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Balanitis and balanoposthitis diagnosis and management

Last updated: January 2017

Diagnosis

Clinical

Diagnosis of non-specific balanitis is made clinically by a typical appearance of the glans penis and foreskin (prepuce), which may include an erythematous maculo-papular rash, with scaling, odour and shallow ulcerations. More severe cases may display oedema, fissuring, crusting, exudate, discharge from glans behind the foreskin, sclerosis, and phimosis.

Specific conditions such as bacterial (aerobic and anaerobic infections), viral (herpes simplex infections), fungal infections (candida) or dermatological conditions (lichen scleroses, which has up to 10% malignant risk, Zoon’s/plasma cell balanitis, psoriasis, circinate balanitis, irritant/allergic balanitis, fixed drug eruptions) and pre malignant conditions like erythroplasia of Queyrat, Bowen’s disease and Bowenoid papulosis display condition specific features.

Laboratory

Subpreputial swabs for Viral (HSV) NAAT especially if erosions or ulcerations present, bacterial and fungal culture as clinically indicated.

Histopathological

Assessment of a biopsy specimen is only indicated in severe cases, or where diagnosis is unclear, as clinically indicated.

Notes

Please note the following:

  • Balanitis is the inflammation of the glans penis and posthitis is the inflammation of the foreskin (prepuce). The term balanoposthitis refers to inflammation of both glans penis and prepuce.
  • It is a collection of disparate conditions with similar clinical presentations but with varying aetiologies affecting a particular anatomical site.
  • Balanitis is uncommon in circumcised men and preputial dysfunction is a common contributing factor.
  • Predisposing factors include:
    • Recent sexual contact
    • Diabetes
    • Recent use of oral antibiotics
  • Diabetic patients often present with more severe balanoposthitis with oedema and fissuring of the foreskin. Fungal balanitis is more common in diabetics, and is suggested by the presence of fissures and satellite lesions
  • Screening for diabetes with urine and / or blood glucose testing should be considered in men presenting with recurrent/ severe balanoposthitis who:
    • Have symptoms of diabetes
    • are aged over 40 years old
    • are overweight
    • have a family history of diabetes.

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Treatment

Non specific balanitis

Although specific pathogens may be isolated from the inflamed area, medication has a limited role in mild-moderate non-specific balanoposthitis.

Some clinicians may choose to use a short course of topical creams containing antifungals such as miconazole and/or 1% hydrocortisone depending on clinical judgement.

For example:

1% hydrocortisone BD for 7 days topically.

Miconazole 2% BD until symptoms resolved and continue for 7 days afterwards

Clotrimazole 1% BD until symptoms resolved and continue for 7 days afterwards

Please note that steroids should only be used short term, and not recurrently without further assessment. Steroids can mask an ongoing condition that needs further assessment and diagnosis if the condition persists or recurs. Patients should be advised not to use OTC steroids recurrently without medical supervision.

If the diagnosis is not clear steroids should be avoided, and herpes should be excluded before steroids are used.

If initial management with topical steroid cream, antifungals and hygiene measures does not resolve the issue, seek specialist Sexual Health Physician or Dermatologist advice and review.

Foreskin hygiene is key. Under-washing and over-washing should be avoided. Patients should be advised to wash once a day. The process involves thoroughly washing the retracted foreskin and glans with water and soap free wash or sorbolene cream followed by exposure of the glans to the air, a fan, hair dryer on low heat, a radiator or a reading light, drying for 5 to 10 minutes then replacement of foreskin.

Avoid soaps and soap products. Soap free washes such as QV lotion or Cetaphil are acceptable soap substitutes.

Note the following:

  • The basis of treatment is to keep the foreskin clean and dry.
  • A tight foreskin should not be retracted as paraphimosis (obstructive constriction of the distal penis by the foreskin) can occur.
  • When severe, balanoposthitis may cause oedema leading to paraphimosis, with worsening swelling and obstruction to distal penile blood flow. In this case, urgent referral to urology is required for reduction.
  • In severe recurrent cases, consider specialist review for circumcision.

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Patient education

The following points should be discussed:

  • The nature of the condition
  • The need for hygiene balanced with avoidance of over washing.
  • Avoidance of soap is advised.
  • Abstinence from sex during episodes as this may flare the condition
  • Routine hygiene after sex will help to decrease the chance of developing balanitis
  • The foreskin should always be retracted during urination.

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Follow up

Follow up is required only if symptoms do not resolve. For severe or recurrent cases refer to a specialist.

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Further information

For further information on the diagnosis and management of balanitis contact Clinic 275.

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Disclaimer

These guidelines are based on review of current literature, current national and international guidelines and recommendations, and expert opinion.

They are written primarily for use by Clinic 275 staff and some flexibility is required in applying them to certain private practice situations.

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