Published on 19/03/2015 by admin
Filed under Dermatology
Last modified 19/03/2015
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Ginat W. Mirowski and Bethanee J. Schlosser
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Balanitis (balanoposthitis, inflammation of the glans penis and occasionally the foreskin [prepuce]) occurs in both men and boys. Balanitis has many causes including poor hygiene, friction, infection, malignancy, and numerous dermatoses and may be multifactorial. The presence of foreskin (uncircumcised state) increases the risk of developing balanitis. Clinically, patients present with itching, irritation, and shiny erythema associated with an exudate or smegma. Urethral discharge is not present. Complications may include fissuring and pain, phimosis (inability to retract the foreskin due to agglutination/scarring), and stenosis or obstruction of the urethral meatus; surgical correction of sequelae may be necessary.
This chapter will focus on the treatment of non-specific balanitis, lichen sclerosus (LS, lichen sclerosus et atrophicus, balanitis xerotica obliterans, BXO) and Zoon’s (plasma cell) balanitis. Genital ulcers, genital warts, and urethral discharge will not be discussed.
Evaluation of a patient with balanitis should include chief complaint, history of present illness, past medical and surgical history, medications, allergies, and review of systems. Specific information should be sought regarding sexual habits (number, gender, and symptomatology of sexual partners) and alleviating or exacerbating factors. To identify potential allergens and/or irritants, the patient’s genital hygiene practices and the use of oral and topical agents (condoms, spermicides, sexual enhancing products, lubricants, etc.) should be sought. A complete mucocutaneous examination including extra-genital sites should be performed. The genital examination includes skin and soft tissue structures extending from the lower abdomen to the perianal skin/gluteal cleft. Examination findings should direct the acquisition of microbiologic studies (KOH preparation, bacterial, fungal and viral cultures), biopsy (hematoxylin and eosin, direct immunofluorescence), and serologic studies. Treatment of balanitis is dictated by results of these investigations.
Patients with balanitis should be instructed on appropriate local hygiene care including retraction of the foreskin prior to cleaning. The glans and shaft should be cleaned with plain water or normal saline twice daily and after sexual activity. Soap and topical products may be irritants or allergens and should be avoided. A bland emollient (plain white petrolatum or similar) applied twice daily will minimize friction and improve barrier function.
Medical therapy for balanitis is dictated by etiology. Circumcision is indicated in refractory cases. Urethral meatotomy or meatoplasty, glans resurfacing and other surgical procedures may be required for patients with significant anatomic distortion or compromised urinary function. Collaboration with urologic specialists is essential.
KOH microscopy for fungi
Tzanck smear or direct fluorescent antigen testing for herpes viruses
Swab culture for bacteria, viruses, and fungi
Biopsy for routine histopathology and direct immunofluorescence, if indicated
Fasting blood glucose
Urinalysis and urine glucose
Serologic tests for syphilis, herpes virus, and human immunodeficiency virus
Serologic tests for vesiculobullous diseases (systemic lupus erythematosus, pemphigus vulgaris, bullous pemphigoid, etc.)
Patch testing
Fornasa CV, Calabro A, Miglietta A, Tarantello M, Biasinutto C, Peserico A. Genitourin Med 1994; 70: 345–6.
Patients (n = 321) with balanitis were evaluated. Infection was diagnosed clinically in 185. Dermatologic conditions included traumatic/irritant contact dermatitis (n = 17), psoriasis (n = 11), lichen planus (n = 9), LS (n = 8), neoplasm (n = 8), Zoon’s (n = 3), and allergic contact dermatitis (n = 3). Of 51 individuals with mild balanitis who required further testing, etiologies included infection (n = 12, including Candida albicans, Chlamydia trachomatis, β-hemolytic streptococcus, gastrointestinal bacterial flora), irritant contact dermatitis (n = 9), mechanical trauma (n = 7), and allergic contact dermatitis (n = 6). No identifiable etiology was found in 17 patients.
Edwards S. Genitourin Med 1996; 72: 155–9.
Thorough review of infectious causes of balanitis with differential diagnosis considerations.
Edwards SK. Int J STD AIDS 2001; 12 (Suppl 3): 68–72.
Comprehensive review of the many causes of balanitis with specific recommendations for evaluation and management.
Teichman JM, Csea J, Thompson IM, Elston DM. Am Fam Physician 2010; 81: 167–74.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
