Bacterial infection of the glans penis and the foreskin (balanoposthitis) is a common condition among preschool-age children. It is usually caused by a physiologically tight foreskin and fingering of the foreskin with soiled hands. The term balanitis is often used for the inflammation of the foreskin even if it actually means inflammation of the glans.
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 (infection of the foreskin) is not settled by topical treatment or if a rapid test for streptococcus taken from the preputial discharge is positive.
In complicated cases, circumcision may be warranted.
Symptoms and diagnosis
Symptoms include redness and swelling of the foreskin, excretion of pus, painful micturition, irritability and even urinary retention. Dermatitis of the foreskin may simulate bacterial posthitis.
The condition may predispose the patient to a urinary tract infection. However, consider bladder puncture only in the case that the child presents with temperature or other generalised symptoms. A urinary sample obtained from a collection bag will always be contaminated in these patients.
Recurrent symptoms from the foreskin may lead to avoidance of urination further to secondary day-time enuresis.
Bulging of the foreskin when urinating is caused by adhesions in the foreskin. It is a physiological phenomenon that will vanish with age and requires no further actions.
In the xerotic obliterating balanoposthitis (balanitis xerotica obliterans, BXO; pictures 12), infections may often occur but there is usually no bulging. In BXO, circumcision is always indicated.
Treatment
There is insufficient evidence on the effectiveness of any therapeutic regimen in the treatment of the condition; all treatment options currently used are therefore empirical and based on recommendations from various experts.
Basic treatment consists of bathing of the inflamed foreskin several times a day without using soap. The child should avoid fingering the foreskin.
If the foreskin is very red or swollen or if there is purulent discharge from under the foreskin, a common practice is to locally apply an eye ointment or eye drops containing fucidic acid or chloramphenicol 2-3 times daily. There is no research on the efficacy of antimicrobial ointments. Fungal posthitis can be treated with antifungal ointments; these have been proven effective in adults.
An orally administered antimicrobial drug may 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 severe and if the condition is complicated by, for example, urinary retention, the child should be admitted to hospital.
Boys usually have posthitis only once. In frequently recurring or complicated (urinary tract infections, secondary enuresis, scarred phimosis) balanitis, circumcision may be considered.