Balanitis


Overview

Balanitis is a nonspecific term meaning inflammation of the glans penis. It is most commonly multifactorial in etiology, restricted to the uncircumcised, and presents as a mildly symptomatic scaly, red macule or patch. Acute suppurative balanitis may also occur in the uncircumcised. The therapy of those two types is discussed separately. Certain specific skin diseases (e.g., Reiter’s disease, psoriasis, lichen planus, lichen sclerosis et atrophicus, syphilis, and scabies) may affect the glans penis preferentially. A total skin examination to rule out these other conditions should be performed. Any area of balanitis not responding to conventional therapy should be biopsied to rule out carcinoma in situ (erythroplasia). Since the diagnosis of balanitis is nonspecific, therapeutic strategy differs depending on the suspected or demonstrated clinical diagnosis.

Treatment

Erythematous Scaly Patch Type

First Steps

  1. Educate the patient on the underlying conditions (moisture, bacterial, and candidal overgrowth, and if appropriate, inadequate local hygiene) which make the patient susceptible to balanitis.
  2. To eliminate moisture, instruct the patient to retract the foreskin and wash with a mild soap (rinsed off well) once daily.
  3. To eradicate candida, which thrives in a moist, warm environment, prescribe nystatin ointment to be applied sparingly to the glans penis after washing.
  4. Order a serologic test for syphilis and evaluate the patient for diabetes mellitus.
  5. Evaluate the sexual partner(s) for candidal, bacterial, or trichomonal vaginitis, proctitis, and oral thrush.

Alternative Steps

An imidazole cream (clotrimazole, miconazole, etc.) may be used instead of the nystatin ointment, but is not as moisturizing.

Subsequent Steps

  1. A mild topical steroid hydrocortisone cream (0.5% to 2.5%) may be added to the topical anticandidal therapy in refractory cases.
  2. Castellani’s paint or gentian violet/potassium permanganate solutions may be effective applied once or twice weekly. This allows therapy in the office to ensure compliance.
  3. Take a careful drug history to rule out a fixed drug eruption.
  4. Consider the possibility of an allergic contact dermatitis (e.g., from condoms or vaginal hygiene spray).
  5. Biopsy patients not responding to these measures.
  6. Circumcision will usually result in resolution in refractory cases.

Pitfalls

  1. Do not make the diagnosis of a nonspecific balanitis until other skin diseases, including carcinoma in situ, have been ruled out.
  2. Do not refer a patient for circumcision until a biopsy has been performed.
  3. Avoid prolonged steroid use on the glans penis, as atrophy is common. In addition, the withdrawal of topical steroids when they have been used chronically often results in a flare of symptoms. Steroid dependency becomes a problem.

Acute Suppurative Balanitis

First Steps

  1. If the foreskin cannot be retracted, consider referral to a urologist for a dorsal slit.
  2. Perform a bacterial culture of the purulent discharge.
  3. Evaluate the patient for urethritis, especially gonococcal, candidal, or trichomonal.
  4. Order a serologic test for syphilis.
  5. Instruct the patient to retract the foreskin twice daily and gently compress with Burow’s solution 1:20 with acetic acid 0.25% for 15 minutes.
  6. Prescribe nystatin ointment applied twice daily after compressing.

Subsequent Steps

  1. If the bacterial culture grows a single pathogen (other than P. aeruginosa) and the balanitis persists, treat with an appropriate oral antibiotic. If P. aeruginosa is cultured, prescribe tobramycin ophthalmic ointment to be applied twice daily. If an anaerobe or Bacteroides species are cultured, prescribe metronidazole 500 mg twice daily for 5 days.
  2. Evaluate the patient for diabetes mellitus.
  3. Take a careful history of intermittent drug ingestion to rule out a fixed drug eruption.
  4. Evaluate the sexual partner(s) for infection with C. albicans, T. vaginalis, and G. vaginalis.

Pitfalls

  1. Failure to retract the foreskin and carefully examine the patient for a penile ulcer or urethritis will often lead to a misdiagnosis.
  2. Since staphylococcus and Group A streptococcus are rare causes of balanitis, the use of topical mupirocin is not recommended.