Balanitis/Balanoposthitis
Inflammatory, Urological
Context
- Balanoposthitis is broad term comprised of numerous penile conditions with similar clinical presentations affecting the glans penis and prepuce.
- Balanitis is inflammation of the glans penis while posthitis is inflammation of the prepuce.
- Balanoposthitis is the term used when both are present.
- Causes include:
- Infectious
- Candida albicans, trichomonas vaginalis, streptococci, staphylococci, HSV, HPV, mycoplasma genitalium, scabies, syphilis, anaerobic bacteria.
- Inflammatory dermatoses
- Lichen sclerosus, lichen planus, psoriasis, Zoon’s balanitis, dermatitis, allergic reactions.
- Premalignant
- Bowen’s disease, Bowenoid papulosis, erythroplasia of Queyrat.
- Other
- Inadequate hygiene, fixed drug eruption, reactive arthritis.
- Infectious
- Clinical presentation:
- Suspect in males with penile pain, erythema, burning sensation or pruritus of the glans or foreskin.
- Balanitis is much more common in uncircumcised men.
- Predisposed in those with diabetes, obesity, CHF, cirrhosis, nephrotic syndrome, trauma, and those with inadequate hygiene.
Diagnostic Process
- Diagnosed by presence of inflamed and erythematous glans and/or prepuce.
- On examination, there is erythema with or without exudate, ulcerations, or other signs depending on the etiology such as edema, erosions, scarring, or purpura.
- Edema and consequently phimosis or paraphimosis may develop without treatment.
- While often nonspecific and caused by inadequate hygiene, contact dermatitis, or external irritants a thorough history and physical exam should assess for other etiologies:
- History of diabetes, HIV, obesity and/or white appearance with curd-like exudate suggests candida.
- High risk sexual history suggests STIs including trichomonas, HSV, HPV, scabies, chlamydia,
- Purulent and foul smelling exudate suggests bacterial infection.
- Vesicular or ulcerative lesions suggest HSV, syphilis.
- Erythematous plaques suggest psoriasis.
- History of dermatitis suggest psoriasis, lichen planus, eczema.
- Splitting, hemorrhagic blisters, and dyspareunia with white patches and structural changes suggest lichen sclerosis.
- Purple, well demarcated plaques suggest lichen planus.
- Systemic symptoms, arthritis, and small, painless, ulcerative lesions suggest circinate balanitis.
- Recommended investigations:
- Microbiology
- Gram stain and culture for bacterial causes including candida as well chlamydia and gonorrhea (if indicated).
- NAAT for HSV, Treponema pallidum, Trichomonas vaginalis
- Urinalysis for candida (high urine glucose) and other potential etiologies.
- Biopsy for to clarify the diagnosis and exclude malignant or pre-malignant causes.
- Patch tests to rule out allergic etiologies (only perform if there is clinical suspicion).
- Microbiology
Recommended Treatment
- Goals of treatment are
- Minimize sexual and urinary dysfunction.
- Exclude malignancy and treat premalignant conditions.
- Treat STIs.
- Prevent complications such as paraphimosis, cellulitis, and abscess formation
- Paraphimosis may require urgent urology consult.
- General management
- Better hygiene practices including saline baths bid, OTC talcum powders, and keeping the foreskin retracted where possible (advising about risk of paraphimosis).
- Avoid soaps, friction, sweat, and other irritants.
- Advice regarding sexual practices such as condom failure risk with cream application.
- Counsel about potential complications of balanoposthitis and what to look out for.
- Specific management depends on etiology if known.
- If no response to improved hygiene, can trial low dose corticosteroids (e.g. hydrocortisone 1% bid x 1 week).
- Candida
- Clotrimazole 1% or miconazole 2% cream bid x 2 weeks.
- OR
- 150 mg Fluconazole PO x 1 dose (recurrent or severe infection).
- Clotrimazole 1% or miconazole 2% cream bid x 2 weeks.
- Anaerobic infection
- Metronidazole 400-500 mg PO bid x 1 week or topical metronidazole 0.75% bid x 1 week for milder cases.
- Aerobic infection
- Erythromycin 500 mg PO qid x 1 week.
- STI
- Treatment should be based on guidelines for the specific etiology.
- Lichen sclerosis
- High potency topical corticosteroids (e.g. clobetasol propionate 0.05% cream) PO daily until remission then weekly.
- Lichen planus
- Moderate to high potency topical corticosteroids (e.g. betamethasone dipropionate ointment 0.05%).
- Psoriasis
- Moderate potency topical steroids (e.g. betamethasone valerate 0.1%) + emollients.
- Eczema
- Mild potency corticosteroid such as 1% hydrocortisone.
- Moderate potency corticosteroid (e.g. betamethasone valerate 0.1%) if no response ± topical antifungal.
Quality Of Evidence?
High
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
Moderate
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
Low
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Justification
Overall evidence in this area is mixed. There is some reasonable evidence for certain aspects of management such as treatment of candida, which is based on randomized control trials. The majority of other recommendations are based on existing clinical data and expert opinion.
Related Information
Reference List
RESOURCE AUTHOR(S)
DISCLAIMER
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Jan 17, 2022
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