INTRODUCTION — This topic will address the clinical manifestations, diagnosis, and treatment of balanitis and balanoposthitis in prepubertal boys and adolescents. Management of balanitis and balanoposthitis in children and adolescents, normal development of the uncircumcised penis, and balanitis in adults are discussed separately. (See "Balanitis and balanoposthitis in children and adolescents: Management" and "Care of the uncircumcised penis in infants and children" and "Balanitis in adults".)
DEFINITIONS — Balanoposthitis describes inflammation of the glans penis and the foreskin (prepuce) in uncircumcised males (picture 1 and picture 2). Balanitis refers to the inflammation of the glans penis alone. Posthitis is inflammation of the prepuce alone. These terms are sometimes used interchangeably and inappropriately in clinical practice and in the literature . Balanoposthitis occurs only in uncircumcised males, with the rare exception of a circumcised boy with a large preputial remnant.
EPIDEMIOLOGY — Balanoposthitis affects males of all ages and ethnicities worldwide. Among Japanese boys, 1.5 percent of over 600 uncircumcised males had balanoposthitis on routine examination . Most cases occurred in toddlers. Other studies confirm that balanoposthitis occurs often in children between ages two and five years [3,4]. Reports from China and Japan that include toilet-trained and school-age uncircumcised boys have found prevalences less than 1 in 1000 patients [5,6].
Limited data are available for the incidence or prevalence of balanoposthitis in adolescents. Among over 70,000 conscripted Korean military men (age 18 to 30 years), annual incidence of balanoposthitis ranged from 0.5 to 2.6 cases per 1000 persons . Another report identified balanoposthitis in 11 percent of uncircumcised male patients undergoing urologic referral . Irritant and infectious balanoposthitis were most common among patients referred to genitourinary clinics. In addition, trauma from foreskin manipulation or sexual activity is sometimes a contributing cause [8-10].
In the pediatric population, several studies have addressed the prevalence of balanitis (penile inflammation alone) [1,3,11]. The results are discordant as to whether uncircumcised or circumcised males have a greater frequency of penile inflammation over their lifetimes. However, it appears that circumcised infants are at greater risk for meatitis and inflammation of the circumcision scar or glans penis, especially in association with diaper dermatitis .
ANATOMY — In the uncircumcised male, the prepuce naturally covers the glans penis at birth (picture 3) and is attached to the glans by preputial adhesions. The prepuce functions to physically and immunologically protect the glans and external urethral orifice (figure 1). The adhesions cause a physiologically natural phimosis, where the foreskin cannot be retracted. Physiologic adhesions do not interfere with urination. The adhesions gradually separate secondary to hormonal influence and intermittent erection. (See "Care of the uncircumcised penis in infants and children", section on 'Phimosis' and "Care of the uncircumcised penis in infants and children", section on 'Physiologic phimosis'.)
Several studies of prepuce development have found that approximately half of uncircumcised males have fully retractable foreskins by age 10 years. By the age of 17 years, 95 to 99 percent of foreskins are fully retractable. (See "Care of the uncircumcised penis in infants and children", section on 'Foreskin retraction'.)
The protective benefit of the foreskin is lost after circumcision and may predispose the young infant to an increased risk of infection . This risk of local infection may be offset by easier hygiene and decreased risks of sexually transmitted infections and cancer later in life. (See "Neonatal circumcision: Risks and benefits".)
CAUSES — Acute balanitis and balanoposthitis may be classified into infectious, irritant, and traumatic causes (table 1).
Infection — In the uncircumcised male, the area between the glans and inner foreskin is a moist environment. Physiologic secretions from the meatus, prostate, and bladder collect in the preputial space. These secretions provide a protective barrier for the urethral meatus and glans penis. In addition, lysozymes in these secretions provide some defense against infection . This natural barrier may be disrupted by excessive smegma (a collection of desquamated squamous epithelial cells, squalene, beta-cholestanol, and long-chain fatty acids), drying from excessive cleansing, or trauma. This compromise of host defense may permit secondary infection. In this situation, the causative organism can arise from overgrowth of organisms normally residing in the groin region, spread of adjacent cutaneous infection, or pathogens introduced by sexual contact (table 1) .
Sexual activity, coexisting chronic diseases (especially diabetes mellitus), and immunodeficiency (especially HIV/acquired immunodeficiency syndrome [AIDS]) increase the risk of infectious balanoposthitis [13-15].
By contrast, circumcised males tend to have the greatest risk for infection prior to toilet training when the meatus and glans penis are directly exposed to feces and adjacent candidal infection . Later in life, absence of the foreskin appears to have a protective effect against infection. (See "Neonatal circumcision: Risks and benefits".)
Specific infectious etiologies include:
●Fungal – Candida albicans is the most common fungal pathogen found in patients with balanitis and balanoposthitis [1,8,16,17]. In the pediatric patient, the acquisition of C. albicans is related to local skin conditions and is frequently seen as a component of diaper dermatitis. In addition, infection with C. albicans often follows antibiotic use. (See "Diaper dermatitis".)
In adolescents and adults, 14 to 18 percent of men are C. albicans carriers, with no difference between circumcised and uncircumcised males [18,19]. Candidal infections are a potential marker for type 2 diabetes mellitus . C. albicans may also be sexually acquired.
Other fungal infections of the penis and/or foreskin are less common . They include pityriasis versicolor (Malassezia species) and tinea genitalis (dermatophytes, eg, Trichophyton rubrum, Epidermophyton floccosum, and Microsporum gypseum).
●Bacterial – Bacterial balanitis and balanoposthitis arise from local flora that may vary according to age:
•Children – Bacterial infection in prepubertal children may arise from overgrowth of normal preputial flora with the common organisms varying by age [20-22]:
-≤2 years of age – Escherichia coli
-3 to 6 years of age – Enterococcus species
-7 to 12 years of age – Staphylococcus aureus and group A beta-hemolytic streptococci
With increasing age, there is also colonization with Corynebacterium spp, C. albicans, gram-negative anaerobes, and potentially pathogenic Mycobacterium smegmatis.
In children with a previously documented group A streptococcal infection at another site, group A Streptococcus is another important organism [22-24].
Pseudomonas aeruginosa is a significant etiology of balanoposthitis in children with hematologic malignancies .
Isolation of Neisseria gonorrhoeae, Chlamydia trachomatis, or rarely, Treponema pallidum may occur in victims of sexual abuse and warrants appropriate investigation [8,26]. (See "Evaluation of sexual abuse in children and adolescents".)
•Adolescents – The most common bacterial causes of balanitis and balanoposthitis in postpubertal patients include Gardnerella vaginalis and anaerobic bacteria [8,26,27]. Anaerobic infections are most commonly caused by Bacteroides spp and may be accompanied by nonspecific urethritis .
Group B streptococci also cause balanoposthitis, presenting in 13 percent of adult males with penile inflammation in one study [8,10]. Males can be asymptomatic carriers and present with nonspecific erythema with or without exudates [29,30].
Sexually transmitted infections by Neisseria gonorrhoeae, C. trachomatis, or rarely, T. pallidum have also been described [8,26]. Group A Streptococcus is rarely isolated in the postpubertal male but has been documented to be sexually transmitted after fellatio (picture 2) [13,31].
Balanitis or balanoposthitis may rarely develop in association with Fournier gangrene, a necrotizing bacterial fasciitis of the perianal and genital regions that is typical polymicrobial [32,33]. Premature and immunocompromised patients are at greatest risk, but it may also occur in previously healthy children as a postinfectious complication of varicella zoster infection. Clinical findings include severe pain out of proportion to skin findings; swelling that may extend into the scrotum, perineum, and lower abdomen; subcutaneous emphysema; high fever; and, in advanced cases, septic shock. Treatment is discussed separately. (See "Necrotizing soft tissue infections", section on 'Treatment'.)
●Viral – Human papilloma virus (HPV) and herpes simplex virus types 1 and 2 have been associated with acute balanitis and balanoposthitis in adults although both are rare etiologies in children and adolescents . Herpes simplex virus presents as a necrotizing balanitis [34,35]. HPV is frequently difficult to eradicate and may follow self-inoculation or sexual contact [36,37].
Poor hygiene — Irritant balanoposthitis often results from poor hygiene with accumulation of smegma . Smegma is a collection of desquamated squamous epithelial cells, squalene, beta-cholestanol, and long-chain fatty acids . When smegma accumulation causes irritation and swelling of the glans and inner foreskin, this type of irritant balanoposthitis is termed nonspecific balanoposthitis .
Irritant contact dermatitis — Irritant contact dermatitis often results from excessive cleansing of the foreskin and/or penis with soap and may lead to recurrent or persistent balanitis or balanoposthitis . Spermicides and condom lubricants are also common culprits in older adolescents. Patients with eczema appear to be predisposed. (See "Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis", section on 'Clinical manifestations'.)
Trauma — Forceful retraction of the foreskin may cause incidental abrasion and tearing of the synechial membranes found in the unseparated foreskin of the young boy. Avoidance of cleansing due to pain sets up conditions for the development of balanoposthitis. In addition, trauma can serve as a nidus for infectious balanoposthitis. This mechanism is prevalent in young infants whose parents or caregivers lack knowledge of proper care of the foreskin. Attempting to forcefully retract the foreskin before the complete breakdown of these physiologic adhesions may also cause paraphimosis, an inability to reduce the foreskin back over the corona of the glans. Paraphimosis is a true urologic emergency . (See "Paraphimosis: Clinical manifestations, diagnosis, and treatment".)
Other forms of trauma that increase the risk of balanitis and balanoposthitis include friction or entrapment against clothing, masturbation, sexual intercourse, and zip-fastener injury [39-41]. (See "Management of zipper entrapment injuries".)
Fixed drug eruption — Fixed-drug eruptions of the glans and/or foreskin may be elicited by a variety of medications, most commonly antibacterial sulfonamides, tetracyclines, nonsteroidal antiinflammatory drugs, acetaminophen, phenolphthalein, barbiturates, or antimalarial drugs [8,42,43]. These eruptions typically occur with reintroduction of the offending agent and resolve once the agent is stopped. (See "Fixed drug eruption".)
Allergy — Although balanoposthitis has been described as a component of Stevens-Johnson syndrome, systemic allergic reactions are uncommon .
History — Common symptoms in patients with balanitis and balanoposthitis include pain, genital itching and irritation, groin rash, and dysuria [22,45,46]. Balanoposthitis is also characterized by penile, but not urethral, discharge. In infants, penile inflammation may be the cause of excessive crying. Inability to void occurs rarely but warrants urgent attention. (See "Balanitis and balanoposthitis in children and adolescents: Management", section on 'Relief of urinary retention'.)
Other symptoms include:
●For uncircumcised prepubertal boys, there may be inability to retract the foreskin to the extent possible prior to the illness.
●For patients with longstanding disease, the patient or parents/caregivers may note scarring or changed appearance.
Several additional historical elements help identify the underlying cause:
●Hygiene – Poor genital hygiene is associated with nonspecific balanoposthitis .
●Irritant use – Overly aggressive cleaning with soap and water can lead to irritant contact balanitis or balanoposthitis, especially in patients with atopic dermatitis . Sexually active adolescents may develop balanitis or balanoposthitis caused by contact allergy to latex condoms, condom lubricants, or spermicides.
●Urethral drainage – In the uncircumcised male, differentiation of urethral drainage from preputial drainage on physical examination helps distinguish gonorrheal or chlamydial urethritis from balanitis or balanoposthitis . However, sexually active patients with balanoposthitis should undergo evaluation for sexually transmitted disease regardless of the source of drainage. (See 'Physical examination' below.)
Sexually transmitted diseases in a prepubertal child warrant further evaluation for sexual abuse . (See "Evaluation of sexual abuse in children and adolescents", section on 'Presentation'.)
●Medication use – Patients with recent antibiotic use are at greater risk for candidal balanitis or balanoposthitis. Exposure to certain drugs, such as antibacterial sulfonamides, tetracyclines, nonsteroidal antiinflammatory drugs, acetaminophen, phenolphthalein, barbiturates, and antimalarial drugs, increases the risk of a fixed drug eruption . (See "Fixed drug eruption", section on 'Eliciting drugs'.)
●Recent or current group A streptococcal infection or exposure – Streptococcus pyogenes infection is an important cause of balanoposthitis in the school-age child.
●Past medical history – Children or adolescents with a history of diabetes, HIV/acquired immunodeficiency syndrome (AIDS), malignancy, or any other immunosuppressive states are at higher risk of infections, including balanitis or balanoposthitis [14,15].
Patients with a history of arthritis, diarrhea, or eye complaints may have penile inflammation as a component of reactive arthritis. (See "Reactive arthritis".)
Prior history of balanoposthitis increases the risk of inflammatory phimosis and the need for referral to a pediatric urologist.
●Family history – Eczema and psoriasis may predispose to balanitis or balanoposthitis and represent skin conditions that can cause other genital lesions. (See 'Differential diagnosis' below.)
●Sexual history – A social history that covers sexual activity should be elicited from all adolescents with genital complaints. This history should cover sexual practices, symptoms in the sexual partner, and any prior history of a sexually transmitted disease. (See "Sexually transmitted infections: Issues specific to adolescents", section on 'Sexual history'.)
●Condom use – Condom use raises the possibility of irritant penile inflammation from contact allergy.
Physical examination — A tender, enlarged, and palpable bladder indicates urinary retention caused by urinary obstruction and warrants prompt intervention . (See "Balanitis and balanoposthitis in children and adolescents: Management", section on 'Relief of urinary retention'.)
•Preputial swelling, tenderness, and erythema
•Scarring between the glans and prepuce
•Lymphadenopathy or lymphadenitis
•In patients with chronic disease, meatal stenosis and phimosis (inability to retract the foreskin) (picture 4)
•Swelling, tenderness, and erythema of the glans penis, meatus, and/or penile shaft
•Lymphadenopathy or lymphadenitis
Urethral discharge is assessed by milking the length of the urethra from the base to the tip and identifies a concomitant urethritis in sexually active patients or victims of sexual abuse . (See 'History' above.)
Genital appearance may also point to the causative agent with certain types of infectious balanoposthitis:
●Streptococcal balanoposthitis is characterized by a fiery red surface and a moist, glistening transudate or exudate under the prepuce in conjunction with an existing or recent group A streptococcal infection at another site, such as the pharynx (picture 2). Streptococcal balanoposthitis may also rarely accompany perianal streptococcal disease and guttate psoriasis [13,22,31,49]. (See 'History' above and "Psoriasis: Epidemiology, clinical manifestations, and diagnosis", section on 'Guttate psoriasis' and "Group A streptococcal tonsillopharyngitis in children and adolescents: Clinical features and diagnosis", section on 'Clinical features'.)
●Anaerobic balanoposthitis presents with superficial erosions, foul-smelling subpreputial discharge, preputial edema, and inguinal adenitis [8,28].
●Candidal balanoposthitis is associated with generalized erythema, fissuring, eroded papules, and a whitish, curd-like discharge. General skin examination may reveal satellite lesions and other characteristics of candidal infection. Occasionally, there may be vesicular lesions [8,18,19]. Infants with candidal balanitis present with erythematous patches with satellite papules and pustules on the glans or penile shaft. (See "Diaper dermatitis".)
●Dermatophytic infections of the penis or foreskin may present with itching, mild discomfort, stinging, and the characteristic annular (ring-shaped) plaque of tinea corporis (common name: ringworm) (picture 5A-C) or an extension of the erythematous proximal thigh patch seen with tinea cruris (picture 6) . (See "Dermatophyte (tinea) infections".)
●Although uncommon, tinea versicolor may also involve the penis or foreskin in older children and adolescents and appear as macules, patches, and thin plaques that may be hypopigmented, hyperpigmented, or mildly erythematous. In light-skinned individuals, hyperpigmented tinea versicolor is often light brown . Hyperpigmented tinea versicolor may present as dark brown to gray-black macules and patches in those with dark skin. Wood's lamp examination will reveal yellow to yellow-green fluorescence in about one-third of patients. (See "Tinea versicolor (pityriasis versicolor)".)
●Necrotizinig balanoposthitis in association with genital ulcers suggest herpes simplex virus infection. (See "Sexually transmitted infections: Issues specific to adolescents", section on 'STI clinical patterns'.)
Systemic findings of ocular uveitis, oral ulceration, and arthritis in the context of balanitis or balanoposthitis suggest reactive arthritis. (See "Reactive arthritis" and 'Differential diagnosis' below.)
DIAGNOSIS — The presence of inflammation of the glans penis and/or foreskin on direct inspection establishes the diagnosis of balanitis (penile inflammation) or balanoposthitis (penile and foreskin inflammation). Further evaluation for patients with balanoposthitis is determined based upon patient age, history, and physical examination (algorithm 1 and algorithm 2). (See 'Physical examination' above.)
Infants and prepubertal boys — Infants and prepubertal boys without induration, exudate, or urethral discharge typically do need not testing and can undergo empiric treatment based upon the presumed clinical diagnosis established by careful history and physical examination (algorithm 1) . Common etiologies include candidal infection in association with diaper dermatitis in infants, nonspecific balanoposthitis (eg, due to poor hygiene or inappropriate forceful retraction of the foreskin), or irritant contact balanitis or balanoposthitis. Fixed drug eruption is rare in young boys but may be diagnosed based upon a history of prior drug exposure and appearance of a foreskin lesion upon reintroduction of the medication. (See 'Fixed drug eruption' above.)
Prepubertal boys with balanitis or balanoposthitis and urethral discharge should have appropriate specimens obtained to evaluate for the presence of sexually transmitted infections. The presence of a sexually transmitted disease in a child requires further evaluation for sexual abuse. (See "Evaluation of sexual abuse in children and adolescents".)
Prepubertal boys with group A Streptococcus exposure, pharyngitis, impetigo, perianal redness, or guttate psoriasis accompanying balanoposthitis should have rapid testing of the pharynx or, if rapid testing is negative, culture of the pharynx for group A, beta-hemolytic Streptococcus [22,23,50]. In this setting, pharyngeal testing is not always positive, and culture of preputial drainage is recommended with these predisposing factors and/or suggestive findings. In addition, we suggest group A Streptococcus pharyngeal culture in young boys whose penile inflammation is not responding to general therapy.
Adolescents — Gram stain and bacterial culture of preputial secretions is appropriate for most adolescents with balanoposthitis to identify infections caused by S. aureus or anaerobic bacteria. In addition, selected adolescents with balanoposthitis should undergo the following testing (algorithm 2) [22,39,45,51,52]:
●Group A Streptococcus culture – Group A Streptococcus culture should be obtained in those with pharyngitis, a history of oral-genital contact, or persistent disease [13,31]. Rapid antigen testing of foreskin drainage for group A Streptococcus utilizing kits designed for pharyngeal testing has been proposed. However, no data exist concerning the reliability of this approach . If a group A Streptococcus rapid antigen test is used, a confirmatory preputial culture for group A Streptococcus should always be obtained as well.
●Potassium hydroxide (KOH) microscopy or fungal culture – KOH microscopy or fungal culture should be ordered for patients with diabetes or those with findings suggestive of C. albicans, tinea versicolor, or dermatophytic infection. Evaluation for diabetes mellitus should also be undertaken for all adolescents and obese, school-age children with candidal balanitis or balanoposthitis. (See "Epidemiology, presentation, and diagnosis of type 1 diabetes mellitus in children and adolescents" and "Epidemiology, presentation, and diagnosis of type 2 diabetes mellitus in children and adolescents".)
●Sexually transmitted infections – Patients with balanitis or balanoposthitis who are sexually active, have genital ulcers, or demonstrate urethral drainage should have appropriate specimens obtained to evaluate for the presence of sexually transmitted infections. (See "Approach to the patient with genital ulcers" and "Trichomoniasis: Clinical manifestations and diagnosis" and "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection" and "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents" and "Clinical manifestations and diagnosis of Chlamydia trachomatis infections".)
If an infection is not identified as the cause of balanitis or balanoposthitis, then the patients should undergo empiric treatment based upon the most likely etiology as suggested by history and physical examination.
Persistent balanoposthitis — A pathologic diagnosis is desirable in any patient who does not respond to appropriate therapy within four to six weeks. These patients warrant referral to a pediatric urologist. In children and adolescents, unresponsive or recurrent balanoposthitis is a potential indication for circumcision . Pathologic evaluation of the prepuce is important to look for balanitis xerotica obliterans (picture 7) . This entity may involve the urethral meatus, require reconstructive urologic surgery, and is considered precancerous in adults. (See "Carcinoma of the penis: Epidemiology, risk factors, and pathology".)
In adolescents, genital biopsy by a urologist is an alternative to circumcision for establishing a diagnosis [9,45,55,56]. While safe, genital biopsy does not always establish a specific diagnosis. For example, in one series from 14 genitourinary clinics in the United Kingdom, over 20 percent of genital biopsy specimens in men showed nonspecific balanitis (balanoposthitis) .
DIFFERENTIAL DIAGNOSIS — Inflammatory changes of the foreskin differentiate pathologic preputial discharge from physiologic smegma secretion. In addition, genital dermatoses may masquerade as or coexist with balanitis or balanoposthitis but may be distinguished by their characteristic appearance [52,57]. When there is uncertainty or balanoposthitis persists for longer than four to six weeks despite treatment, then referral to a urologist is warranted for circumcision or, in adolescents, biopsy.
Common dermatoses in children and adolescents include:
●Psoriasis, especially inverse psoriasis, may affect intertriginous areas including the inguinal, perineal, and genital regions. This variant can easily be misdiagnosed as a fungal or bacterial infection because there is frequently no visible scaling (picture 8). (See "Psoriasis: Epidemiology, clinical manifestations, and diagnosis", section on 'Inverse (intertriginous) psoriasis'.)
●Nummular eczema consists of intensely pruritic patches of eczematous dermatitis, each showing evidence of papules, scaling, slight crusting, and some serous oozing on close inspection (picture 9). (See "Nummular eczema", section on 'Clinical manifestations'.)
●Genital lichen planus in males presents with violaceous papules on the glans penis (picture 10). Erosive mucosal lesions can also occur. (See "Lichen planus", section on 'Genital lichen planus'.)
●In patients with reactive arthritis, circinate erosive balanitis appears as a circular plaque that extends onto the edge of the penis and foreskin but may be indistinguishable from other forms of balanoposthitis (picture 11). (See "Reactive arthritis", section on 'Extraarticular signs and symptoms'.)
●Balanitis xerotica obliterans is the male analog of lichen sclerosus et atrophicus and is characterized by white atrophic plaques and induration on the glans, coronal sulcus, and prepuce (picture 7) [54,58,59]. There can be blisters, ulceration, or hemorrhagic vesicles. The foreskin can become thickened and phimotic, and urethral strictures can develop. These changes can result in bladder outlet obstruction, which may manifest as new-onset incontinence, urinary tract infection, and acute urinary retention . (See "Carcinoma of the penis: Epidemiology, risk factors, and pathology".)
●Fixed drug eruption is characterized acutely by erythematous and edematous plaques with a grayish center, frank bullae, or erosion (picture 12) and chronically by a dark postinflammatory pigmentation. The defining features of this eruption include the postinflammatory hyperpigmentation and the recurrence of lesions at exactly the same site with drug re-exposure. (See "Fixed drug eruption", section on 'Diagnosis'.)
●Human papillomavirus (HPV) infection occurs as single or multiple papules on the preputial cavity (glans penis, coronal sulcus, frenulum, and inner aspect of the foreskin) in uncircumcised males (picture 13).
●Scabies is suggested by a small, erythematous, nondescript papule, often excoriated and tipped with blood crusts (picture 14). (See "Scabies: Epidemiology, clinical features, and diagnosis".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Balanoposthitis".)
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SUMMARY AND RECOMMENDATIONS
●Definition – Balanoposthitis describes inflammation of the glans penis and the foreskin (prepuce) in uncircumcised males and consists of the following types: irritant, infectious, allergic/immunologic, and traumatic (picture 1 and picture 2 and table 1). Balanitis refers to inflammation of the glans penis alone. (See 'Definitions' above and 'Causes' above.)
●Presenting symptoms – Common symptoms in patients with balanitis and balanoposthitis include pain, genital itching and irritation, groin rash, and dysuria. Balanoposthitis is also characterized by penile discharge. In infants, penile inflammation may be the cause of excessive crying. (See 'History' above.)
●Physical findings – Balanitis presents with swelling, tenderness, and erythema of the glans penis, meatus, and/or penile shaft. Genital findings of balanoposthitis include (picture 1 and picture 2) (see 'Physical examination' above):
•Preputial swelling and erythema
•Scarring between the glans and prepuce
•Lymphadenopathy or lymphadenitis
•In patients with chronic disease, meatal stenosis and phimosis (inability to retract the foreskin) (picture 4)
A tender, enlarged, and palpable bladder indicates urinary retention with obstruction and warrants prompt bladder catheterization and urologic consultation. (See "Balanitis and balanoposthitis in children and adolescents: Management", section on 'Relief of urinary retention'.)
●Diagnosis and further evaluation – The presence of inflammation of the glans penis and foreskin on direct inspection establishes the diagnosis of balanoposthitis. Inflammation of the glans penis alone identifies balanitis. Further evaluation depends on the suspected etiology, physical findings, and patient age:
•Infants and prepubertal males – Careful history and physical examination in infants and prepubertal boys often identify nonspecific balanoposthitis, candidal infection in association with diaper dermatitis, or irritant contact balanitis or balanoposthitis without the need for further testing (algorithm 1). Prepubertal boys with urethral discharge warrant evaluation for sexual abuse (see "Evaluation of sexual abuse in children and adolescents"). Pharyngeal rapid testing and/or culture for group A streptococcal infection should be performed in boys with group A Streptococcus exposure, pharyngitis, impetigo, perianal redness, or guttate psoriasis. (See 'Infants and prepubertal boys' above.)
•Adolescents – Most adolescents with balanoposthitis should undergo Gram stain and bacterial culture of preputial secretions; patients with findings of Candida albicans, tinea versicolor, or other dermatophytic infections also warrant testing with potassium hydroxide (KOH) microscopy, and individuals with pharyngitis, oral-genital contact, or persistent disease warrant testing for group A streptococcal infection (algorithm 2). In addition to these tests, patients with balanitis or balanoposthitis who are sexually active, have genital ulcers, or demonstrate urethral drainage should have appropriate specimens obtained to evaluate for sexually transmitted infections. (See 'Adolescents' above.)
Adolescents with candidal balanitis or balanoposthitis warrant evaluation for diabetes mellitus. (See "Clinical presentation, diagnosis, and initial evaluation of diabetes mellitus in adults" and "Epidemiology, presentation, and diagnosis of type 1 diabetes mellitus in children and adolescents" and "Epidemiology, presentation, and diagnosis of type 2 diabetes mellitus in children and adolescents".)
●Differential diagnosis – Inflammatory changes of the foreskin differentiate pathologic preputial discharge from physiologic smegma secretion. Several genital dermatoses may masquerade as or coexist with balanitis and balanoposthitis but may be distinguished by their characteristic appearance. When there is uncertainty or balanoposthitis persists for longer than four to six weeks despite treatment, referral to a urologist is warranted for circumcision or, in adolescents, biopsy. (See 'Differential diagnosis' above and 'Persistent balanoposthitis' above.)