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PA Boards 101: Balanitis A Clinical Review

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Introduction

Balanitis is inflammation of the glans penis.
Posthitis is inflammation of the prepuce – only occurs in uncircumcised males.
Balanoposthitis is inflammation of the glans and prepuce – only occurs in uncircumcised males.

Often times all conditions are referred to balanitis in clinical practice.

The prepuce is attached by adhesions early in life resulting in a physiological phimosis – which is normal. The adhesions separate usually by age 11 and nothing needs to be done so long as patients can urinate.

Etiology

The inflammation may or may not be due to infection. Infectious causes include: anaerobic infection, candida, gonorrhea, HSV (rare), HPV (rare), and strep infection. Non infectious causes include allergy, contact dermatitis, atopic dermatitis, psoriasis, drug eruption, and poor hygiene.

Candida is more common in patients who are diabetic or who have partners with recurrent candidiasis. Candida albicans is the most common species isolated.

In children, balanitis is usually do to poor hygiene. If candida is present in children it’s usually a result of diaper dermatitis or recent antibiotic use.

Bacterial causes include: ecoli, enterococci, strep (group A and B), and staphylococcus aureus.

Contact dermatitis often results from excessive cleansing with soap. Those with an allergy to latex may have a reaction after condom use.

Drug eruption can present with balanitis as the sole manifestation. Typically occurs 30 minutes to 8 hours after ingestion. Common medications include tetracyclines, sedative hypnotics, and salicylates

Symptoms

Patients often present with pain, pruritis, discharge, and rash. The rash can have small erythematous lesions which can ulcerate or scale. If left untreated edema, exudates, and adhesions may occur.

Ultimately, patients are at risk for developing phimosis (tight foreskin can’t be pulled back over the head of the penis) and even paraphimosis (trapping of the foreskin behind the glans – emergency).

Paraphimosis can often times be mistaken for balanitis because often times it can look like an erythematous penis – but in reality the glans is red due to the blood flow and a constricting band will be noticed.

Foul smelling discharge can be seen in anaerobic infection.

Recent streptococcal infection from another site points to strep as a possible etiology.

Candida will show satellite lesions.

Ulcers and discharge should prompt a workup for an STI.

Tenderness to palpation of the bladder may signify urinary retention which means the patient should have a catheter placed.

Diagnosis

The first step is to inspect the penis to make sure paraphimosis is not present as this is an emergency.

Poor hygiene and contact dermatitis can be diagnosed clinically with a good history. If this is the case start on the appropriate treatment. Candida infection can also be diagnosed fairly easily on clinical grounds.

Other patients might require laboratory testing that might include glucose screening, microscopy, and a screening for chlamydia/gonorrhea. Bacterial cultures add little to the diagnosis but should still be done if unsure of the etiology. Also consider a GAS culture – this can be transmitted with oral sex.

Be on the lookout for inverse psoriasis – psoriasis involving the intertriginous areas without scaling.

Scabies, eczema, and HPV can all present with papules and excoriations.
Genital lichen planus in males presents with violaceous papules on the glans penis.

Treatment

Sitz baths help with symptoms and proper hygiene should be discussed. Clean with a q-tip under the foreskin and irrigate with water until inflammation resolves.

Candida: clotrimazole or miconazole cream applied twice daily for 1-3 weeks. Fluconazole 150mg given as a single dose or nystatin cream can be used as alternative therapies.

Hygiene: Uncircumcised men should retract the foreskin and clean routinely. Otherwise the buildup of skin, debris, and organisms can lead to balanitis. So, retraction and cleansing will help symptoms – avoid soaps.

Dermatitis/allergy: avoid the offending agent and treat with hydrocortisone 1% cream.

Drug eruption: Self limiting but you may treat with hydrocortisone 1% for symptom relief for no more than one week.

Anaerobic infection: metronidazole 500mg BID for seven days, augmentin 875/125 BID for seven days, or clindamycin topical cream twice daily.

Group A strep is treated like pharyngitis: penicillin for 10 days. Cephalosporin, clindamycin, or macrolide for those with a penicillin allergy.

Word of caution: forcing the foreskin back on the penis in phimosis can result in paraphimosis which is an emergency. Paraphimosis acts as a tourniquet reducing venous outflow while simultaneously allowing arterial inflow.

If no improvement occurs after 4-6 weeks, then referral to urologist is warranted.