4.3.3 Balanitis

GB06.01 Irritant balanitis/balanoposthitis;

GB06.02 Balanitis/balanoposthitis due to infection;

GB06.0Z Balanoposthitis, unspecified;

GB06.0Y Circinate balanitis;.

1F23.11 Candida balanoposthitis;

2E67.4 Carcinoma in situ of penis (penile intraepithelial neoplasia).

Inflammation of the glans penis and/or prepuce (foreskin).

Balanitis/balanoposthitis is one the most frequent male genital skin problems affecting both, pediatric patients and adults. Prevalence in males of all ages is between 12% to 20%. In adult men, uncircumcised males with diabetes mellitus have the highest prevalence of 35%. Circumcision considerably decreases the prevalence of inflammatory conditions of the glans penis.

Inflammation of the glans penis and/or the prepuce (posthitis).

The most common etiology of balanoposthitis is poor hygiene. Preputial dysfunction and diabetes are promoting factors. Circumcision considerably decreases the risk.

Spectrum of possible pathogenetic factors: see symptoms and classification respectively.

The symptoms and signs vary according to the aetiology.

• Candidal balanoposthitis: blotchy erythema with small papules.

• (Anaerobic) Bacterial infection: uniform erythema with exudative preputial foul smelling discharge.

• Irritant / allergic balanitis-balanoposthitis: mild erythema with or without pruritus, resulting from frequent genital washing, atopy, delayed hypersensitivity to common allergens  (e.g. latex condoms, preservatives, fragrances).

• Fixed drug eruptions (tetracyclines, phenolphthalein, phenacetin, NSAIDs, barbiturates or sulfa-drugs): round, erythematous patches, turning dark upon healing. Vesicles may occur.

• Non- specific balanoposthitis: no evidence of underlying cause.

• Lichen sclerosus: white patches on the glans, often with involvement of the prepuce; haemorrhagic vesicles, purpura and rarely haemorrhagic blisters and ulceration; itching. Blunting of the coronal sulcus, destruction of the frenulum, phimosis or ‘waisting’ of the prepuce (constrictive posthitis), and meatal thickening and narrowing may develop.

• Lichen planus: purplish, well demarcated plaques or erosive, annular lesions on the glans and prepuce.

• Psoriasis: red plaques without scaling.

• Zoon’s (plasma cell) balanitis: in uncircumcised males aged 40 years or older.  It presents with well-circumscribed orange-red glazed areas on the glans and the inside of the foreskin, with multiple pinpoint redder spots - “cayenne pepper spots”.

• Circinate balanitis: greyish white areas on the glans which coalesce to form “geographical” areas with a white margin.

  • sporadically.

  • as a sign of the post infective Reiter’s disease (triggered by urethritis or enteritis in genetically predisposed individuals).

  • in association with HIV infection.

• Premalignant lesions

  • Erythroplasia of Queyrat: red, velvety, well-circumscribed area on the glans or visceral prepuce (45%), glans (38%) or shaft of the penis (3%).

  • Bowen’s disease: scaly, discrete, erythematous patches or plaques and

  • Bowenoid papulosis: firm papules to plaques, often grouped and pigmented or erythematous.

Glans penis and/or prepuce (foreskin).

The balanitis/balanoposthitis is classified in three main groups based on the etiopathogenesis.

• Infective balanoposthitis

  • Viral infections: Human papillomavirus (HPV).

  • Herpes simplex virus (HSV).

  • Fungal infections Candida spp.

  • Bacterial infections: Staphylococcus spp; Streptococcus spp. Sexually transmitted infections (Trichomonas vaginalis, syphilis; Mycoplasma genitalium).

• Inflammatory balanoposthitis: lichen sclerosus, lichen planus,  psoriasis and circinate balanitis, Zoon’s balanitis, eczema (irritant, allergic or seborrheic), allergic reactions (including fixed drug eruptions). 

• Penile intraepithelial neoplasia (PeIN) is a premalignant precursor lesion of invasive penile SCC, a SCC in situ (Bowen’s disease, Bowenoid papulosis and Erythroplasia of Queyrat). 

Skin diseases affecting the glans penis and genitalia (psoriasis, erythema multiforme, immuno-bullous disorders (e.g. pemphigus), dermatitis artefacta). 

Sub-preputial swab for Candida and bacterial cultures (e.g. Gardnerella vaginalis as a facultative anaerobe), urinalysis for glucose (if candidal infection suspected), Trichomonas vaginalis  nucleic acid amplification test (NAAT), full routine screening for other STIs. Testing for HLAB27 in case of circinate balanitis. Patch testing with common allergens.

A penile biopsy should be performed if features are atypical or do not resolve with treatment.

Not needed for infectious balanoposthitis patients.

• Lichen sclerosus: atrophic epidermis with follicular hyperkeratosis. Band of hyalinisation with loss of the elastin fibres in the upper dermis with an underlying perivascular lymphocytic infiltrate.  

• Lichen planus: irregular saw-toothed acanthosis, increased granular layer and basal cell liquefaction and a band-like dermal lymphocytic infiltrate.

• Fixed drug eruptions: hydropic degeneration of the basal layer and epidermal detachment and necrosis with pigmentary incontinence.

• Zoon’s plasma cell balanitis: epidermal thickening, followed by epidermal atrophy.  Predominantly plasma cell infiltrate in the dermis with haemosiderin deposition and extravasated red blood cells.

• PeIN: dysplastic changes of the squamous epithelium. 

Most balanitis cases recover with changes in hygiene and therapy with emollients within one to two weeks. 

Severe balanitis may be complicated by phimosis and urinary retention. Impact on the patient’s sexual life and psychosocial problems.

Clinical features and laboratory workup (see above).

See classification.

Exclusion or treatment of predisposing factors (poor hygiene, diabetes mellitus). Good personal hygiene, washing daily, avoiding irritants; keeping the foreskin retracted. 

• Nonspecific balanoposthitis:   gentle cleaning of the area 2 to 3 times per day by retracting the foreskin and cleaning with gentle use of cotton swab.

• Candidal balanoposthitis: clotrimazole or miconazole cream, twice a day for 7-14 days. Topical imidazole with 1% hydrocortisone is a choice if marked inflammation is present.

• Aerobic bacterial: topically mupirocin cream twice a day or with clobetasone butyrate /oxytetracycline/ nystatin-cream once or twice daily for 7-10 days. Severe cases may require systemic antibiotics while awaiting culture results: flucloxacillin 500 mg x4/ d or clarithromycin 250 mg twice daily for seven days.

• Anaerobic subpreputial infection: improved genital hygiene, topical or oral metronidazole 400 - 500mg twice daily for one week. Alternatively, co-amoxiclav 375mg three times daily for one week or clindamycin cream twice daily until resolved.

• HSV, Trichomonas vaginalis, Mycoplasma genitalium or syphilis is treated as per specific guidelines for these diseases.

• Irritant / allergic balanitis-balanoposthitis: avoidance of precipitants like soaps, use of low-allergy products, emollients (used as a soap substitute), hydrocortisone once or twice daily until resolution of symptoms. Avoidance of potential allergens (latex condom, lubricants).

• Fixed drug eruptions: symptomatica treatmant with mild to moderate steroid creams.

• Seborrheic dermatitis: topical antifungal cream with a mild to moderate steroid.

• Psoriasis: moderate potency topical steroids (+/- antibiotic and antifungal), emollients, calcipotriol or calcitriol (applied twice daily). 

• Circinate balanitis  is treated similarly.

• Lichen sclerosus: Topically, ultrapotent topical steroids (e.g. clobetasol proprionate) twice daily for a month.

• Lichen planus: for treatment of lichen planus, see the corresponding chapter.

• Zoon’s (plasma cell) balanitis: good hygiene, topical steroid creams and antibacterial creams (e.g. mupirocin) applied twice daily. Alternative topical calcineurin inhibitors and imiquimod 5% cream.

• Premalignant penile lesions, PeIN, should be referred to specialists in dermatology and urology/andrology. For topical therapy imiquimod 5%, fluorouracil cream 5%, fluorouracil 0.5% / salicylic acid 10% combination or podophyllotoxin 0.5% are alternatives.  Local surgical excision, cryotherapy, photodynamic therapy or laser treatment. 

Lichen sclerosus may be complicated by phimosis and paraphimosis, urethral stenosis, penile intraepithelial neoplasia (PeIN) or even malignant transformation to squamous cell carcinoma (about 50%).

2020 European guideline for the management of balanoposthitis, by Sarah K. Edwards, Christopher B. Bunker, Eric M. van der Snoek and Willem I. van der Meijden/  IUSTI Europe, European Academy of Dermatology and Venereology (EADV), European Dermatology Forum (EDF), European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Union of European Medical Specialists (UEMS)