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Balanitis

Balanitides

Balanitis is an inflammation of the glans penis.


Presentation

Some of the following are complaints presented by patients of balanitis [7]:

Systemic symptoms such as fever and nausea are rarely seen in patients.

Following physical examination the following findings may be noted:

Reiter's Syndrome
  • Circinate balanitis is the commonest cutaneous manifestation of reactive arthritis (Reiter syndrome), but can also occur independently.[ncbi.nlm.nih.gov]
  • Reactive arthritis (formerly Reiter syndrome) is associated with inflammation around the head of the penis (circinate balanitis).[rxlist.com]
  • There are also forms of balanitis that are associated with certain diseases such as circinate balanitis which is associated with adults who have Reiters syndrome and balanitis xerotica obliterans (BXO) in patients with lichen sclerosis .[aocd.org]
Heart Failure
  • Below are the proven etiologic factors of balanitis: Poor levlels of hygiene Use of soap and other chemical causes of irritation Congestive heart failure Cirrhosis Nephrosis Allergies Severe obesity The organisms and viruses that have been proven to cause[symptoma.com]
  • Less frequently, conditions such as penile cancer, congestive heart failure, cirrhosis, or morbid obesity underlie its appearance.[familiprix.com]
  • failure Morbid obesity Presentation Sore, inflamed and swollen glans/foreskin Non-retractile foreskin/phimosis Penile ulceration Penile plaques Satellite lesions May be purulent and/or foul-smelling discharge (most common with streptococcal/anaerobic[unityskinclinic.com]
Cutaneous Manifestation
  • Circinate balanitis is the commonest cutaneous manifestation of reactive arthritis (Reiter syndrome), but can also occur independently.[ncbi.nlm.nih.gov]
Penile Lesion
  • A middle-aged uncircumcised man presented with two long-standing erythematous prepucial penile lesions unresponsive to antibiotics.[ncbi.nlm.nih.gov]
  • It is important to differentiate PCB from a syphilitic chancre in a patient presenting with a nonhealing penile lesion. This case report demonstrates that these entities may be seen in the same patient at different times.[ncbi.nlm.nih.gov]
  • Although lesion biopsy and referral to a dermatologist is always a viable option, urologists can deliver excellent patient care when aware of the current knowledge of common penile lesions and recommended treatments.[scholars.northwestern.edu]
Chordee
  • All patients had a normal meatus and none had recurrent stricture, chordee or erectile dysfunction. A functional and cosmetic outcome was achieved in 100% of the patients.[ncbi.nlm.nih.gov]
  • All patients had a normal slit-like meatus and none had chordee or erectile dysfunction. Four group 2 patients (28.6%) required stomal revision and 2 had glans cleft narrowing after stage 1 urethroplasty.[ncbi.nlm.nih.gov]
Renal Impairment
  • Presented here is the case of a previously well 13-year-old boy who developed obstructive renal impairment (serum creatinine 190 micromol/l) at least in part from phimosis due to BXO.[ncbi.nlm.nih.gov]
Scrotal Mass
  • We describe an unusual case of balanitis xerotica obliterans (BXO) involving the entire anterior urethra and the scrotum that had presented as a palpable nodular scrotal mass with obstructive voiding symptoms in middle aged man.[ncbi.nlm.nih.gov]

Workup

In uncomplicated cases of balanitis, laboratory studies are not always necessary but the following can be useful when appropriate [8]:

Imaging studies that can be deployed include ultrasonography or bladder scan which will helps in detection of urinary obstruction following cases of severe balanitis. A biopsy carried out by a urologist is important in chronic cases.

Treatment

In patients with balanitis but without the accompanying phimosis, the following are useful recommendations [9]:

  • The foreskin must be gently retracted and soaked in warm water, cleaning the foreskin and the penis.
  • In patients with mild balanitis xerotica and in pediatric cases, a 2-month trial of antifungals may be attempted. The patient or parent of the pediatric case should retract the foreskin gently and apply 0.05% betamethasone two times a day. This is applicable to children older than 3 years of age. It is more successful in males older than 10 years however, with a success rate of 65-95%. 
  • Topical steroids will only bring about limited success especially in patients with moderate-to severe cases of balanitis xerotica obliterans. Using these in such cases often leads to the distal scarring of the foreskin. 
  • In recurrent cases, 1% pimecromillus cream can be used instead of steroids. 
  • In pediatric patients, bacitracin can be applied if bacterial infection is suspected. Neosporin should not be used. 
  • In adult men with probable candida balanitis, topical clotrimazole should be used. 
  • In complicated cases such as those with associated cellulitis, a culture of discharge should be obtained. Treatment should then be done empirically with the right antibiotics. 
  • Fluticasone proprionate is effective in treatment of associated phimosis and the success rate is placed at 91.1% of cases. 

Patients with severe urinary obstruction as a complication of balanitis should get the following care:

  • Surgical intervention should be performed by a urologist when possible
  • Steroid cream and gentle retraction of the foreskin when phimosis isn’t excessively tight should be used before surgery is contemplated.
  • Without damaging the glans penis, the foreskin should be dilated with the use of a clamp. Analgesia, local anaesthesia and sedation may be required in some instances. 
  • A formal circumcision can be performed.

It is important to note that circumcision is not a preventative treatment of balanitis in males younger than 3 years of age [10].

Prognosis

Prognosis is largely dependent on the main causes of the condition and also the presence of any predisposing risk factors [6]. For instance, candidal balanitis often resolves rapidly with the right treatment but it is more than likely to recur in men with phimosis, poor genital hygiene and diabetes mellitus.

Balanitis as a result of contact irritants often gets resolved over a few days following removal of the provoking irritant or allergen. However, it may recur following future exposure.

Etiology

There are many possible causes of this inflammation [2]. Some of them include irritation by environmental substances, physical trauma, and infection by a wide variety of pathogens which may include bacteria, virus, fungus or sexually transmitted diseases (STDs). Diabetes has also been noted as a risk factor for balanitis especially when blood sugar is not properly controlled.

Below are the proven etiologic factors of balanitis:

The organisms and viruses that have been proven to cause balanitis, including the following:

Borrelia vincentii and Borrelia burgdorferi, trichomonal species, syphilis, Gardnerella vaginalis, human papillomavirus (HPV), chlamyida species, Neisseria gonorrhea and in people with diabetes, candidal species. 

Epidemiology

In the United States, balanitis is a common condition which affects at least 3 to 11% of males [3]. There is however, no proof of mortality associated with balanitis. Morbidity on the other hand is associated with the complications of phimosis.

The condition is seen mostly in blacks and Hispanics. There is no clear reason for this but it may be related to the different rates of circumcision.

Balanitis can be seen in males at any age but etiologies vary depending on the age of the individual [4].

Sex distribution
Age distribution

Pathophysiology

The males most affected by balanitis are those with poor personal hygiene [5]. Due to smegma and discharge around the glans penis, lack of aeration and irritation ensues and this leads to inflammation and edema. The main complications of balanitis include phimosis and cellulitis but these are relatively uncommon. Meatal stenosis accompanied by urinary retention is seen with balanitis in rare cases. Another rare occurrence is the buried penis syndrome as a result of balanitis.

Prevention

Personal hygiene is the most important preventive measure for this condition. Also, use of all irritants must be instantly halted as soon as discomfort or irritation is noticed. Circumcision is not a guarantee for prevention but circumcision done at birth greatly reduces the chances of balanitis.

Summary

Balanitis refers to the inflammation of the glans penis [1]. When the condition affects the foreskin as well, it is known as balanoposthitis. Recurrent cases of balanitis may cause a complication known as phimosis. It most commonly occurs in uncircumcised men.

Patient Information

Balanitis is a condition where the head of the penis develops a sort of a wound. There are many causes of this condition but the most common causes are the use of irritating substances as well as sexually transmitted infections.

The condition can affect men of all ages but it can be easily treated with the use of special creams as long as there has not been any opportunistic complications or infections.

References

Article

  1. Lisboa C, Ferreira A, Resende C, Rodrigues AG. Infectious balanoposthitis: management, clinical and laboratory features. Int J Dermatol. Feb 2009;48(2):121-4.
  2. Kuehhas FE, Miernik A, Weibl P, Schoenthaler M, Sevcenco S, Schauer I, et al. Incidence of Balanitis Xerotica Obliterans in Boys Younger than 10 Years Presenting with Phimosis. Urol Int. Dec 29 2012.
  3. Mohammed A, Shegil IS, Christou D, Khan A, Barua JM. Paediatric balanitis xerotica obliterans: an 8-year experience. Arch Ital Urol Androl. Mar 2012;84(1):12-6.
  4. Philippou P, Shabbir M, Ralph DJ, Malone P, Nigam R, Freeman A, et al. Genital lichen sclerosus/balanitis xerotica obliterans in men with penile carcinoma: a critical analysis. BJU Int. May 2013;111(6):970-6.
  5. Georgala S, Gregoriou S, Georgala C, et al. Pimecrolimus 1% cream in non-specific inflammatory recurrent balanitis. Dermatology. 2007;215(3):209-12. 
  6. Peutherer JF, Smith IW, Robertson DH. Necrotising balanitis due to a generalised primary infection with herpes simplex virus type 2. Br J Vener Dis 1979; 55:48.
  7. Kinghorn GR, Jones BM, Chowdhury FH, Geary I. Balanoposthitis associated with Gardnerella vaginalis infection in men. Br J Vener Dis 1982; 58:127.
  8. Edwards S. Balanitis and balanoposthitis: a review. Genitourin Med 1996; 72:155.
  9. Palamaras I, Hamill M, Sethi G, et al. The usefulness of a diagnostic biopsy clinic in a genitourinary medicine setting: recent experience and a review of the literature. J Eur Acad Dermatol Venereol 2006; 20:905.
  10. Buechner SA. Common skin disorders of the penis. BJU Int 2002; 90:498.

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Last updated: 2017-08-09 18:02