Balanitis

Definition

Balanitis is an inflammation of the head and foreskin of the penis.

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Balanitis generally affects uncircumcised males. These are men who have a foreskin, which is the "hood" of soft skin that partially covers the head of the penis. In balanitis, the head and foreskin become red and inflamed. (In circumcised men, who lack a foreskin, these symptoms only affect the tip of the penis.) The condition often occurs due to the fungus Candida albicans, the same organism that causes vaginal yeast infections in women. Balanitis (which is also referred to as balanoposthitis) can be caused by a variety of other fungal or bacterial infections, or may occur due to a sensitivity reaction to common chemical agents.

Uncircumcised men are more at risk for balanitis due to the presence of the foreskin. The snug fit of the foreskin around the top of the penis tends to create a damp, warm environment that encourages the growth of microorganisms. Most of the organisms associated with balanitis are already present on the penis, but in very small numbers. However, if the area between the head and foreskin is not cleansed thoroughly on a regular basis, these organisms can multiply and lead to infection.

Diabetes can increase the risk of developing the condition.                                                                       

What is Balanitis?

Balanitis is the inflammation of the glands located in the head and foreskin of the penis. It is common in uncircumcised men. Men with diabetes are more prone to developing balanitis.

Balanitis is not sexually transmitted. It is the result of an overgrowth of organisms which are normally present on the skin of the glands.

What causes Balanitis?

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The most common causes are:

• Irritants: neglected hygiene and tight foreskin (particularly in young boys) lead to irritation by smegma (a cheesy substance secreted under the foreskin).

• Seborrhoeic dermatitis: an inflammatory rash of uncertain cause that is commonly seen on the scalp, behind the ears and in the skin folds.

• Thrush (candida): although this infection is probably over-diagnosed by doctor and patient.

• Contact allergy: latex and additives used in rubber manufacture (eg condoms) and constituents of skincare products (used by the patient or partner).

• balanitis xerotica obliterans (BXO, also termed lichen sclerosis): this condition primarily affects the foreskin, leading to loss of skin colouration, scarring and tightness of the foreskin, and phimosis (inability to pull the foreskin back behind the glans), which may require circumcision. Involvement of the opening of the urethra (urine tube) can lead to irritation and burning. Surgery might be needed to prevent a stricture (narrowing) in the urethra. Steroid creams may help the irritation but patients require long-term follow-up to prevent recurrence.

• balanitis circinata: a skin manifestation of Reiter's syndrome, in which the patient also has arthritis (often of the knees), urethritis (inflammation of the urine tube in the penis) and conjunctivitis (red eyes).

• generalised skin conditions: these can also affect the penis, including: lichen planus, psoriasis, erythema multiforme, erythema fixum (particularly caused by tetracycline antibiotics), erythroplasia of Queyrat (a rare, pre-cancerous skin condition).

• diabetes.

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Predisposing factors include:

• Moisture (sweat), which permits the microorganisms to thrive. Nonspecific balanitis nearly always affects uncircumcised men, as the tissue under the foreskin may fail to dry out properly.
• Infrequent washing and/or failure to dry the glans after washing
• Conversely, over-frequent washing, especially with standard alkaline soap, or drying vigorously with a harsh towel
• Diabetes mellitus, which especially increases the likelihood of Candida albicans infection
• Sexual partner suffering from vaginal thrush (in which case it's the partner's yeasts that cause the irritation rather than a sexually transmitted infection)
• Chemical irritants, e.g., lubricating jelly, medicated creams
• Minor trauma – this may include friction during sexual intercourse
• Obesity

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Balanitis in young boys is usually associated with a tight foreskin that cannot be pulled back behind the glans (phimosis).

Phimosis leads to deficient hygiene and persistent contact of urine and smegma with the skin of the glans. Straightforward cases usually respond to antibiotic ointments but recurrent cases require investigation to exclude urinary tract infection.

Occasionally, irritation and swelling of the glans can be due to paraphimosis ('Spanish collar'), caused when a tight foreskin is retracted down the shaft behind the glans.

The tightness around the shaft slows the venous drainage of the end of the penis, and the glans swells, which tightens the paraphimosis further, making the foreskin virtually impossible to retract.

Ultimately, the restriction can interfere with the blood supply to the glans and urgent medical treatment is required. Often the foreskin can be returned to its normal position under sedation, but, if not, circumcision is required.

 Diagnosis

Balanitis is usually diagnosed based on a brief physical examination. This may be conducted by your regular health care provider or by a urologist, the type of doctor who specializes in such disorders. The doctor may take a sample of the discharge (if any) to determine the nature of the possible infection. A urine test may be recommended to evaluate glucose (sugar) levels in the urine. Balanitis treatment is typically covered by medical insurance.

What investigations are needed?

• Skin swabs for bacterial or fungal culture might be taken to confirm infection, particularly in cases that do not respond to a first-line antibiotic.

• A urine sample might be sent for microscopy and culture if urinary tract infection (UTI) is suspected.

• Patch testing might be required to confirm allergies.

• A dermatologist or urologist might perform a biopsy if BXO or erythroplasia of Queyrat are suspected.

• The urine or blood should be checked for diabetes.

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Symptoms

The incubation period varies from 3 days to 1 week. The first signs of involvement may be small red erosions on the glans or undersurface of the prepuce, with concomitant development of much preputial exudation; the purulent discharge may be accompanied by phimosis. If the disease is unchecked, confluent ulcerations will develop along with considerable edema of the penis. 

Redness of foreskin or penis

Other rashes on the head of the penis

Foul-smelling discharge

Painful penis and foreskin

Tenderness

Discharge from the penis

Impotence

Swelling

Difficulty with passing urine

Inability to retract the foreskin

Chronic inflammation or infection can:

§  Scar and narrow the opening of the penis (urethral stricture)

§  Make it difficult and painful to retract the foreskin to expose the tip of the penis (a condition called phimosis)

§  Make it difficult to reposition the foreskin over the head of the penis (a condition called paraphimosis); swelling can affect the blood supply to the tip of the penis

When to Contact a Medical Professional

Notify your health care provider if you are experiencing any signs of balanitis including swelling of the foreskin or pain.

Prevention

Good hygiene can prevent most cases of balanitis. During bathing, the foreskin should be retracted to adequately clean and dry the area beneath it.                                                     

Can it be Treated Successfully?

Yes if we can identify what is causing the problem.

§  Check for infection by taking swabs and examine the skin. Treatment (such as hydrocortisone) may be given if needed. Partners may also be advised to attend if the balanitis is thought to be due to sexual activity.

§  Care should be taken with hygiene. Hands should be washed before and after urinating.

§  Avoid scented soaps and cosmetics                     

§  Avoid biological powders/softeners for washing underwear.

§  Use condoms without spermicidal lubricants. Non-oxynol-9 is usually the major culprit. Sensitol is better. Check with your local clinic sexual health adviser on the more suitable brands available.

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Why Balanitis Occurs

Balanitis is not sexually transmitted. It results from an overgrowth of organisms which are normally present on the skin of the glans. The condition most commonly occurs in men who have a foreskin (i.e. have not been circumcised). The environment under the foreskin is warm and moist, and these conditions often favour the growth of the organisms that cause balanitis.

These organisms are especially likely to multiply and cause inflammation if moisture is allowed to persist under the foreskin for a while. This may occur if you have not washed for a couple of days, or sometimes after sexual activity (vaginal, oral or anal - with or without a condom).

One common organism associated with balanitis is a yeast known as Candida albicans.  Balanitis may occur because of excessive growth of Candida, due to moisture and warmth under the foreskin.

Protective Effect of Circumcision

Herzog and Alvarez demonstrated that uncircumcised boys had approximately twice the risk of developing balanitis or irritation (irritation is itself a form of balanitis). A later study by Fergusson et al. confirmed this finding.

The protective effect may be greater in adulthood. In a cross-sectional study of 398 patients, Fakjian reported that balanitis occurred more than five times as often in uncircumcised men than in circumcised men. Another study by Mallon et al. provided supportive evidence for this.

Mycobacterium smegmatis has been implicated in the formation of Zoon's balanitis

 Dissenting views

One study, suggested that circumcised boys were at greater risk of developing balanitis, though his study was limited by the small number of uncircumcised males in his sample (only 36 of the 468 in total were uncircumcised).

Table 1: Summary of comparative findings (studies with available data)

Management of Balanitis

The aim of treatment is to keep the glans and foreskin clean and dry to make it difficult for organisms to grow under the foreskin. Medication (e.g. cream or ointment) is

rarely necessary, and is usually less effective than good hygiene measures.

Once a day, ideally when you have a shower, slide your foreskin back towards your body until the glans is completely uncovered (Figures 1a and 1b). Do not use any force. If there is any resistance or discomfort, check with a doctor.        

Wash the end of your penis and foreskin thoroughly using warm water only. Alternatively, sorbolene and glycerine cream (available from chemists and supermarkets) may be used as a substitute for soap.

After washing, dry the end of the penis and foreskin thoroughly. If convenient, sit with the glans exposed to the air for 10 minutes. More thorough drying can be achieved by using a fan or hair dryer (Figure 2).

After drying, replace the foreskin (Figures 3a & 3b).

When you urinate, slide the foreskin back so that urine does not wet the foreskin (Figures 4a & 4b). After urination, dry the end of the penis and replace the foreskin.     

If you are prone to develop balanitis a few hours after sex, wash the penis as described above shortly after having sex. Make sure the glans is completely dry before replacing the foreskin.

These measures should lead to a rapid improvement in symptoms and help prevent further episodes of balanitis. 

If you experience repeated attacks of balanitis despite adequate foreskin hygiene, consult your doctor

Treatment

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