Balanitis, Balanoposthitis and Paraphimosis in the Adult

Essentials

• The aetiology should be determined critically (avoid overdiagnosing candidiasis)
• Treat the cause, if possible, but in most cases treatment is symptomatic.
• Consider circumcision in recurrent balanitis.

Definitions

• Balanitis is a rash or skin infection of the glans (picture ).
• The inner surface of the foreskin is usually also inflamed; in this case the accurate term is balanoposthitis.
• Paraphimosis ("Spanish collar"; picture ) occurs when a tight foreskin is retracted and the resulting stasis causes marked swelling of the distal foreskin.

Aetiology

• Possible causes of balanitis
  • Irritation and intertrigo: poor hygiene, tight foreskin, irritation by smegma or by soap
  • Seborrhoeic eczema Seborrhoeic Dermatitis in the Adult; check the scalp, skin behind the ears, and skin folds (picture )
  • Diabetes, poor hygiene, advanced age, immunosuppression or significant overweight may predispose to this.
  • Candida; a positive culture result does not yet prove causality. Candidiasis is overdiagnosed.
  • Contact allergy Seborrhoeic Dermatitis in the Adult
    • Rubber (latex or additives used for rubber manufacture in condoms)
    • Preservatives and perfumes in ointments and gels (used by the patient or his partner)
    • Ingredients in topical treatments (antimicrobial agents, such as neomycin ointments; local anaesthetic agents, such as benzocaine; antiherpetic ointments)
  • Lichen sclerosus (balanitis xerotica obliterans, BXO; pictures and ) are rare skin manifestation of Reiter's syndrome
  • Balanitis circinata (picture ): a rare skin manifestation of Reiter's syndrome
    • Are there other signs of Reiter's disease - arthritis, conjunctivitis?
    • The patient seeks medical care primarily due to the articular symptoms; detection of balanitis supports the diagnosis.
  • Balanitis plasmacellularis Zoon (a clearly defined, erythematous or weeping spot on the glans, cause unclear; rare)
• Other possible skin disorders in the same location as balanitis or balanoposthitis
  • Lichen (ruber) planus Lichen Planus - is more common in the glans than is generally believed (picture )
  • Psoriasis Psoriasis (picture ) - check other typical locations of psoriasis
  • Erythema fixum Hypersensitivity to Drugs (drug-induced; picture )
  • Erythroplasia Queyrat (a variant of Bowen's disease in the glans), which is a carcinoma in situ!

Workup

• Bacterial and fungal culture results should be interpreted with caution. Colonization is common, and candida is the real cause in every fifth case at the most.
• Fasting blood glucose to exclude diabetes, particularly if there is recurrent balanitis
• Urethritis due to chlamydia Chlamydial Urethritis and Cervicitis or gonorrhoea Gonorrhoea may be associated with fulminant balanitis; urethral discharge ending up under the foreskin causes skin irritation and maceration. Genital herpes Genital Herpes, syphilis Syphilis (primary symptoms, ulcer) and condylomas Human Papillomavirus (HPV) Infection may also be associated with balanitis.
• Perform tests for sexually transmitted diseases, as necessary.
• Skin biopsy (such as 4-mm punch biopsy) and histological examinations should be performed if there is no response to treatment or a malignancy is suspected. A punch biopsy of the glans can be taken by a GP (see video Large Thyroid Cyst).

Treatment

• Treatment should primarily be provided according to the aetiology: Decide what you actually want to treat!
• Appropriate hygiene: reposition of the foreskin and washing with water once daily, keeping the area dry, use of talcum powder, as necessary
• Avoidance of irritating topical agents (such as soap)
• For irritant contact dermatitis or seborrhoeic eczema, use low- or mid-potency glucocorticoid ointment intermittently, twice daily in courses of 2 to 3 weeks, with breaks of similar length in between.
• A combination ointment with an antiseptic/antimicrobial and a glucocorticoid or with an antifungal and a glucocorticoid can be tried.
• For lichen ruber planus or psoriasis, use mid- or high-potency glucocorticoid ointments intermittently in courses of 2-3 weeks, for example.
• Courses of calcineurin inhibitor ointments help in persistent balanitis. They can be used after a glucocorticoid ointment, for instance.
• The penis is bathed 2-3 times a day (e.g. with antiseptic soap or liquid body wash or just warm water for 10-15 min).
• Potassium permanganate baths ("tea cup bath") can also be used for the treatment of secretory balanitis.
  • Water-soluble tablets (Permitabs^® ) are available.
• For acutely infected (weeping and secretory) balanitis, systemic antimicrobial treatment may be required,
  • such as cephalexin 500-750 mg 3 times daily for 7-10 days.
  • Other options include amoxicillin / clavulanic acid 875/125 mg twice daily or clindamycin 300-600 mg 3 times daily.
  • For suspected anaerobic infection (malodorous secretion), prescribe oral metronidazole 400 mg 2-3 times daily for 7-10 days.
• For typical candida balanitis, prescribe topical antifungal medication twice daily in courses of 2 to 3 weeks; in addition, a single dose of 150 mg oral fluconazole, as necessary.
• Sexually transmitted diseases should be treated according to the appropriate guidelines.
• Lichen sclerosus et atrophicus can be treated with intermittent high- or superpotency glucocorticoid ointments in courses of 3 to 4 weeks, for instance, monitoring the response, and with circumcision, as necessary.
• Phimosis usually requires surgical treatment.

Specialist consultation

• Poorly responding and chronic balanitis may require consulting a dermatologist (to confirm the diagnosis).
• Response to treatment may vary greatly, and the disease may be reactivated after remission.
• Do not hesitate to consult a surgeon or a urologist in case of paraphimosis or phimosis.
• In severe cases or ones that are difficult to treat, refer the patient to a urologist for consideration of circumcision.

Pictures