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Posthitis (Balanoposthitis) in Children

Essentials

  • Bacterial infection of the glans penis and the foreskin (balanoposthitis) is a common condition among preschool-age children. It is usually associated with a physiologically tight foreskin.
  • Bathing is the only treatment needed in mild cases. Local antimicrobial or antifungal ointment may be necessary in more severe ones.
  • An orally administered antimicrobial drug may be considered if posthitis is not settled by topical treatment or if a rapid test for streptococcus taken from the preputial discharge is positive.
  • It is important to make sure that the patient can urinate.
  • In complicated cases, circumcision may be warranted.

Symptoms and diagnosis

  • Symptoms include redness and swelling of the foreskin, excretion of pus, painful micturition, and even urinary retention.
    • Dermatitis of the foreskin may simulate bacterial posthitis.
  • Recurrent symptoms from the foreskin may lead to avoidance of urination and further to secondary day-time enuresis or predispose the patient to a urinary tract infection.
  • Consider bladder puncture if the child presents with temperature or other generalized symptoms.
    • A urinary sample obtained from a collection bag will be contaminated by purulent discharge from underneath the foreskin and is therefore not reliable in the diagnosis of urinary tract infection in patients with balanoposthitis.
  • Bulging of the foreskin when urinating is usually caused by a physiologically tight foreskin. It is a phenomenon that will vanish with age and loosening of the foreskin and requires no further actions if the bladder empties well.
  • In penile lichen sclerosus (balanitis xerotica obliterans, BXO; picture 1) urinating may become more difficult as scarring proceeds.
    • BXO is treated by circumcision.
    • BXO may be associated with bacterial posthitis, or the foreskin may become ulcerated and sore.

Treatment

  • There is insufficient evidence regarding the effectiveness of any therapeutic regimen; all treatment options currently used are therefore empirical and based on recommendations from various experts.
  • Basic treatment consists of bathing the inflamed foreskin several times a day with water. Soap and other stronger cleansing agents should be avoided when washing the foreskin to avoid irritation.
  • If the foreskin is very red, swollen and sore, or if there is purulent discharge from under the foreskin, a common practice is to locally apply an eye ointment or eye drops containing chloramphenicol or fucidic acid 2-4 times daily. This should be continued for a couple of days after the symptoms have subsided.
    • There is no research on the efficacy of antimicrobial ointments. Nevertheless, symptoms are usually alleviated rather quickly after starting the administration of topical antimicrobial treatment.
    • Fungal posthitis can be treated with antifungal ointments; these have been proven effective in adults.
  • An orally administered antimicrobial drug should be considered if bacterial posthitis is not settled by topical treatment in a couple of days or if a rapid test for streptococcus taken from the preputial discharge is positive. Either a penicillin or a cephalosporin may be chosen.
  • If the symptoms are very severe or if the child is not able to urinate, the child should be referred to hospital.
    • If a boy with balanoposthitis is afraid to urinate because of pain, or if this is impossible for other reasons, he should first be given sufficient oral pain medication at the emergency appointment; plenty of analgesic gel should then be applied to the foreskin before urination and/or urinating in the bath or under a shower can be attempted. If this is not sufficiently useful and the boy cannot urinate, the bladder should be catheterized and referral to hospital should be considered.
  • Boys usually have posthitis only once or a few times, and in most boys, the situation will calm down as the foreskin starts to become looser or when the boy no longer needs nappies. In frequently recurring or complicated cases (scarred phimosis, BXO, urinary tract infections), circumcision may be considered.

    References

    • Edwards SK, Bunker CB, van der Snoek EM, et al. 2022 European guideline for the management of balanoposthitis. J Eur Acad Dermatol Venereol 2023;37(6):1104-1117 [PubMed]
    • Celis S, Reed F, Murphy F, et al. Balanitis xerotica obliterans in children and adolescents: a literature review and clinical series. J Pediatr Urol 2014;10(1):34-9 [PubMed]
    • Babu R, Harrison SK, Hutton KA. Ballooning of the foreskin and physiological phimosis: is there any objective evidence of obstructed voiding? BJU Int 2004;94(3):384-7 [PubMed]
    • Stary A, Soeltz-Szoets J, Ziegler C, et al. Comparison of the efficacy and safety of oral fluconazole and topical clotrimazole in patients with candida balanitis. Genitourin Med 1996;72(2):98-102 [PubMed]
    • Schwartz RH, Rushton HG. Acute balanoposthitis in young boys. Pediatr Infect Dis J 1996;15(2):176-7 [PubMed]
    • Kyriazi NC, Costenbader CL. Group A beta-hemolytic streptococcal balanitis: it may be more common than you think. Pediatrics 1991;88(1):154-6 [PubMed]
    • Escala JM, Rickwood AM. Balanitis. Br J Urol 1989;63(2):196-7 [PubMed]