What is balanitis?
Balanitis is a term used to include all inflammation of the skin covering the head (glans) of the penis.

What causes balanitis?
The most common causes are:

irritants: neglected hygiene and tight foreskin (particularly in young boys) lead to irritation by smegma (a cheesy substance secreted under the foreskin).

seborrhoeic dermatitis: an inflammatory rash of uncertain cause that is commonly seen on the scalp, behind the ears and in the skin folds.

thrush (candida): although this infection is probably over-diagnosed by doctor and patient.

contact allergy: latex and additives used in rubber manufacture (eg condoms) and constituents of skincare products (used by the patient or partner).

balanitis xerotica obliterans (BXO, also termed lichen sclerosis): this condition primarily affects the foreskin, leading to loss of skin colouration, scarring and tightness of the foreskin, and phimosis (inability to pull the foreskin back behind the glans), which may require circumcision. Involvement of the opening of the urethra (urine tube) can lead to irritation and burning. Surgery might be needed to prevent a stricture (narrowing) in the urethra. Steroid creams may help the irritation but patients require long-term follow-up to prevent recurrence.

balanitis circinata: a skin manifestation of Reiter's syndrome, in which the patient also has arthritis (often of the knees), urethritis (inflammation of the urine tube in the penis) and conjunctivitis (red eyes).

generalised skin conditions: these can also affect the penis, including: lichen planus, psoriasis, erythema multiforme, erythema fixum (particularly caused by tetracycline antibiotics), erythroplasia of Queyrat (a rare, pre-cancerous skin condition).

diabetes.

Balanitis in young boys is usually associated with a tight foreskin that cannot be pulled back behind the glans (phimosis). Phimosis leads to deficient hygiene and persistent contact of urine and smegma with the skin of the glans. Straightforward cases usually respond to antibiotic ointments but recurrent cases require investigation to exclude urinary tract infection.

Occasionally, irritation and swelling of the glans can be due to paraphimosis ('Spanish collar'), caused when a tight foreskin is retracted down the shaft behind the glans. The tightness around the shaft slows the venous drainage of the end of the penis, and the glans swells, which tightens the paraphimosis further, making the foreskin virtually impossible to retract. Ultimately, the restriction can interfere with the blood supply to the glans and urgent medical treatment is required. Often the foreskin can be returned to its normal position under sedation, but, if not, circumcision is required.

What investigations are needed?

Skin swabs for bacterial or fungal culture might be taken to confirm infection, particularly in cases that do not respond to a first-line antibiotic.

A urine sample might be sent for microscopy and culture if urinary tract infection is suspected.

Patch testing might be required to confirm allergies.

A dermatologist or urologist might perform a biopsy if BXO or erythroplasia of Queyrat are suspected.

The urine or blood should be checked for diabetes.

How is balanitis treated?
Treatment depends on the underlying cause. The common interventions are:

infection requires the relevant antibiotic or antifungal drug. Oral antibiotics can be required for severe cases and often in children.

potassium permanganate solution (1 in 10,000 dilution) is nearly always beneficial when used to wash the penis but causes temporary purple discolouration.

steroid creams of mild to moderate strength are used in short-term courses for non-infective eczematous or inflammatory skin conditions.

BXO and rarer skin conditions require referral to a urologist or dermatologist.

phimosis and paraphimosis sometimes require circumcision to prevent recurrence.

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