Balanitis

Aka: Balanitis, Posthitis, Balanoposthitis, Foreskin Infection, Foreskin Inflammation

1. See Also
   1. Circinate Balanitis
   2. Balanitis Xerotica Obliterans
2. Definitions
   1. Balanitis
      1. Glans penis inflammation or infection
   2. Posthitis
      1. Foreskin Inflammation or infection
   3. Balanoposthitis
      1. Foreskin and glans penis inflammation or infection
3. Epidemiology
   1. Incidence: 3% of uncircumsized males
4. Pathophysiology
   1. Limited to uncircumsized males, especially if poor hygiene
   2. Results from irritant or infection
   3. Fungal infection (especially candida) is most common cause in all ages
      1. Higher risk in Diabetes Mellitus
   4. Bacterial Infection can also cause Foreskin Infection (especially in children)
5. Causes
   1. Contact Dermatitis (Irritant Balanitis)
      1. Soap
      2. Bubble bath
      3. Fabric softeners
      4. Laundry detergent
   2. Infectious Balanitis
      1. Candida albicans (40% of cases)
      2. Gram-Negative Bacteria
      3. Trichomoniasis (Trichomonas Vaginalis)
      4. Group A Beta-hemolytic Streptococcus (may be passed via oral sex)
      5. Neisseria gonorrhoeae
      6. Chlamydia
      7. Gardnerella
      8. Anaerobic Bacteria
      9. Herpes Simplex Virus
      10. Human Papilloma Virus
      11. Primary Syphilis
          1. Erosive Balanitis (Chancre may be absent)
   3. Circinate Balanitis (geographic appearance) due to Reactive Arthritis (previously known as Reiter's Syndrome)
      1. Chlamydia trachomatis (most common)
      2. Yersinia
      3. Campylobacter
      4. Shigella
      5. Salmonella
      6. Chlamydia pneumoniae
6. Risk Factors
   1. Diabetes Mellitus
   2. Poor hygiene
   3. Irritants (See causes above)
7. Findings: Signs and Symptoms
   1. Local pain and swelling at glans penis
   2. Discharge between foreskin and glans penis
   3. Pruritus
8. Differential Diagnosis
   1. Contact Dermatitis (as above)
   2. Infectious Balanitis (as above)
   3. Inflammatory Conditions
      1. Lichen Sclerosus
      2. Lichen Planus
      3. Psoriasis
      4. Eczematous Dermatitis
      5. Seborrhea
      6. Balanitis Xerotica Obliterans
         1. Chronic inflammation of peri-mucosal skin
      7. Circinate Balanitis (Reactive Arthritis)
         1. Urethral discharge may be present in Chlamydia infection
         2. Diarrhea may be present (e.g. Yersinia, Campylobacter, Shigella, Salmonella)
         3. Associated Arthritis, Conjunctivitis and Urethritis
   4. Premalignant Conditions
      1. Penile Carcinoma-in-situ (Bowen's Disease, Erythroplasia or Queyrat)
9. Management
   1. Irritant Balanitis
      1. Sitz bath
      2. Retract foreskin and clean glans
      3. Consider brief topical Hydrocotisone 0.5%
   2. Infectious Balanitis (Candida most common source)
      1. Good hygiene
      2. Fungal causes (esp. adults)
         1. Topical Antifungal cream (e.g. Clotrimazole, Nystatin)
         2. Systemic Antifungals
            1. Fluconazole 150 mg orally for one dose
            2. Itraconazole 200 mg twice daily for one day
      3. Bacterial causes (esp. children)
         1. Topical antibiotic (e.g. Bacitracin)
         2. Consider Metronidazole (Flagyl) 2 grams for 1 dose (adult dose) for anaerobic causes
         3. Cellulitis or erythema extends onto penile shaft
            1. First generation Cephalosporin (e.g. Cephalexin or Keflex)
   3. Circinate Balanitis (geographic pattern)
      1. Test Chlamydia trachomatis PCR (and treat if present)
      2. Consider other causes of Reactive Arthritis
      3. Topical Corticosteroids
10. Prevention
    1. Foreskin hygiene
       1. Retract foreskin and clean with soap and water daily
    2. Circumcision
       1. Indicated in recurrent foreskin-related infection
11. References
    1. Marx (2002) Rosen's Emergency Medicine, Mosby, p. 2838
    2. Lisboa (2009) Int J Dermatol 48(2):121-4 +PMID:19200183 [PubMed]
    3. Lundquist (2001) Emerg Med Clin North Am 19(3):529-46 [PubMed]
    4. Pandya (2014) Indian J Sex Transm Dis AIDS 35(2): 155-7 [PubMed]
       1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4553848/