatments.

Typically, the failure of a 4-week course of standard balanitis therapy or rapid growth despite treatment suggests a diagnosis of penile carcinoma.

In selected cases, dermoscopy may help differentiate common benign inflammatory disorders from the more dangerous premalignant and malignant causes.[28][29][30][31][32][33][34][35][36][37] If dermoscopy results are positive or inconclusive or the examination is unavailable, a biopsy, excision, or ablation should be performed for further evaluation and diagnosis.[28][29][30][31]

Please see StatPearls' companion resources, "Penile Cancer and Penile Intraepithelial Neoplasia," and "Dermoscopy Overview and Extradiagnostic Applications," for more information.

Treatment / Management

Proper genital washing performed gently with normal saline is recommended as initial therapy for all patients with balanitis.[38]

Topical antifungals, typically applied twice daily for 1 to 2 weeks or until symptoms resolve, are the treatment of choice for most adult patients with balanitis or balanoposthitis.[39] Topical imidazoles, such as clotrimazole 1% and miconazole 2%, are the preferred first-line therapy choices.[39] Nystatin cream is an alternative for patients allergic to imidazoles.[39] Bacitracin ointment (not neosporin) is typically recommended for children with balanitis.[40] Please see StatPearls' companion resources, "Clotrimazole," "Antifungal Ergosterol Synthesis Inhibitors," and "Bacitracin Topical," for more information.

In cases of more severe inflammation, adding fluconazole 150 mg orally or combining a topical imidazole and a low potency steroid, such as hydrocortisone cream 0.5% to 1% applied twice a day, often leads to resolution. Please see StatPearls' companion resources, "Fluconazole," and "Topical Corticosteroids," for more information.

Treatment with an oral antibiotic (dicloxacillin 500 mg or cephalexin QID × 7 days) and mupirocin topical cream applied TID for 7 to 14 days is appropriate if there is a concern for concomitant cellulitis or a secondary infection. Please see StatPearls' companion resource, "Cephalexin," for more information.

Anaerobic infections can be treated with metronidazole, whereas aerobic infections may be treated with oral cephalosporins, erythromycin, or amoxicillin/clavulanic acid.[39]

A failure of first-line therapy should raise concerns about a possible secondary infection or an underlying malignancy. In such cases, cultures should be obtained, and a tissue biopsy should be considered.

Circumcision is recommended for recurrent and intractable episodes, especially in immunocompromised and diabetic patients with significant phimosis. The use of a steroid cream with gentle manual retraction of the foreskin may be considered in milder cases of phimosis that are not too severe before resorting to surgical intervention.[41][42][43](A1)

In some cases, gentle dilation of a tight foreskin with a clamp may be attempted, but this can damage the hidden glans and urethra underneath and is contraindicated if there are penile adhesions between the glans and foreskin. This procedure typically requires sedation or local anesthesia. 

In emergency situations, a dorsal slit can be performed under local anesthesia to open a phimotic foreskin that interferes with voiding and otherwise precludes effective treatment.[44] Please see StatPearls' companion resource, "Phimosis," for more information.

Maintaining proper hygiene, such as frequent washing and drying of the prepuce, is an essential preventive measure. However, excessive genital washing with soap or potentially irritating substances may aggravate the condition. 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.[28]

There are several specific types of balanitis: 

Zoon balanitis: Balanitis circumscripta plasmacellularis, also called Zoon balanitis, is an erythematous inflammation of the glans penis that may also involve the foreskin. This balanitis typically affects middle-aged to older uncircumcised men and presents as symmetrical, well-demarcated, erythematous, shiny plaques with multiple pinpoint reddish specks called cayenne pepper spots on affected tissues. Treatment generally involves circumcision. Please see StatPearls' companion resource, "Balanitis Circumscripta Plasmacellularis," for more information.

Circinate balanitis: Circinate balanitis is associated with reactive arthritis, formerly known as Reiter's disease. This balanitis is characterized by small, shallow, erosive but painless ulcers on the glans penis. Circinate balanitis may appear as erythematous, annular plaques with polycyclic margins involving the meatus.[45] Histologically, it shows pustules in the upper epidermis that are 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.[28] This lesion can be mistaken for psoriasis on physical examination, and even a histological evaluation cannot always reliably distinguish between the 2 disorders.[45] 

The distinction between circinate balanitis and psoriasis is generally made clinically based on the history of reactive arthritis or psoriasis. Dermoscopy can also aid in differentiation.[32] 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.[45] Please see StatPearls' companion resource, "Reactive Arthritis," for more information.

Pseudoepitheliomatous keratotic and micaceous balanitis: Pseudoepitheliomatous keratotic and micaceous balanitis are extremely rare conditions characterized by dry, scaly, thick, wart-like skin lesions on the head of the penis, typically in men who were circumcised late in life.[46] Although typically benign, these conditions can become locally invasive or progress to verrucous carcinoma. The etiology is uncertain, and treatment varies according to the severity of the presentation.[46][47] Topical 5-fluorouracil can be used in the early stages.[47] Please see StatPearls' companion resource, "Fluorouracil," for more information.

Treatment Summary

Bacitracin ointment is most commonly used in children, whereas clotrimazole or miconazole is typically used in adults. More severe infections may require oral fluconazole and hydrocortisone cream. Intractable cases warrant a biopsy or a circumcision.[17]

Management generally includes the following:

• Topical antifungals for nonspecific balanitis
• Oral or systemic antifungals for severe or intractable fungal infections
• Antibiotics (oral or topical) for bacterial infections
• Topical corticosteroids for non-infectious dermatologic conditions
• Circumcision (or a dorsal slit procedure) for significant or symptomatic phimosis
• If available, consider dermoscopy for persistent or intractable cases. If positive or equivocal, proceed with a biopsy, ablative therapy, or excision
• Biopsy, ablation, or excision for suspected premalignant and neoplastic lesions

Differential Diagnosis

Balanitis is a descriptive and diagnostic term for a heterogeneous class of inflammatory or infectious dermatoses involving the glans penis, which require differentiation from potentially malignant conditions. Causes of balanitis include Candida spp. and bacterial infections, including anaerobic bacteria, viruses, parasites, and other STIs.[15][48]

Balanoposthitis is similar to balanitis but also involves the foreskin. The treatments for balanoposthitis are generally similar to those for balanitis.[39] Please see StatPearls' companion resource, "Balanoposthitis," for more information.

Various skin conditions may also mimic balanitis. Examples include the following: [39]

• Atopic dermatitis presents with penile dryness, pruritus, and edema of the glans and erythema. There is typically a history of recurrent nonspecific rashes. Please see StatPearls' companion resource, "Atopic Dermatitis," for more information.

• Contact dermatitis, an inflammatory skin condition, is caused by direct exposure to an irritant or allergens. Treatment involves gently washing with soap and water and applying a 1% hydrocortisone cream twice daily. Please see StatPearls' companion resource, "Contact Dermatitis," for more information.

• Eczema is a chronic or long-term dermal condition resulting in itchy, reddened, cracked, and dry skin. Treatment with 1% hydrocortisone twice daily is recommended.[39]

• Lichen planus is a skin pathology characterized by small, itchy, pink, or purple spots, typically on the arms or legs and male genitalia. Treatment varies from moderate to ultrapotent topical steroids depending on severity. Please see StatPearls' companion resource, "Lichen Planus," for more information.

• Lichen sclerosis, or balanitis xerotica obliterans, is an autoimmune dermatological disorder associated with whitish skin discoloration, hyperpigmentation, skin retraction, and atrophy that may occur on the glans. Clinically, it can cause meatal stenosis and phimosis characterized by white skin coloration and constriction of the involved lumen. Treatment is with ultrapotent topical steroids such as clobetasol propionate, but surgery such as circumcision, dorsal slit, or meatotomy may be necessary. Please see StatPearls' companion resource, "Lichen Sclerosus," for more information.

• Psoriasis is a dry, scaly skin disorder typically present in multiple body areas and can also appear on the glans. When psoriasis involves the glans, it is typically treated with a mild or medium-strength steroid, mild topical coal tar compound, calcipotriene cream (a type of vitamin D that works by slowing down skin cell growth), or a topical calcineurin inhibitor (pimecrolimus cream or tacrolimus ointment).[49][50][51][52] Please see StatPearls' companion resource, "Psoriasis," for more information.

Penile intraepithelial neoplasia is the new term that describes all precancerous penile dermatological lesions, replacing former terms such as Bowen disease, Bowenoid papulosis, squamous carcinoma in situ of the penis, and erythroplasia of Queyrat. These conditions are now classified as premalignant or early malignant penile cancers. Diagnosis and differentiation are based on histopathology, immunohistochemistry, dermoscopy, and reflectance confocal microscopy.[53] Penile intraepithelial neoplasia is often associated with balanoposthitis, phimosis, lichen planus, lichen sclerosis, immunosuppressive drugs, organ transplantation, HPV, and genital warts.[54] Please see StatPearls' companion resource, "Bowenoid Papulosis," for more information.

• Treatment is varied and individualized but may include topical therapies, such as imiquimod and fluorouracil; photodynamic therapy using topical methyl amino-levulinate followed by narrow-band red light exposure; radiation therapy; laser ablation; surgical excision; Moh's micrographic surgery; curettage with cautery; and cryotherapy.[53]
• Please see StatPearls' companion resources, "Penile Cancer and Penile Intraepithelial Neoplasia," and "Mohs Micrographic Surgery," for more information.

Prognosis

Balanitis and balanoposthitis generally have a good prognosis with appropriate treatment. Implementing optimal hygienic measures, particularly in older uncircumcised men with diabetes, can significantly reduce the incidence of these conditions.

Recognizing early that a failure of treatment could be an early indication of penile carcinoma is crucial in minimizing the morbidity and mortality associated with such cancers.

Complications

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

Phimosis is an abnormal constriction of the foreskin opening that precludes retraction over the glans penis caused by chronic inflammation and edema of the foreskin. The development of phimosis often complicates sexual function, voiding, and personal hygiene. If the patient or medical staff forcibly retracts the foreskin, paraphimosis (trapping of the foreskin behind the glans) can occur, requiring urgent surgical intervention.

In an emergency, phimosis is treatable by dilation using a surgical clamp and pain medication, possibly including a penile block. If this approach is unsuccessful, a dorsal slit can be performed to mitigate the problem. Definitive treatment, under elective circumstances, is generally a complete circumcision. Please see StatPearls' companion resources, "Phimosis," and "Dorsal Penile Nerve Block," for more information.

Paraphimosis is a urologic emergency characterized by the trapping of the foreskin behind the glans penis. In this condition, the constricting foreskin becomes positioned proximal to the glans, creating a band that restricts venous and lymphatic outflow while allowing continued arterial inflow. Within minutes to hours, this can lead to significant swelling and severe pain in the glans, necessitating urgent intervention to reduce or eliminate the paraphimosis. Please see StatPearls' companion resource, "Paraphimosis," for more information.

Genital yeast infections, also known as candidiasis or thrush, are uncommon in healthy individuals. However, in immunocompromised patients, such as those affected by HIV infections, transplant recipients, diabetics, and cancer patients, C. albicans can also cause sepsis with serious consequences.[3] Please see StatPearls' companion resource, "Candidemia," for more information.

Penile cellulitis, meatal stenosis, and balanoposthitis are additional potential complications.