Approach to balanitis/balanoposthitis: Current guidelines

INTRODUCTION

Balanitis describes inflammation of the glans penis and posthitis means inflammation of the prepuce. In practice, both areas are often affected together, and the term balanoposthitis then used. It is a collection of disparate conditions with similar clinical presentation and varying etiologies affecting a particular anatomical site [Table 1]. Balanitis is common in uncircumcised men as a result of poorer hygiene and aeration or because of irritation by smegma and in many cases preputial dysfunction is a causal or contributing factor. Balanitis may be more severe in the presence of some underlying medical conditions. It has been reported as a source of fever and bacteremia in neutropenic men and candidal balanitis may be especially severe in patients with diabetes mellitus.[1]

Table 1.

Conditions affecting the glans and prepuce2

CLINICAL FEATURES

Symptoms and signs vary according to etiology. Descriptions of the typical appearances of infective balanitides are discussed in detail [Table 2].

Table 2.

Infectious causes[2]

APPROACH TO PATIENT WITH BALANITIS

Diagnosis [Table 2]

Balanitis is a descriptive term covering a variety of unrelated conditions, the appearances of which maybe suggestive, but should never be thought to be pathognomonic, and biopsy is sometimes needed to exclude premalignant disease.

Management [Table 2]

The objectives of management are:

• To minimize sexual dysfunction

• To minimize urinary dysfunction

• To exclude penile cancer

• To treat premalignant disease

• To diagnose and treat sexually transmitted disease.

*All persistent/undiagnosed genital lesions regardless of appearance must be evaluated for herpes

Take home message:

• Predisposing factors include poor hygiene and over washing, over-the-counter (OTC) medications, as well as nonretraction of the foreskin

• Many cases of balanitis seen in practice are a simple intertrigo; that is, inflammation between two layers of skin with bacterial or fungal overgrowth

• Rapid resolution can be achieved most frequently in practice by advising the patient to keep his foreskin retracted if possible, having advised him of the risk of paraphimosis

• Saline baths are also useful and medicated OTC talcum powders are helpful in drying the area. This advice is simple, but compliance may be challenging

• Many patients will present having tried antifungal creams, often obtained OTC. Such cases usually come with relapse. The simple measures have a more durable effect

• HIV should be ruled out in every case not responding to therapy/having atypical presentation.

Figure 1.

Herpetic balanitis