Balanitis and foreskin hygiene
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Last updated: January 2017
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.
Subpreputial swabs for Viral (HSV) NAAT especially if erosions or ulcerations present, bacterial and fungal culture as clinically indicated.
Assessment of a biopsy specimen is only indicated in severe cases, or where diagnosis is unclear, as clinically indicated.
Please note the following:
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.
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 following points should be discussed:
Follow up is required only if symptoms do not resolve. For severe or recurrent cases refer to a specialist.
For further information on the diagnosis and management of balanitis contact Adelaide Sexual Health Centre.
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 Adelaide Sexual Health Centre staff and some flexibility is required in applying them to certain private practice situations.