Balanitis

Template:BalanitisV Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vishal Devarkonda, M.B.B.S[2]

Synonyms and keywords: Balanoposthitis

• Please click here to know more about Zoon's Balanitis
• Please click here to know more about Balanitis xerotica obliterans

Overview

Balanitis is inflammation of glans penis. When inflammation involve the foreskin and prepuce, it is termed as balanoposthitis. Based on the etiology, balanitis can be mainly categorized into infectious, inflammatory dermatoses, and penile carcinoma in situ. Patients with balanitis may present with asymptomatic or symptomatic lesions with itch or pain in the genital region. Risk factors, pathogenesis, clinical presentation, diagnosis and management varies from etiology to etiology.

Classification

There is no established classification system for Balantis. Based on the etiologies, Balanitis can be classified into:

• Infectious
• Inflammatory dermatoses
• Penile carcinoma in situ

Balanitis

Infectious

Inflammatory dermatoses

Premalignant(penile carcinoma in situ)

Candida (albicans, krusei) Streptococci Anaerobes Staphylococci Trichomonas vaginalis Herpes simplex virus Human papillomavirus Mycoplasma genitalium

Lichen sclerosus Lichen planus Psoriasis Circinate balanitis Zoon's balanitis Eczema Allergic reactions

Bowen's disease Bowenoid papulosis Erythroplasia of Queyrat

Diagnosis and management

2008 UK National Guideline on the Management of Balanoposthitis 

Balanitis/balanoposthitis                                                     Take history and examine                                                                                               Perpuce retracts                           Perpuce does not retract                                                                                                   Ulceration present         Erythema,subpreputial discharge           Prepuce scarred       Prepuce swollen                                                                         Follow genital ulcer protocol   Fowl smelling     No odour       Refer to surgical opinion       Treat as genital ulcer disease                                                                         Metronidazole 400 mg bd     Antifungal+1% Hydrocortisone cream apply bd                                                                                                               Review                                                                                                                                                                 If better discharge   If not better 1) Reassess-try alternative pathway 2) Erythromycin 500 bd 3) Potent steroid cream

Synopsis

Symptoms			Signs
	Malaise	Pruritus	Skin lesions	Regional lymphadenopathy	Erythema	Swelling		Key distinguishing features
Candida balanitis	✖	✔	✖	✔	✖	✖	✖	Erythematous rash with soreness and/or itch, blotchy erythema with small papules which may be eroded, or dry dull red areas with a glazed appearance
Anaerobic infection	✔	✔	✖	✔	✖	✖	✖	Foul smelling sub-preputial inflammation and discharge: in severe cases associated with swelling and inflamed inguinal lymph nodes
Aerobic infection	✔	✔	✖	✔	✖	✖	✖	Variable inflammatory changes including uniform erythema and edema
Trichomonas vaginalis	✖	✔	✖		✖	✖	✖	Superficial erosive balanitis which may lead to phimosis
Treponema pallidum	✖		✖		✖	✖	✖	Multiple circinate lesions which erode to cause irregular ulcers have been described in the late primary or early secondary stage. A primary chancre may also be present.
Herpes simplex	✔	✔	✔		✖	✖	✖	Grouped vesicles on erythematous base over glans, prepuce and shaft which rupture to form shallow erosions. In rare cases primary herpes can cause a necrotic balanitis, with necrotic areas on the glans accompanied by vesicles elsewhere and associated with headache and malaise.
Human papilloma virus	✖	✔	✖		✖	✖	✖	Papilloma virus may be associated with patchy or chronic balanitis, which becomes acetowhite after the application of 5% acetic acid
Lichen sclerosus	✖	✔	✖		✖	✖	✖	White patches on glans, which may often involve prepuce
Lichen planus	✖	✔	✖		✖	✖	✖	Purplish lesions on the penis
Psoriasis	✖	✔	✖	✖	✔	✖	✖	Red scaly plaques
Circinate	✔	✔	✖	✖	✖	✖	✖	Greyish white areas on the glans
Zoon's balanitis	✖	✔	✖	✖	✖	✔	✖	Well-circumscribed orange-red glazed areas on the glans and foreskin.
Eczema	✖	✔	✖	✖	✖	✖	✖	Eczema may present has mild non-specific erythema to wide spread edema of penis.
Fixed drug eruption	✖	✔	✖	✖	✖	✖	✖	Well demarcated and erythematous lesions.
Bowen's disease	✖	✔	✖	✖	✖	✖	✔	Multiple, small, well-demarcated, grey-brown, red, pink, or skin-colored papillomatous papules or small patches on the penile shaft, glans, or foreskin, vulva, and perianal area
Bowenoid papulosis	✖	✔	✖	✖	✖	✖	✔	Single or multiple red, shiny, slightly raised, sharply demarcated, velvety, non-healing plaques associated with scaling, crusting, and sometimes bleeding, affecting the mucosal surfaces of the penis.
Erythroplasia of Queyrat	✖	✔	✖	✔	✖	✖	✔	Red, sometimes slightly pigmented, scaly, moist, velvety patches and plaques of keratinization on penis.

	Fowl smelling discharge	Circinate lesions	Grouped vesicles present	Becomes aceto white on application of 5% acetic white	Purplish lesion	Pinpoint redder spots	Failure to respond to treatment	Key distinguishing features
Candida balanitis	✖	✖	✖	✖	✖	✖	✖	Erythematous rash with soreness and/or itch, blotchy erythema with small papules which may be eroded, or dry dull red areas with a glazed appearance
Anaerobic infection	✔	✖	✖	✖	✖	✖	✖	Foul smelling sub-preputial inflammation and discharge: in severe cases associated with swelling and inflamed inguinal lymph nodes
Aerobic infection	✖	✖	✖	✖	✖	✖	✖	Variable inflammatory changes including uniform erythema and edema
Trichomonas vaginalis	✖	✖	✖	✖	✖	✖	✖	Superficial erosive balanitis which may lead to phimosis
Treponema pallidum	✖	✔	✖	✖	✖	✖	✖	Multiple circinate lesions which erode to cause irregular ulcers have been described in the late primary or early secondary stage. A primary chancre may also be present.
Herpes simplex	✖	✖	✔	✖	✖	✖	✖	Grouped vesicles on erythematous base over glans, prepuce and shaft which rupture to form shallow erosions. In rare cases primary herpes can cause a necrotic balanitis, with necrotic areas on the glans accompanied by vesicles elsewhere and associated with headache and malaise.
Human papilloma virus	✖	✖	✖	✔	✖	✖	✖	Papilloma virus may be associated with patchy or chronic balanitis, which becomes acetowhite after the application of 5% acetic acid
Lichen sclerosus	✖	✖	✖	✖	✖	✖	✖	White patches on glans, which may often involve prepuce
Lichen planus	✖	✖	✖	✖	✖	✖	✖	Purplish lesions on the penis
Psoriasis	✖	✖	✖	✖	✔	✖	✖	Red scaly plaques
Circinate	✖	✔	✖	✖	✖	✖	✖	Greyish white areas on the glans
Zoon's balanitis	✖	✖	✖	✖	✖	✔	✖	Well-circumscribed orange-red glazed areas on the glans and foreskin.
Eczema	✖	✖	✖	✖	✖	✖	✖	Eczema may present has mild non-specific erythema to wide spread edema of penis.
Fixed drug eruption	✖	✖	✖	✖	✖	✖	✖	Well demarcated and erythematous lesions.
Bowen's disease	✖	✖	✖	✖	✖	✖	✔	Multiple, small, well-demarcated, grey-brown, red, pink, or skin-colored papillomatous papules or small patches on the penile shaft, glans, or foreskin, vulva, and perianal area
Bowenoid papulosis	✖	✖	✖	✖	✖	✖	✔	Single or multiple red, shiny, slightly raised, sharply demarcated, velvety, non-healing plaques associated with scaling, crusting, and sometimes bleeding, affecting the mucosal surfaces of the penis.
Erythroplasia of Queyrat	✖	✖	✖	✖	✖	✖	✔	Red, sometimes slightly pigmented, scaly, moist, velvety patches and plaques of keratinization on penis.