INTRODUCTION — Balanitis is defined as inflammation of the glans penis . The word is derived from the Greek "balanos," which means "acorn."
When the prepuce (foreskin) also becomes involved, the condition is known as balanoposthitis. In common usage, "balanitis" and "balanoposthitis" are interchangeable, although balanoposthitis occurs only in uncircumcised males. For the remainder of this discussion, we will refer to both conditions using the term "balanitis."
The diagnosis and treatment of balanitis in adult males will be reviewed here. The disorder in children is discussed separately. (See "Balanitis and balanoposthitis in children and adolescents: Clinical manifestations, evaluation, and diagnosis" and "Balanitis and balanoposthitis in children and adolescents: Management".)
EPIDEMIOLOGY — In the United States, balanitis accounts for approximately 11 percent of men seen in urology clinics. Approximately 3 percent of uncircumcised men are affected globally .
ETIOLOGY — Balanitis has a wide range of causes, but most cases are related to inadequate hygiene in uncircumcised men. When the foreskin is not routinely retracted and the glans is not cleansed in an appropriate fashion, buildup of sweat, debris, exfoliated skin, and bacteria or fungi can occur, resulting in inflammation. Predisposing factors include diabetes mellitus, trauma (eg, zipper injury), obesity, and edematous conditions (eg, congestive heart failure, cirrhosis, nephrotic syndrome).
Of cases with identifiable etiologies, candidal infection is the most common. Various other infectious agents, dermatologic conditions, and premalignant conditions have been associated with balanitis [3-19]. Chronic balanitis may predispose to premalignant and malignant lesions, but there is contradictory evidence on this topic [20,21]. An organizational scheme is included as part of the 2013 European guideline for the management of balanoposthitis (table 1) .
Overview of symptoms — The symptoms of balanitis generally evolve over three to seven days. It often presents as pain, tenderness, or pruritus of the glans and/or foreskin. Physical examination shows erythema, which may be associated with a curd-like or purulent exudate, ulcerations, or other findings depending upon the etiology. For example, candidal balanitis may have a white curd-like exudate, whereas anaerobic bacterial infections often manifest with a thick foul-smelling purulent exudate (picture 1). Circinate balanitis, which presents with shallow ulcers on the glans (picture 2), is generally associated with reactive arthritis. Herpes simplex virus (HSV) infection may present similarly.
Localized edema may develop if balanitis is allowed to progress without treatment. The combination of inflammation and edema can result in adherence of the foreskin to the glans [2,23]. Persistent inflammation may result in scarring. Ultimately, this process can evolve into tightening of the foreskin, known as “phimosis.” Phimosis is an abnormal constriction of the opening in the foreskin that precludes retraction over the glans. Paraphimosis, which refers to trapping of the foreskin behind the glans penis, requires urgent reduction. (See 'Complications' below.)
Balanitis is sometimes associated with other symptoms, including painful joints, more generalized dermatitis, mouth sores, swollen and/or painful glands, and malaise or fatigue. These findings, if present, may help elucidate the underlying cause. (See 'Diagnostic evaluation' below.)
Candidal infection — Candida colonization of the penis occurs in 15 to 20 percent of men and is more common in diabetic persons and in individuals who are uncircumcised or who have partners with recurrent vaginal candidiasis [24,25]. C. albicans is the dominant species.
Symptomatic candidal infection typically presents with a painful or pruritic erythematous rash; a white curd-like exudate is sometimes present. Pruritus and burning are most noticeable after sexual intercourse. Physical examination may reveal the presence of small papules with blotchy erythema and an eroded, dry, or glazed appearance [22,26].
The development of balanitis or phimosis in an otherwise healthy man can be the first presentation of diabetes mellitus . Poorly controlled blood glucose is associated with proliferation of candidal species beneath the foreskin, which may lead to balanitis.
Less common etiologies
Bacterial and other infections — Anaerobes have been reported as a cause of balanitis (with mixed species, which may include Gardnerella vaginalis), especially in uncircumcised males . Subpreputial anaerobic infection can result in a foul-smelling discharge, inflammation and edema of the glans/foreskin, erosive lesions, and inguinal lymphadenopathy (picture 1). Group A streptococcus and Staphylococcus aureus, which are common skin pathogens, can also be responsible for balanitis. They present with erythema and edema. Sexually transmitted pathogens, including Trichomonas vaginalis, HSV, human papillomavirus (HPV), syphilis, scabies, and Mycoplasma genitalium, may also cause this condition.
The other clinical manifestations associated with these organisms is discussed elsewhere. (See "Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis" and "Trichomoniasis: Clinical manifestations and diagnosis", section on 'Individuals with a penis or neophallus' and "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection", section on 'Clinical features' and "Condylomata acuminata (anogenital warts) in adults: Epidemiology, pathogenesis, clinical features, and diagnosis", section on 'Clinical manifestations' and "Syphilis: Epidemiology, pathophysiology, and clinical manifestations in patients without HIV", section on 'Clinical manifestations' and "Scabies: Epidemiology, clinical features, and diagnosis", section on 'Clinical manifestations' and "Mycoplasma genitalium infection in males and females", section on 'Associated clinical syndromes'.)
Dermatologic conditions — Dermatologic conditions that may result in balanitis include psoriasis, eczema, lichen planus, lichen sclerosus, plasma cell (Zoon’s) balanitis, and contact dermatitis .
●Psoriasis – Psoriasis generally presents as erythematous scaly plaques on the glans and may also affect intertriginous areas. It may also manifest as “inverse psoriasis,” which is characterized by no visible scaling. (See "Psoriasis: Epidemiology, clinical manifestations, and diagnosis", section on 'Inverse (intertriginous) psoriasis'.)
●Eczema – Eczema may involve the penis with symptoms of dryness and pruritus and physical findings of erythema and edema of the glans. There is often a prior history of eczema or recurrent nonspecific skin rashes. (See "Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis", section on 'Clinical manifestations'.)
●Lichen planus – Lichen planus is an inflammatory disorder with skin, genital, and oral mucous membrane manifestations. Pruritic purplish plaques are the characteristic finding on physical examination, but erosive mucosal lesions can also occur. (See "Lichen planus", section on 'Clinical features'.)
●Lichen sclerosus – This chronic inflammatory dermatosis frequently involves the genitalia. It is also known in men as balanitis xerotica obliterans (BXO), which is analogous to lichen sclerosus et atrophicus in women. BXO often presents with white penile lesions, pruritus, painful erections and voiding, and bleeding or ulceration with intercourse. There can be blisters, ulceration, or hemorrhagic vesicles. The foreskin can become thickened and phimotic, and urethral strictures can develop. There is a 1 percent risk of malignant transformation .
●Plasma cell (Zoon’s) balanitis – Plasma cell (Zoon’s) balanitis is a disease of older men who are uncircumcised. It presents as symmetrical, well-marginated erythema of the glans and foreskin and may be confused with carcinoma in situ (CIS) .
●Contact dermatitis – The typical appearance of an irritative or allergic reaction can range from slight erythema to severe penile edema. The history will often include frequent genital cleansing with soaps. If a specific agent is identified, patch testing can be conducted to determine the presence of an allergy. (See "Irritant contact dermatitis in adults", section on 'Clinical manifestations'.)
Premalignant conditions — Premalignant conditions that may result in balanitis include Bowenoid papulosis and CIS . Benign lesions associated with HPV are referred to as “Bowenoid papulosis.”
●Bowenoid papulosis – Bowenoid papulosis presents similarly to genital warts with discrete papules or plaques that may occur in groups or be pigmented.
●Carcinoma in situ – When CIS affects the glans penis, it is referred to as erythroplasia of Queyrat. The typical appearance is a well-circumscribed red velvety lesion. Induration and white patches may be indicative of the presence of squamous cell carcinoma.
The clinical features of Bowenoid papulosis and CIS are discussed in detail elsewhere. (See "Carcinoma of the penis: Clinical presentation, diagnosis, and staging", section on 'Premalignant lesions'.)
Miscellaneous conditions — Other conditions associated with balanitis include reactive arthritis and fixed drug eruption .
●Reactive arthritis – Reactive arthritis (formerly Reiter syndrome) is a multisystem disorder that primarily affects the joints, eyes, and genitourinary tract.
Twenty to 40 percent of men with reactive arthritis develop circinate balanitis, which is characterized by small, shallow painless ulcerative lesions on the glans penis (picture 2) . There may also be a serpiginous annular dermatitis that often has a grayish white granular appearance with a "geographical" white margin . Circinate balanitis, when occurring as a component of reactive arthritis, is often a self-limited condition but can persist for several months. Men with circinate balanitis associated with reactive arthritis may also have other genital symptoms, including dysuria, penile discharge, and prostatitis.
Additional clinical manifestations of reactive arthritis are discussed elsewhere. (See "Reactive arthritis", section on 'Clinical manifestations'.)
●Fixed drug eruption – Balanitis can represent a reaction to a number of medications. A fixed drug eruption is characterized by the recurrent appearance of skin lesions at the same site each time the offending agent is administered. The lesions develop over the course of 30 minutes to eight hours. They often manifest as round or oval plaques with erythema, edema, and sharply defined borders. The most commonly offending agents are tetracyclines, salicylates, phenacetin, phenolphthalein, and some hypnotics [22,31-33] (see "Drug eruptions"). The pathophysiology of balanitis as a manifestation of a drug eruption is not well understood.
DIAGNOSTIC EVALUATION — Balanitis should be suspected in men who complain of penile pain and/or redness. The diagnosis is confirmed by the presence of an inflamed and erythematous glans on physical examination. For men who are uncircumcised, mobility of the foreskin should be assessed to exclude phimosis and paraphimosis (trapping of the foreskin behind the glans) (picture 3), which are complications of balanitis. Paraphimosis requires urgent urologic consultation. (See 'Complications' below.)
Although many cases of balanitis in uncircumcised males are the result of inflammation from rubbing of the foreskin against the glans (sometimes with superimposed fungal or bacterial infection) and will respond to local hygiene measures, history and physical examination findings sometimes point to other etiologies (table 2 and algorithm 1) .
In particular, certain historical (eg, diabetes mellitus, HIV infection, obesity) or examination (eg, white, curd-like exudate) features raise suspicion for candidal infection, the most common identified etiology of balanitis. If available, a potassium hydroxide (KOH) stain can be examined by microscopy for budding yeast and/or pseudohyphae (picture 4). Patients with candidal balanitis with no identifiable predisposing conditions should be screened for diabetes mellitus .
History and physical examination findings sometimes point to other etiologies that have management implications . History should assess the risk for sexually transmitted infections (STIs), as well as any underlying dermatologic (eg, eczema, psoriasis) or systemic (eg, reactive arthritis) diseases. Beyond inspection of the glans and foreskin, physical examination should include assessment of the urethral meatus for inflammation and discharge, as well as extragenital manifestations (eg, generalized rash, oral ulcers, inguinal lymphadenopathy, arthritis).
A dermatologic cause, allergic reaction, or (less likely) premalignant condition may also be responsible. In some cases, a dermatologic cause (eg, psoriasis or lichen planus) is evident based on the characteristic appearance of the lesions and their presence elsewhere on the body. Referral for dermatology or urology consultation and biopsy is recommended for nonresponders to topical corticosteroid therapy . (See 'Less common etiologies' below.)
In particular, small, shallow, painless ulcerative lesions on the glans penis (picture 2) are suggestive of circinate balanitis, a particular type of balanitis associated with reactive arthritis. There may also be a serpiginous annular dermatitis that often has a grayish white granular appearance with a "geographical" white margin . This lesion can be mistaken for psoriasis on physical examination, and histological evaluation cannot reliably distinguish between the two disorders. Biopsy of circinate balanitis can show pustules in the upper epidermis, similar in appearance to pustular psoriasis. The distinction between circinate balanitis and psoriasis is generally made by the clinical context (eg, if the patient has known reactive arthritis or psoriasis). If circinate balanitis is suspected clinically in a patient without known reactive arthritis, screening for STIs and testing for human leukocyte antigen (HLA)-B27 is advised.
Additional evaluation may be warranted based upon the history and physical findings. This might include bacterial culture (in the presence of purulent exudate), herpes simplex virus (HSV) testing (in the presence of vesicular or ulcerative lesions), syphilis testing (in the present of an ulcer), testing for scabies, and testing for trichomonas and Mycoplasma genitalium (in the presence of urethritis). Details of diagnostic testing of these infections is discussed elsewhere. (See "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection", section on 'Diagnosis' and "Syphilis: Screening and diagnostic testing", section on 'Approach to testing' and "Scabies: Epidemiology, clinical features, and diagnosis", section on 'Diagnosis' and "Trichomoniasis: Clinical manifestations and diagnosis", section on 'Diagnosis' and "Mycoplasma genitalium infection in males and females", section on 'Diagnosis'.)
Hygiene measures and empiric treatment — Management of balanitis without an identifiable cause is initially focused on implementation of local hygiene measures. In addition, empiric treatment for candidal infection and/or noninfectious dermatitis is warranted in some patients (algorithm 1).
Attention to genital hygiene is the most important approach for most men with balanitis. Retraction of the foreskin with thorough genital cleansing can be both preventive and therapeutic. Twice-daily bathing of the affected area with saline solution should be encouraged [22,26]. If a contact dermatitis is suspected, use of soap may cause further irritation and should be avoided .
A delicate balance must be established between overly aggressive and inadequate hygiene measures. Overuse of detergents, soaps, perfumes, condoms, and other chemicals (spermicidal agents, petroleum jelly), similar to poor hygiene, can also result in inflammation to the skin of the glans/foreskin. In addition, dermatitis can result from irritation secondary to the shearing effects of clothing.
In uncircumcised males, nonspecific balanitis may respond to saline solution bathing alone. In circumcised males and in uncircumcised males who do not respond to saline solution bathing, we suggest empiric treatment for candidal infection with clotrimazole 1% cream or miconazole 2% cream twice daily for 7 to 14 days (see 'Candidal infection' below). For those who have no improvement on antifungal therapy, we suggest a trial of hydrocortisone 1% cream or ointment twice daily for seven days for nonspecific dermatitis.
Patients with nonspecific balanitis who do not respond to local hygiene measures with or without topical antifungal and hydrocortisone therapies should be referred for dermatologic or urologic consultation for consideration of biopsy to evaluate for specific dermatologic causes and/or to rule out premalignant disease.
Directed treatment for identifiable causes
Candidal infection — For most patients, treatment includes the use of topical antifungal agents, usually for one to three weeks. First-line therapy includes a topical imidazole, either clotrimazole 1% or miconazole 2%, each applied twice daily . Nystatin cream (100,000 units/g) can be used in patients allergic to imidazoles. For patients who have severe symptoms, options are a single dose of oral fluconazole 150 mg  or the combination of a topical imidazole and hydrocortisone 1% cream twice daily. These recommendations are supported by evidence from treatment of cutaneous candidiasis in general.
Some patients may be interested in taking lactobacillus-containing yogurt as an attempt to decrease candidal colonization. Although there are no studies of lactobacillus in the treatment or prevention of candidal balanitis, given that it decreases candidal colonization of the rectum and vagina among women, there is a theoretical basis for its utility [38,39]. We do not suggest alternative therapies with phytogenic agents including garlic, calendula, and goldenseal since there are no reliable data showing their effectiveness.
Female sexual partners of men with balanitis should be offered testing for candida or empiric treatment to reduce the likelihood or reinfection . (See "Candida vulvovaginitis: Treatment", section on 'Recurrent treatment'.)
Less common etiologies — If other specific etiologies are identified, directed therapy is warranted. Management generally consists of topical antibiotics for bacterial infections, topical steroid cream for dermatologic conditions, and potential ablation or excision of premalignant lesions.
●Bacterial and other infections – Specific pathogens are not usually identified, and treatment choices are generally empiric. For suspected anaerobic infection, we suggest topical metronidazole 0.75% applied twice daily for seven days; oral metronidazole (500 mg twice daily for seven days) may be necessary for more severe cases . Oral amoxicillin-clavulanate or clindamycin topical cream are alternative regimens. For suspected streptococcal or staphylococcal infection, we suggest mupirocin cream applied three times daily for 7 to 14 days; oral dicloxacillin (500 mg four times daily for seven days) or cephalexin (500 mg four times daily for seven days) may be necessary for more severe cases.
Circumcision or dorsal slit surgery should be strongly considered in patients with a history of recurrent infectious balanitis but not during active infection.
Management of trichomonas, herpes simplex virus (HSV) infection, syphilis, scabies, and Mycoplasma genitalium infection is discussed separately. (See "Treatment of genital herpes simplex virus infection" and "Syphilis: Treatment and monitoring", section on 'Treatment of early syphilis' and "Mycoplasma genitalium infection in males and females", section on 'Treatment' and "Scabies: Management".)
•Lichen planus – Lichen planus is managed with high- to super high-potency topical steroid cream (table 3); topical or oral cyclosporin, topical calcineurin inhibitor, or circumcision may be recommended in refractory cases. (See "Lichen planus", section on 'Treatment'.)
•Lichen sclerosus – The recommended treatment is daily high-potency topical corticosteroid (eg, clobetasol propionate 0.05% cream or ointment) . Therapy is generally administered until remission and then transitioned to weekly intermittent use to maintain the remission. Acitretin is a systemic retinoid that is effective as alternative therapy for balanitis xerotica obliterans (BXO) resistant to topical glucocorticoids . However, acitretin has several adverse effects including cheilitis, alopecia, and abnormal liver function tests.
Circumcision is indicated in the event of phimosis , and meatoplasty or urethroplasty is warranted if meatal stenosis is present. Even after surgery, the skin condition still requires treatment. Follow-up should occur at least annually after remission has been achieved.
•Contact dermatitis – Treatment includes local cleansing and avoidance of the precipitating agent(s). In the place of soaps, aqueous cream is encouraged to soften and soothe the skin surface . (See "Irritant contact dermatitis in adults", section on 'Management'.)
•Carcinoma in situ – Surgical excision, topical chemotherapeutic therapy, or laser excision are reasonable treatment options . Mohs surgery is also an acceptable treatment.
•Reactive arthritis – The suggested treatment of circinate balanitis is hydrocortisone 1% cream applied twice daily for relief of symptoms. In addition, any concurrent infection should be treated. Systemic corticosteroid treatment is required infrequently. (See "Reactive arthritis", section on 'Treatment of other clinical features'.)
•Fixed drug eruption – Management of a fixed drug eruption consists of discontinuation of the causative agent in conjunction with mild- to moderate-strength topical steroid cream and oral antihistamines as needed. (See "Fixed drug eruption", section on 'Management'.)
COMPLICATIONS — Morbidity associated with balanitis includes the development of pain, ulcerative lesions of the glans/foreskin, phimosis, paraphimosis, meatal/urethral stricture, and malignant transformation of premalignant lesions. (See "Paraphimosis: Clinical manifestations, diagnosis, and treatment" and "Strictures of the adult male urethra" and "Carcinoma of the penis: Epidemiology, risk factors, and pathology" and "Carcinoma of the penis: Clinical presentation, diagnosis, and staging".)
Phimosis — Phimosis, an abnormal constriction of the opening in the foreskin that precludes retraction over the glans penis, results from chronic inflammation and edema of the foreskin. Development of a phimosis often complicates sexual function, voiding, and hygiene. If the patient or medical staff forcibly retracts the foreskin, a paraphimosis (trapping of the foreskin) can occur. (See 'Paraphimosis' below.)
Phimosis can be treated in the emergent setting by dilation using a surgical clamp and pain medication. In the event this is not successful, a dorsal slit circumcision can be performed by a urologist to temporize the problem. Definitive treatment, under elective circumstances, is complete circumcision.
Paraphimosis — Paraphimosis refers to the trapping of the foreskin behind the glans penis and is a urologic emergency (picture 3). The constricting foreskin has become located proximal to the glans penis. Under these circumstances, the constricting band will limit the venous and lymphatic outflow while allowing continued arterial inflow. Over the course of minutes to hours the glans will increase in size and become exquisitely painful. This must be addressed by a urologist with reduction of the paraphimosis. (See "Paraphimosis: Clinical manifestations, diagnosis, and treatment", section on 'Paraphimosis reduction'.)
The single most important step in treatment is making the correct diagnosis. In the hospital setting, the diagnosis can often be complicated by abnormal mental status or sedation of the patient. Medical staff may identify a "red penis" and assume that the diagnosis is balanitis alone. However, closer inspection can reveal the constricting foreskin.
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" and "Society guideline links: Lichen sclerosus".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Lichen sclerosus (The Basics)" and "Patient education: Balanitis (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Definition – Balanitis is defined as inflammation of the glans penis, and balanoposthitis includes inflammation of the foreskin. (See 'Introduction' above.)
●Causes – The most common cause of balanitis is related to inadequate personal hygiene in uncircumcised males. Of cases with identifiable causes, candidal infection is the most common. Various other infectious agents, dermatologic conditions, and premalignant conditions have been associated with balanitis. An organizational scheme is included as part of the 2013 European guideline for the management of balanoposthitis (table 1). (See 'Etiology' above.)
●Symptoms – Balanitis may present as pain, tenderness, or pruritus associated with erythematous lesions on the glans and/or the foreskin; an exudate may also be present. If balanitis is a manifestation of reactive arthritis, it may be associated with joint inflammation, mouth sores, and/or generalized symptoms. (See 'Clinical manifestations' above.)
●Physical examination findings – Physical examination should include inspection of the glans and foreskin and the urethral meatus for inflammation/discharge. Careful inspection for possible paraphimosis (trapping of the foreskin behind the glans penis) should be performed. (See 'Diagnostic evaluation' above.)
●Management – Management of balanitis without an identifiable cause is initially focused on implementation of local hygiene measures. In addition, empiric treatment for candidal infection and/or noninfectious dermatitis is warranted in some patients (algorithm 1). (See 'Management' above.)
•Hygiene measures – Retraction of the foreskin with thorough genital cleansing can be both preventive and therapeutic. We suggest twice-daily bathing of the affected area with saline solution (Grade 2C). In uncircumcised males, nonspecific balanitis may respond to saline solution bathing alone. (See 'Hygiene measures and empiric treatment' above.)
•Additional empiric treatment – In circumcised males and in uncircumcised males who do not respond to saline solution bathing, we suggest empiric treatment for candidal infection with clotrimazole 1% twice daily or miconazole 2% twice daily (Grade 2C). For those who have no improvement on antifungal therapy, we suggest a trial of hydrocortisone 1% cream twice daily for nonspecific dermatitis (Grade 2C). (See 'Candidal infection' above.)
•Specific treatment for other etiologies – If other specific etiologies are identified, directed therapy is warranted. Management generally consists of topical antibiotics for bacterial infections, topical steroid creams for dermatologic conditions, and potential ablation or excision of premalignant lesions. (See 'Less common etiologies' above.)
●Complications – Phimosis, a constriction of the opening of the foreskin so that it cannot be retracted over the glans penis, is a possible complication of balanitis. Paraphimosis is the trapping of the foreskin behind the glans penis and requires urgent reduction by a urologist. (See 'Complications' above.)