Balanoposthitis

Definitions:

• Balanitis - inflammation of the glans penis
• Posthitis - inflammation of the foreskin
• Balanoposthitis - inflammation of the glans penis and foreskin

Balanitis is common in young boys with a non-retractile foreskin and in the elderly where there may be predisposing factors such as malignancy or diabetes. The organisms most commonly involved are faecal bacteria and candida.

Presentation is with irritation or pain in the penis and discharge from beneath the foreskin. Inflammation is visible. Recurrent balanitis may cause a phimosis with disturbance of micturition.

Management:

• treatment depends on the cause
  • anyone with balanitis should be advised to (1):
    • avoid contact with any potential skin irritants (e.g. soap)
    • keep area clean by bathing twice daily with a weak saline solution while symptoms persist
• in consideration of men with acute balanitis
  • refer all men with acute balanitis and suspected urethritis, ulceration, or lymphadenopathy to a genito-urinary medicine clinic (1)
    • with the exception of recurrent ulceration due to herpes simplex in someone with an established diagnosis
• swab the sub-preputial space prior to starting empirical treatment (1)
• balanitis secondary to candida responds to topical antifungal cream or oral antifungal treatment
  • in adults, treatment options include:
    • topical imidazole e.g. econazole, ketoconazole, sulconazole, clotrimazole 1% or miconazole 2% applied twice a day till the symptoms resolve
    • oral fluconazole - 150mg stat if symptoms are severe
    • topical nystatin - in case of resistance and allergy to imidazole (2)
    • topical terbinafine
  • in children, treatment options include
    • a topical imidazole e.g. clotrimazole, econazole, ketoconazole, miconazole, sulconazole
    • topical nystatin
  • recommended that treatment with a topical antifungal should be continued for 2-3 days after clinical cure
• bacterial balanitis may require oral antibiotic treatment (e.g. flucloxacillin or erythromycin)
• sometimes a combined steroid/antibiotic cream (e.g. hydrocortisone acetate 1%, fusidic acid 1%) or combined antifungal/steroid cream (e.g. hydrocortisone 1%, clotrimazole1%) is used to reduce inflammation caused by infection
  • topical corticosteroid should be applied until the inflammation has cleared
    • twice a day for up to 2 weeks (2)

Referral for consideration for circumcision may be necessary once the inflammation has settled. (3)

Older patients should be tested for diabetes. (1)

Reference:

1. Edwards SK, Bunker CB, van der Snoek EM, et al. 2022 European guideline for the management of balanoposthitis. J Eur Acad Dermatol Venereol. 2023 Jun;37(6):1104-17.

2. British Association for Sexual Health and HIV. 2008 UK National Guideline on the Management of Balanoposthitis

3. Hayashi Y et al. Prepuce: phimosis, paraphimosis, and circumcision. ScientificWorldJournal. 2011 Feb 3;11:289-301.