Balanitis

Definition/diagnostic criteria

Balanitis is defined as inflammation of the glans penis, which can also involve the foreskin (balanoposthitis) in uncircumcised males. Diagnosis is primarily clinical, characterised by erythema, irritation, and sometimes a discharge under the foreskin. It can be caused by a variety of factors including infection, poor hygiene, dermatological conditions, and irritants.

Epidemiology

Balanitis is a common condition affecting males of all ages, but is more prevalent in those with poorly controlled diabetes, uncircumcised males, and those with a history of poor genital hygiene. While exact prevalence rates in the UK are difficult to ascertain, it is a frequent reason for consultation in primary care and urology clinics.

Diagnosis

Clinical Features

The diagnosis of balanitis is largely clinical. Key features include redness, swelling, and soreness of the glans and, if applicable, the foreskin. Patients may also report pruritus, a discharge (particularly in infectious cases), and difficulty retracting the foreskin (phimosis). In diabetic patients, balanitis may present recurrently or be particularly resistant to treatment.

Investigations

While the diagnosis is primarily clinical, investigations may be warranted to identify specific causes or in cases where treatment fails. Swabs for bacterial culture and sensitivity, and for sexually transmitted infections (STIs) like herpes simplex virus and candida, should be considered. Blood glucose levels or HbA1c tests may be indicated to investigate diabetes as an underlying factor. Dermatological conditions may require biopsy for histological examination.

Typical abnormalities in investigations may include the presence of Candida spp. in fungal cultures, detection of STI pathogens in swabs, or elevated blood glucose levels indicating poorly controlled diabetes.

Treatment

The treatment of balanitis depends on the underlying cause. For candidal balanitis, topical antifungals such as clotrimazole are recommended. Bacterial infections may require topical or oral antibiotics based on culture results and sensitivity. For non-specific or irritant-induced balanitis, gentle cleansing and the use of emollients are advised. Corticosteroids may be beneficial in inflammatory dermatoses. In cases related to poorly controlled diabetes, optimizing glycaemic control is crucial. Refractory cases, particularly those associated with phimosis, may necessitate circumcision.

Prognosis

The prognosis for balanitis is generally good with appropriate identification and management of the underlying cause. Recurrences can occur, especially in cases related to poorly controlled diabetes or persistent high-risk sexual behaviour. Complications are rare but can include phimosis, paraphimosis, and in chronic cases, an increased risk of penile cancer. Patient education on hygiene and the importance of glucose control in diabetic individuals is key to prevention.