What is balanitis?
Balanitis is inflammation of the glans penis (head or knob of the penis) due to any cause. In uncircumcised males (the foreskin or “prepuce” is still present) inflammation of both the glans and the foreskin together is called balano-posthitis.
What causes balanitis?
Balanitis and balano-posthitis may be caused by many different skin conditions including:
• non-infectious skin conditions such as dermatitis (eczema) or psoriasis
• infections of the skin if uncircumcised such as candidiasis or “thrush”
• non-infectious inflammatory conditions found on the penis including lichen sclerosus, lichen planus and Zoon’s plasma cell balanitis
• occasionally caused by tablets taken by mouth (fixed drug eruption)
• pre-cancerous skin conditions including in situ squamous cell carcinoma or penile intra-epithelial neoplasia (PIN).
Sexually transmissible diseases (STDs) are only rarely a cause of balanitis or balano-posthitis. Fear of a possible STD often causes anxiety, distress or confusion.
What does balanitis look like?
Inflammation of the glans penis or foreskin may cause redness, itching, discomfort, flaking of skin, swelling or soreness.
Balano-posthitis in uncircumcised males may cause difficulty in retracting the foreskin, resulting in discomfort and difficulty with erections and sexual activity.
Balanitis and balano-posthitis may be a relatively minor problem or may become a major issue, greatly affecting enjoyment of life. Fear of a sexually acquired infection or fear of cancer of the penis may be aggravated by inappropriate and incorrect advice offered by family, friends or inexperienced health professionals.
Zoon’s balanitis – Image reproduced with permission of Associate Professor Anthony P. Hall
What other problems can occur with balanitis?
Balano-posthitis (in uncircumcised males) is more common than balanitis alone. Balanitis or balano-posthitis is mostly an irritant dermatitis (eczema) that may follow earlier childhood atopic dermatitis (atopic eczema) or be part of later-onset atopic dermatitis (genetically determined). Balanitis and balano-posthitis may be aggravated by the use of irritants including soap, increase in body temperature, sweating or friction. In uncircumcised males, irritant dermatitis of the glans penis and foreskin may become secondarily infected with candida or bacteria. Smegma, an asymptomatic, white, cheesy natural secretion, is sometimes seen under the foreskin and is often confused with candidiasis.
Balanitis or balano-posthitis due to psoriasis may be associated with more widespread psoriasis with scaly, red, itchy plaques of psoriasis of the scalp, elbows, knees and the anus. Occasionally psoriasis may damage joints resulting in painful arthritis.
Lichen sclerosus is an important cause of balanitis and balano-posthitis that causes whitening or redness of the glans penis. Some boys and men with lichen sclerosus have difficulty retracting the foreskin easily while others progress to severe tightening of the foreskin and total inability to retract the foreskin, known as phimosis. Urological surgeons refer to lichen sclerosus with phimosis as balanitis xerotica obliterans. Lichen sclerosus with inability to retract the foreskin (phimosis) rarely may lead to cancer of the penis later in life.
Lichen planus, another cause of balanitis and balano-posthitis, may be associated with itchy skin spots on arms, legs or the body. Lichen planus may cause painful ulceration of the mouth as well as hair and nail abnormalities.
Zoon’s plasma cell balanitis occurs in uncircumcised men causing either a non-itchy red or orange patch on the glans penis or under the foreskin or a patch that is quite itchy or sore.
It is important to be sure that balanitis and balano-posthitis is not caused by early (in situ) squamous cell carcinoma, also called penile intra-epithelial neoplasia, or simply “PIN”. PIN may progress to true cancer of the glans penis in some men. Fortunately cancer of the penis is a rare disease. Cancer of the penis appears as a persisting ulcer or a slowly growing lump on the glans penis.
How is balanitis diagnosed?
A doctor who is knowledgeable and skilled in recognising disorders of the male genital region is most helpful to make a diagnosis of balanitis or balano-posthitis. The doctor can also explain the cause of these conditions. Dermatologists are the most qualified and trained doctors in recognising diseases of the male genitalia as most genital disease is disease of genital skin.
Your family doctor (GP) may refer you to a specialist dermatologist. Sexual heath physicians and urologists may also be consulted but have less experience in dealing with all diseases of skin.
A skin swab may be necessary if candida or bacterial infection is suspected.
Blood tests may be helpful to exclude an associated sexually transmissible disease (STD) but blood tests cannot diagnose balanitis or balano-posthitis. Blood tests and special swabs that exclude an STD are very reassuring when there is concern of a possible STD.
A skin biopsy of the glans penis or foreskin is necessary if pre-cancerous disease or cancer is suspected. While skin biopsy sounds frightening, an experienced dermatologist can take a genital skin biopsy with minimal pain and distress.
Skin patch testing is occasionally necessary if an allergic substance is suspected.
How is balanitis treated?
The first step in treating non-specific balanitis is to clean and dry the glans penis after washing or going to the toilet. Try to avoid contact with irritants of the genital skin. Replacing soap with a non-soap wash is important, combined with regularly applying soft white paraffin ointment (also known as petrolatum or Vaseline® ointment) under the foreskin after showering or bathing. Soft white paraffin ointment (petrolatum or Vaseline® ointment) can also be used as a lubricant for sexual activity.
Stop any unnecessary over-the-counter creams or potions, particularly if they contain perfumes or fragrances. Avoid using all “baby wipes” as these can be very irritating and may lead to a true allergic contact dermatitis. Importantly avoid any proven allergic substance.
Use a mild topical cortisone ointment (such as 1% hydrocortisone ointment) when the glans penis or foreskin appears red or irritated. Stop using this topical cortisone ointment once the glans or foreskin appears normal. Mild cortisone creams and ointments are extremely safe when used under the supervision of an experienced doctor. Many “natural” products are no safer than “not natural” products and may also cause irritation or allergies.
Infection with candida usually responds quickly to an antifungal cream, particularly if combined with a mild cortisone cream or ointment.
More difficult or serious causes of balanitis or balano-posthitis need specific treatment under the guidance of a dermatologist, particularly any pre-cancerous genital skin disease. This is important for proper treatment as well as to prevent and detect early cancer of the penis.
What is the likely outcome of balanitis?
• Balanitis or balano-posthitis due to dermatitis (eczema) or psoriasis usually improves quickly but may need repeated treatment for any flare-up.
• Infection with candida resolves quickly after treatment but may recur in uncircumcised males.
• Lichen sclerosus requires long-term treatment and follow-up by a dermatologist to detect complications such as phimosis or early cancer.
• Zoon’s plasma cell balanitis requires intermittent treatment with a combination of creams. Zoon’s balanitis resolves if circumcision is performed but circumcision is not always desired or necessary. Intermittent treatment with a mild cortisone cream and an antibacterial cream usually settles any flares of this chronic disorder.
• Lichen planus may recur after treatment with stronger cortisone creams or other medications and needs long-term treatment and follow-up by a dermatologist.
• Modern treatment of pre-cancerous disease (in situ squamous cell carcinoma or penile intra-epithelial neoplasia) and cancer of the penis needs specialist care. Early treatment often leads to a normal life expectancy. More advanced cancer carries a greater risk but the outcome for each man is very variable so specialist care, often with an urologist and dermatologist is necessary.
• Vaccination of young men with the human papilloma virus (HPV) vaccine (Gardasil vaccine) before sexual activity, together with careful management of any pre-cancerous genital disease are important in preventing the development of penile cancer.
This information has been written Associate Professor Anthony P. Hall
last updated 13/03/17