Balanitis is an inflammatory condition of the glans penis or prepuce that manifests with erythema, swelling, and discomfort, often progressing to ulceration or scaling. The condition typically develops over a period of three to seven days and is predominantly seen in uncircumcised men, especially those with poor personal hygiene.

Etiology and Risk Factors

Balanitis can arise from several underlying causes, which can broadly be categorized into infectious, autoimmune, and irritant-related etiologies.

• Infectious Causes:
  • Fungal Infections: Candida species are a common cause of balanitis, particularly in individuals with poorly controlled diabetes. The elevated glucose levels in these individuals facilitate the overgrowth of Candida under the prepuce. Topical antifungal treatments, such as imidazoles (clotrimazole and miconazole), are the mainstay of therapy for Candida-related balanitis.
  • Bacterial Infections: Both aerobic and anaerobic bacteria, including Gardnerella vaginalis and Treponema pallidum (syphilis), can be implicated in balanitis. In these cases, appropriate antibiotic therapy based on culture results is recommended.
  • Viral Infections: Human papillomavirus (HPV) and herpes simplex virus (HSV) can also lead to balanitis, manifesting as ulcerative lesions on the glans penis.
  • Other Infectious Agents: Less common causes include Borrelia burgdorferi, the causative agent of Lyme disease, and Treponema pallidum (syphilis), which can present with balanitis as part of a broader systemic infection.
• Autoimmune and Inflammatory Conditions:
  • Balanitis Xerotica Obliterans (BXO): This form of balanitis is associated with lichen sclerosus, a chronic inflammatory skin disorder that leads to atrophic changes in the foreskin, causing scarring and phimosis.
  • Circinate Balanitis: This type is linked to Reiter’s syndrome (also known as reactive arthritis), a condition characterized by the triad of arthritis, urethritis, and conjunctivitis. Circinate balanitis typically presents with lesions on the glans penis that may mimic other dermatologic conditions.
• Other Contributing Factors:
  • Poor personal hygiene is a significant risk factor, especially in uncircumcised men. The accumulation of smegma can create an environment conducive to infection.
  • Trauma or irritation due to mechanical friction, such as during sexual activity, may also contribute to balanitis.
  • Contact Dermatitis and allergic reactions to soaps, detergents, or latex condoms are common non-infectious causes of balanitis.
  • Certain medications, including tetracyclines, salicylates, and phenacetin, can induce fixed drug eruptions that may result in balanitis.

Clinical Presentation

Balanitis typically presents with symptoms such as pain, tenderness, pruritus, and erythema on the glans penis or prepuce. In more severe cases, small erythematous lesions may develop, which can become ulcerated, scaly, or covered with a thick, foul-smelling purulent exudate. Edema is common, and in untreated cases, adhesions may form, causing the prepuce to adhere to the glans and leading to further complications such as phimosis and scarring. In rare cases, difficulty urinating or changes in the urine stream may occur due to the swelling and inflammation. Systemic symptoms, including joint pain, mouth sores, and malaise, may be present, particularly in cases associated with autoimmune or infectious diseases such as Reiter’s syndrome or syphilis.

Diagnosis

A comprehensive diagnostic approach is essential to determine the underlying cause of balanitis. The initial evaluation should include a detailed clinical assessment, focusing on the patient’s medical history, hygiene practices, and potential exposure to infectious agents. Several laboratory tests can further aid in confirming the diagnosis. A serum glucose test is crucial for assessing underlying diabetes, which is a common predisposing factor for balanitis, particularly fungal infections such as Candida. Microbiological cultures of discharge or lesions are essential for identifying the causative organism, whether bacterial, viral, or fungal. 

Additionally, syphilis serology may be necessary to rule out syphilis, especially in patients presenting with ulcerative lesions. The potassium hydroxide test is used to diagnose fungal infections, including Candida. In severe or atypical cases, testing for human papillomavirus and HIV titers may be indicated to detect viral infections. Lastly, ultrasound or bladder scans are useful when urinary obstruction is suspected, particularly in cases with significant swelling or difficulty urinating. This multi-faceted diagnostic approach helps ensure accurate identification of the underlying cause and facilitates appropriate treatment.

Management and Treatment

The treatment of balanitis is directed towards addressing the underlying etiology, alleviating symptoms, and preventing complications such as scarring or phimosis.

• Antifungal Therapy: Topical imidazole agents such as 1% clotrimazole or 2% miconazole are typically used to treat Candida-induced balanitis, applied twice daily for 1-3 weeks. In severe cases or in patients with systemic involvement, oral antifungals like fluconazole may be used. For patients with allergies or resistance to imidazoles, nystatin cream may be an alternative.
• Antibiotic Therapy: For bacterial balanitis, appropriate antibiotic treatment should be based on culture results. Common antibiotics include topical or systemic agents like flucloxacillin or tetracycline, depending on the specific pathogen identified.
• Corticosteroids: In cases where inflammation is severe or unresponsive to antifungals, 1% hydrocortisone cream can be used as an adjunct to reduce inflammation and control symptoms.
• Management of Underlying Conditions: If an underlying medical condition such as diabetes or HIV is present, managing the condition is critical in preventing recurrent episodes of balanitis. In diabetic patients, maintaining good glycemic control has been shown to reduce the incidence of Candida infections.
• Surgical Intervention: In cases of chronic or refractory balanitis, particularly in BXO or phimosis, circumcision may be considered to prevent further episodes and alleviate symptoms.

Conclusion

Balanitis is a common condition that can result from a range of etiologies, including infections, autoimmune diseases, and irritants. Proper diagnosis through clinical evaluation and laboratory testing is essential to identify the underlying cause and guide appropriate treatment. Although topical antifungal agents remain the first-line treatment for many cases, severe or recurrent cases may require systemic therapy, corticosteroids, or even surgical intervention. Addressing underlying medical conditions such as diabetes is also crucial in preventing future episodes. With appropriate treatment, the prognosis for balanitis is generally favorable, although recurrences may occur, particularly in individuals with risk factors or chronic underlying conditions.

References

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8. Zhou, M., Wang, X., & Zhang, W. (2020). Circinate balanitis in Reiter’s syndrome: Diagnosis and management. Rheumatology International, 40(1), 125-130. https://doi.org/10.1007/s00296-019-04434-9