Balanitis
Balanitis - Summary
Balanitis is inflammation of the glans penis and often the foreskin. It can be acute, chronic, or recurrent.
In children, non-specific dermatitis is thought to be the most common cause of balanitis. Other possible causes include:
Infection (fungal or bacterial).
Irritant or allergic contact dermatitis.
Dermatological conditions such as seborrhoeic dermatitis and rarely, lichen sclerosus.
Manipulation (such as 'foreskin fiddling').
In adults, non-specific dermatitis, with or without candidal colonization, is thought to be the most common cause of balanitis. Other causes include:
Contact dermatitis.
Skin conditions such as psoriasis and seborrhoeic dermatitis.
Neoplastic conditions such as squamous cell carcinoma.
Balanitis affects approximately 4% of pre-pubertal boys, most frequently during the pre-school years. About one in 10 men attending a genitourinary clinic have balanitis.
Balanitis should be diagnosed on the basis of clinical findings.
Penile soreness, itch, and odour are common symptoms.
Redness of the glans penis (and often the foreskin) with exudate is usual.
The glans penis and foreskin may be swollen.
Dysuria and dyspareunia may occur.
Balanitis is mostly seen in uncircumcised men and an inability to retract the foreskin is common.
The cause should be identified by:
Asking about hygiene practices, exposure to irritants, trauma, and other skin conditions.
Asking about exposure to infections and a history of diabetes or immunosuppression.
Looking for clinical features of balanitis and skin conditions which may suggest a specific underlying cause.
Taking a sub-preputial swab if balanitis is severe (suggesting a secondary infection); recurrent; or mild and persistent despite treatment.
Management involves:
Advising the person to clean the penis with lukewarm water and gently dry it. No attempt should be made to retract the foreskin to clean under it, if it is still fixed.
For suspected non-specific dermatitis (with or without candidal or bacterial colonization), application of topical hydrocortisone 1% combined with an imidazole cream (e.g. clotrimazole or miconazole).
For suspected irritant or allergic contact dermatitis, advice on avoidance of triggers and application of topical hydrocortisone 1% cream or ointment.
For suspected or confirmed candidal balanitis, prescribe an imidazole cream.
For suspected or confirmed bacterial balanitis, prescribe oral flucloxacillin or a macrolide (in penicillin allergy).
For suspected or confirmed Gardnerella-associated balanitis, prescribe oral metronidazole and hydrocortisone 1% cream or ointment if inflammation is causing discomfort.
For suspected or confirmed streptococcal balanitis, prescribe oral amoxicillin (or a macrolide in penicillin allergy) and hydrocortisone 0.5 - 1% cream or ointment if inflammation is causing discomfort.
Have I got the right topic?
This CKS topic is based on the UK national guideline on the management of balanoposthitis, from the British Association for Sexual Health and HIV [BASHH, 2008].
This CKS topic covers the management of balanitis in boys and men presenting in primary care.
There are separate CKS topics on Herpes simplex - genital and Urethritis - male.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.
CKS gratefully acknowledges the contribution of the British Association of Dermatologists in the development of this topic.
How up-to-date is this topic?
How up-to-date is this topic?
Changes
August 2010 — minor update. Sulconazole 1% cream (Exelderm®) has been discontinued. The prescription has been removed. Issued in August 2010.
February to June 2009 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.
There are no major changes to the recommendations.
Previous changes
December 2008 — correction to a typographical error in the Overview of management section. Issued in January 2009.
August 2008 — minor update. Nystatin cream and ointment discontinued; prescriptions removed and text amended. Issued August 2008.
July–September 2006 — reviewed. Validated in December 2006 and issued in January 2007.
October 2005 — minor technical update. Issued in November 2005.
April 2005 — minor update. Tinaderm-M® cream (nystatin 100 000 units/g and tolnaftate 1% cream) has been discontinued. The prescription has been removed. Issued in April 2005.
October 2003 — written. Validated in December 2003 and issued in February 2004.
Update
New evidence
Evidence-based guidelines
No new evidence-based guidelines since 1 January 2009.
HTAs (Health Technology Assessments)
No new HTAs since 1 January 2009.
Economic appraisals
No new economic appraisals relevant to England since 1 January 2009.
Systematic reviews and meta-analyses
No new systematic review or meta-analysis since 1 January 2009.
Primary evidence
No new randomized controlled trials published in the major journals since 1 January 2009.
New policies
No new national policies or guidelines since 1 January 2009.
New safety alerts
No new safety alerts since 1 January 2009.
Changes in product availability
Sulconazole 1% cream (Exelderm®) has been discontinued.
Goals and outcome measures
Goals
To assess the severity of balanitis in adults and young boys
To give appropriate treatment in primary care
To refer people to secondary care if appropriate
To provide appropriate advice to adults and parents of boys with balanitis
Background information
Definition
What is it?
Balanitis is inflammation of the glans penis. Often, inflammation also involves the foreskin [Waugh, 1998].
It can be acute, chronic (lasting for more than a few weeks), or recurrent.
Causes in children
What causes balanitis in children?
Non-specific dermatitis is thought to be the most common cause of balanitis in boys.
The foreskin in young boys is completely or partially non-retractile due to adhesions, leading to poor hygiene and a build up of smegma. This can result in non-specific dermatitis, and predisposes to colonization with a mixture of organisms such as Candida albicans, group A beta-haemolytic streptococci, and Staphylococcus aureus. This colonization may be harmless or may progress to a clinical infection.
Infection:
Candida albicans and group A beta-haemolytic streptococci are often implicated. Infection may occur by autoinoculation from other body sites (such as the throat).
Other possible causes include:
Irritant or allergic contact dermatitis due to soap or bubble bath.
Dermatological conditions such as seborrhoeic dermatitis and eczema (see the CKS topics on Seborrhoeic dermatitis and Eczema - atopic) and, rarely, lichen sclerosus (balanitis xerotica obliterans).
Manipulation (such as 'foreskin fiddling').
Basis for recommendation
There is very little evidence on the causes of balanitis in children. In the absence of studies specific to primary care, the causes listed have been found in a few small studies undertaken in secondary care. The findings of these studies may not be generalizable to children presenting in primary care [Escala and Rickwood, 1989].
Causes in adults
What causes balanitis in adults?
Non-specific dermatitis, with or without candidal colonization, is thought to be the most common cause of balanitis.
In uncircumcised men, poor hygiene and irritation of the glans penis by smegma can cause non-specific dermatitis which predisposes to colonization with Candida albicans and the development of secondary infection.
In many cases, dysfunction of the foreskin causes or contributes to balanitis.
Other causes of balanitis:
Candidal infection — C. albicans is the most common organism isolated in balanitis, especially in men with diabetes.
Streptococcal infection — of bacterial infections, group B beta-haemolytic streptococci are most frequently isolated in balanitis.
Other infections with Gardnerella, Chlamydia, Gonorrhoea, syphilis, Staphylococcus, herpes, Trichomonas, and scabies.
Contact dermatitis due to soap, lubricants, douches, latex condoms, and topical medications.
Dermatological conditions such as psoriasis, lichen planus, and seborrhoeic dermatitis (see the CKS topic on Seborrhoeic dermatitis).
Specific balanitides:
Lichen sclerosus is a chronic, progressive, sclerosing, inflammatory skin problem commonly affecting the genital area. In uncircumcised men, the tip of the foreskin develops a tight white ring which may lead to inability to retract the foreskin (phimosis).
Zoon's balanitis is a benign condition of uncertain origin affecting uncircumcised men. It may be secondary to other conditions such as lichen sclerosus or erythroplasia of Queyrat. It presents with orange-red lesions with pinpoint redder spots on the glans and adjacent areas of foreskin in uncircumcised men.
Circinate balanitis is a chronic balanitis in men with Reiter's syndrome, although it can occur in isolation. It presents with a well-demarcated erythematous plaque with a ragged white border.
Neoplastic conditions:
Erythroplasia of Queyrat is an in-situ squamous cell carcinoma. It presents with single or multiple plaques with a red, velvety appearance and is often asymptomatic.
Squamous cell carcinoma. Lesions may be papillary or flat. Papillary lesions usually appear on the glans which eventually becomes necrotic and ulcerated. Flat lesions usually ulcerate early. Squamous cell carcinoma may arise on the background of lichen planus or lichen sclerosus.
Basis for recommendation
In the absence of studies specific to primary care, the causes of balanitis listed have been found in studies of men attending urology and dermatology departments. The findings of these secondary care studies may not be generalizable to men presenting with balanitis in primary care [Fornasa et al, 1994; Edwards, 1996; English et al, 1997; Waugh, 1998; Alsterholm et al, 2008; Bhalani et al, 2008; Singh and Bunker, 2008].
Prevalence
How common is it?
Balanitis affects approximately 4% of pre-pubertal boys, most frequently during the pre-school years [Escala and Rickwood, 1989].
Balanitis is uncommon in circumcised men [BASHH, 2008].
About one in 10 men attending a genitourinary clinic have balanitis [Birley et al, 1993].
Diagnosis
Diagnosis
Diagnosis - children
Diagnosis of balanitis in children
Diagnosis
How should I diagnose balanitis in children?
Diagnose balanitis in a child on the basis of clinical findings:
Penile soreness, itch, and odour which usually develop over a few days.
Redness of the glans penis (and often the foreskin) with exudate is usual.
The glans penis and foreskin may be swollen.
A sub-preputial swab is not necessary to make a diagnosis, but can be useful for identifying the underlying cause if symptoms are severe or persistent.
Basis for recommendation
Basis for recommendation
This information is based on expert opinion from review articles of secondary care management [Escala and Rickwood, 1989; Orden et al, 1996].
Identifying the cause
How should I assess a child with balanitis to identify the cause?
For a list of causes of balanitis in children, see Causes in children.
Ask about:
Hygiene practices (for example, how often is the nappy changed or penis cleaned?) — lack of hygiene predisposes to non-specific dermatitis.
Exposure to irritants — such as bubble bath, detergents, or creams.
Trauma — from 'foreskin fiddling'.
Other skin conditions (such as eczema).
Look for clinical features and skin conditions which may suggest a specific underlying cause.
Take a sub-preputial swab if balanitis is:
Severe (suggesting a secondary infection).
Mild, but persists despite treatment.
Clinical features of underlying causes
Clinical features of underlying causes
Non-specific dermatitis — redness of the glans penis which often extends onto the skin of the shaft of the penis.
Contact balanitis — redness of the glans penis with localized swelling. This is most commonly irritant contact dermatitis; allergic contact dermatitis is unusual in children.
Candidal balanitis — redness on the undersurface of the glans penis, with sparing around the urethral meatus. Small, eroded papules may be present with a white cheese-like matter, that can be rubbed off easily.
Bacterial infection (for example group A beta-haemolytic streptococci or Staphylococcus aureus) — penile redness and pain, often accompanied by a purulent exudate. Systemic symptoms, such as fever, may also occur.
Basis for recommendation
Basis for recommendation
These recommendations are based on expert advice from review articles [Orden et al, 1996; Schwartz and Rushton, 1996].
Predisposing factors
Non-specific dermatitis is thought to be the most common cause of balanitis. However, occasionally, specific irritants may be identified that will require avoidance [Schwartz and Rushton, 1996].
Sub-preputial swab
A swab can be useful to confirm, or exclude, an infectious cause of balanitis. However, most children with balanitis presenting in primary care probably have mild non-specific dermatitis (with or without candidal or bacterial colonization), which usually responds quickly to empirical treatment — making it unnecessary to swab all children.
A case series investigating boys (n = 32) with balanitis presenting in secondary care suggests that more severe balanitis (increased erythema and exudate) indicates a bacterial infection [Escala and Rickwood, 1989]. Therefore, it seems sensible to swab when balanitis is severe, or not responding to treatment with a combined topical corticosteroid and antifungal.
Diagnosis - adults
Diagnosis of balanitis in adults
Diagnosis
How should I diagnose balanitis in adults?
Diagnose balanitis in an adult on the basis of clinical findings:
Penile soreness, itch, and odour are common symptoms.
Redness on the glans penis (and often the foreskin) with exudate are usual. Swelling of the glans penis and foreskin may be seen.
Dysuria and dyspareunia may occur.
Balanitis is mostly seen in uncircumcised men and an inability to retract the foreskin is common.
Swabs (for example, a sub-preputial swab) are not necessary for diagnosis, but can be useful for identifying the underlying cause if symptoms are severe, recurrent, or persistent.
Basis for recommendation
Basis for recommendation
These recommendations are based on expert opinion from secondary care review articles which indicate that balanitis usually presents with specific clinical features [Edwards, 1996; English et al, 1997].
Identifying the cause
How should I assess an adult with balanitis to identify the cause?
For a list of causes in adults, see Causes in adults.
Ask about:
Hygiene practices (for example, how often is the penis cleaned?) — lack of hygiene predisposes to non-specific dermatitis.
Exposure to irritants — such as soaps or creams.
Trauma — for example, during sexual intercourse or vigorous cleaning.
Exposure to infections — has the man's partner had bacterial vaginosis or a vaginal candidal infection?
A history of diabetes or immunosuppression — which predisposes to infection.
Look for clinical features of balanitis and for other skin conditions elsewhere (such as seborrhoeic dermatitis), which suggest a specific underlying cause.
Take a sub-preputial swab if balanitis is:
Severe.
Recurrent.
Mild, but persists despite treatment.
Only swab for Gardnerella-associated balanitis if this is suspected clinically. State 'gardnerella' on the laboratory form when requesting the test, as most laboratories will not routinely test for the organism.
Check blood glucose levels or urine for glycosuria if balanitis is severe, persistent, or recurrent (especially if candidal balanitis is present).
Clinical features of underlying causes
Clinical features of underlying causes
Non-specific dermatitis — redness of the glans penis, which often extends onto the skin of the shaft of the penis.
Candidal balanitis — redness on the undersurface of the glans penis, with sparing around the urethral meatus. Small, eroded papules may be present with a white cheese-like matter, that can be rubbed off easily. In people with diabetes, candidal balanitis often presents with more severe features (such as intense redness of the glans penis and pain).
Irritant or allergic contact dermatitis — redness of the glans penis with localized swelling (especially in allergic contact dermatitis).
Gardnerella-associated balanitis — a fishy odour and a sub-preputial mucoid discharge (see the CKS topic on Bacterial vaginosis).
Streptococcal infection — may present with a rapid onset of severe penile redness and pain, and is usually accompanied by a purulent exudate. Streptococcal balanitis with exudate can be distinguished clinically from urethritis with urethral discharge by the pattern of redness on the glans penis. In streptococcal infections there is usually no redness of the urethral meatus, unlike urethritis where the urethral meatus is typically red.
Basis for recommendation
Basis for recommendation
These recommendations are based on expert advice from review articles [Alsterholm et al, 2008; Bhalani et al, 2008; Singh and Bunker, 2008].
Predisposing factors
Poor hygiene, recurrent trauma, or exposure to irritants are common causes of balanitis; therefore, identifying and correcting these predisposing factors will reduce the risk of recurrence [Birley et al, 1993; Fornasa et al, 1994].
Sub-preputial swab
A swab is useful to confirm, or exclude, an infectious cause of balanitis. Most people with balanitis presenting in primary care have mild non-specific dermatitis (with or without candidal colonization), which usually responds rapidly to empirical treatment. Therefore, it seems sensible to swab when balanitis is severe or recurrent, or not settling despite treatment with a combined topical corticosteroid and antifungal.
Excluding diabetes
Diabetes predisposes to skin infections, especially candidal infections, and people with diabetes often develop severe infections. A survey of 138 men with candidal balanitis found one in 10 had diabetes that was previously undiagnosed. Therefore, excluding diabetes in men with severe or recurrent balanitis is recommended [Waugh, 1998].
Management
Management
Scenario: Balanitis - children: covers the management of balanitis in boys younger than 16 years of age, in primary care.
Scenario: Balanitis - adults: covers the management of balanitis in men and boys 16 years of age or older, in primary care.
Scenario: Balanitis - children
Scenario: Balanitis in children
Management
How should I manage a child with balanitis?
Advise the child or the parents or carers to clean the penis with luke warm water and gently dry it.
No attempt should be made to retract the foreskin to clean under it, if it is still fixed.
Soap, bubble bath, or baby wipes should not be used.
If the child is still in nappies, these need to be changed frequently (see the CKS topic on Nappy rash).
For suspected non-specific dermatitis, with or without candidal or bacterial colonization:
Prescribe topical hydrocortisone 1% combined with an imidazole cream (clotrimazole 1%, miconazole 2%, or econazole 1%) once or twice a day until symptoms settle, or for up to 14 days.
If symptoms are not improving by 7 days:
Advise people to stop treatment with topical hydrocortisone.
Take a sub-preputial swab to exclude or confirm a fungal or bacterial infection, and treat accordingly.
For suspected irritant or allergic contact dermatitis:
Discontinue any suspected triggers (such as soap or creams).
Prescribe a mild topical hydrocortisone 1% cream or ointment once a day until symptoms settle, or for up to 14 days.
If symptoms are not improving by 7 days:
Advise people to stop treatment with topical hydrocortisone.
Take a sub-preputial swab to exclude or confirm a fungal or bacterial infection, and treat accordingly.
For suspected or confirmed candidal balanitis:
Prescribe an imidazole cream (clotrimazole 1%, econazole 1%, ketoconazole 2%, or miconazole 2%) twice a day until symptoms settle.
If inflammation is causing discomfort, consider prescribing hydrocortisone 1% cream or ointment for up to 14 days in addition to an antifungal.
If symptoms are not improving by 7 days:
Advise people to stop treatment with topical hydrocortisone.
Take a sub-preputial swab to exclude or confirm a fungal or bacterial infection, and treat accordingly.
For suspected or confirmed bacterial balanitis:
Prescribe oral flucloxacillin for 7 days.
Oral erythromycin or clarithromycin for 7 days are alternatives for boys who are allergic to penicillin (see Prescriptions).
Adjust treatment if indicated by sub-preputial swab results.
If inflammation is causing discomfort, consider prescribing hydrocortisone 1% cream or ointment for up to 14 days in addition to an antibiotic.
If symptoms are not improving by 7 days:
Advise people to stop treatment with topical hydrocortisone.
Take a sub-preputial swab to exclude or confirm a fungal or bacterial infection, and treat accordingly.
Basis for recommendation
Basis for recommendation
These recommendations are based on expert advice from review articles [Orden et al, 1996; Schwartz and Rushton, 1996].
Non-specific dermatitis, with or without candidal or bacterial colonization
A mild topical corticosteroid combined with an imidazole to treat the dermatitis (and any candidal infection) seems a logical approach if the balanitis is mild and clinical suspicion of a bacterial infection is low.
Candidal balanitis
Topical imidazoles are recommended by experts based on their proven effectiveness in the treatment of candidiasis of the skin, toenails, and perineum in infants [Hay and Moore, 2004].
CKS recommends continuing treatment until symptoms have settled, based on advice given in the UK national guideline on the management of balanoposthitis from the British Association for Sexual Health and HIV, for people older than 16 years of age [BASHH, 2008]. Although the licences for most antifungal drugs recommend continuing treatment for a short period of time after clinical cure, CKS found no evidence to support this approach in balanitis.
Bacterial balanitis
An antibiotic with activity against group A beta-haemolytic streptococci and Staphylococcus aureus (bacteria that commonly cause bacterial balanitis) will usually result in rapid resolution of symptoms and eradication of the offending organism. CKS found no specific trial evidence for the use of antibiotics for balanitis.
The recommendation to use the flucloxacillin antibiotic is based on expert opinion from personal communication [Barrett, Personal Communication, 2009].
Referral
When should I refer a child with balanitis?
If balanitis is recurrent or chronic, refer to a paediatrician or a dermatologist.
Basis for recommendation
Basis for recommendation
This recommendation is based on expert advice from review articles [Edwards, 1996; English et al, 1997].
Most pre-pubertal boys only experience a single episode of balanitis. Therefore, if symptoms are recurrent or significant phimosis is present, a paediatric urologist may consider circumcision [Escala and Rickwood, 1989].
Scenario: Balanitis - adults
Scenario: Balanitis in adults
Assessment
How should I assess an adult with balanitis?
Look for ulceration, inguinal lymphadenopathy, urethritis (dysuria and urethral discharge), and features suggestive of specific balanitides or neoplasia (as referral is indicated).
Basis for recommendation
Basis for recommendation
This recommendation is based on the criteria for referral — see the Basis for recommendation for Referral.
Management
How should I manage an adult with balanitis?
Advise daily cleaning under the foreskin with luke warm water, followed by gentle drying.
Soap or other irritants should not be used on the genitalia.
Consider prescribing an emollient (such as emulsifying ointment) as a soap substitute.
For suspected non-specific dermatitis, with or without candidal colonization:
Prescribe topical hydrocortisone 1% combined with an imidazole cream (clotrimazole 1%, miconazole 2%, or econazole 1%) once or twice a day until symptoms settle, or for up to 14 days.
If symptoms are not improving by 7 days:
Advise people to stop treatment with topical hydrocortisone.
Take a sub-preputial swab to exclude or confirm a fungal or bacterial infection, and treat accordingly.
For suspected irritant or allergic contact dermatitis:
Discontinue any suspected triggers (such as latex condoms, creams, or soaps).
Prescribe a mild topical hydrocortisone 1% cream or ointment once a day until symptoms settle, or for up to 14 days.
If symptoms are not improving by 7 days:
Advise people to stop treatment with topical hydrocortisone.
Take a sub-preputial swab to exclude or confirm a fungal or bacterial infection, and treat accordingly.
For suspected candidal balanitis:
Prescribe an imidazole cream (clotrimazole 1%, econazole 1%, ketoconazole 2%, or miconazole 2%) twice a day until symptoms settle, or oral fluconazole 150 mg as a single dose (licensed for people 16 years of age and older).
If inflammation is causing discomfort, consider prescribing hydrocortisone 1% cream or ointment for up to 14 days in addition to antifungal treatment.
If symptoms are not improving by 7 days:
Advise people to stop treatment with topical hydrocortisone.
Take a sub-preputial swab to exclude or confirm a fungal or bacterial infection, and treat accordingly.
For suspected or confirmed Gardnerella-associated balanitis:
Prescribe oral metronidazole (400 mg twice a day) for 7 days.
If inflammation is causing discomfort, consider prescribing hydrocortisone 1% cream or ointment for up to 14 days in addition to metronidazole.
If symptoms are not improving by 7 days:
Advise people to stop treatment with topical hydrocortisone.
Take a sub-preputial swab to exclude or confirm a fungal or bacterial infection, and treat accordingly.
For suspected or confirmed streptococcal balanitis:
Prescribe oral amoxicillin (500 mg four times a day) for 7 days.
Oral erythromycin (500 mg four times a day) or clarithromycin (250 mg twice a day) for 7 days are alternatives for men who are allergic to penicillin.
If inflammation is causing discomfort, consider prescribing hydrocortisone 0.5–1% cream or ointment for up to 14 days in addition to antibiotic treatment. If symptoms are not improving by 7 days:
Advise people to stop treatment with topical hydrocortisone.
Take a sub-preputial swab to exclude or confirm a fungal or bacterial infection, and treat accordingly.
If symptoms are worsening or have not settled with treatment, review the diagnosis, take a sub-preputial swab (if this has not been done already) and adjust treatment (if indicated), or seek specialist advice.
Basis for recommendation
Basis for recommendation
These recommendations are based on expert advice from review articles [Edwards, 1996; English et al, 1997] and the UK national guideline on the management of balanoposthitis from the British Association for Sexual Health and HIV [BASHH, 2008].
Non-specific dermatitis, with or without candidal colonization
A combination product which treats both dermatitis and any candidal infection seems a logical approach if a bacterial infection is not suspected [Alsterholm et al, 2008].
Contact dermatitis or marked inflammation
Topical corticosteroids are widely recommended by experts [Alsterholm et al, 2008; BASHH, 2008]. CKS found no evidence evaluating the role of topical corticosteroids in the treatment of balanitis.
Candidal balanitis
Topical imidazoles and oral fluconazole are widely recommended by experts based on their proven effectiveness in the treatment of candidiasis of the skin, toenails, and perineum in infants [Hay and Moore, 2004].
CKS recommends continuing treatment until symptoms settle based on advice given in the UK national guideline on the management of balanoposthitis from the British Association for Sexual Health and HIV. Although the licences for most antifungal drugs recommend continuing treatment for a short period of time after clinical cure, CKS found no evidence to support this approach in balanitis.
CKS found no evidence that one antifungal is more effective than any other in the treatment of balanitis. However, in one study oral fluconazole was preferred to topical treatment by approximately 80% of men requiring treatment for candidal balanitis [Stary et al, 1996].
CKS found no evidence for the use of topical terbinafine for candidal infection of the skin and it is not recommended for use in children [ABPI Medicines Compendium, 2006]. Systemic treatment with terbinafine is not appropriate for refractory candidiasis and it is not licensed for this purpose [BNF 56, 2008].
Gardnerella-associated or streptococcal balanitis
An appropriate antibiotic should result in rapid resolution of symptoms and eradication of the offending organism. CKS found no specific trial evidence for the use of antibiotics for balanitis, but antibiotics are routinely used by experts when balanitis is thought to be caused by a bacterial infection.
The recommendation to use amoxicillin in streptococcal balanitis is based on expert opinion from personal communication [Barrett, Personal Communication, 2009].
Recurrent balanitis
How should I manage recurrent balanitis?
Treat as for an acute episode of balanitis.
Reinforce advice on personal hygiene.
In addition:
Consider prescribing an emollient (such as emulsifying ointment) as a soap substitute.
For irritant or allergic contact dermatitis, advise avoiding potential triggers such as lubricant gels, latex condoms, and topical medications.
For candidal, streptococcal or Gardnerella-associated balanitis, advise the man that his partner should be tested for infection and treated if appropriate (see the CKS topics on Bacterial vaginosis and Candida - female genital).
Basis for recommendation
Basis for recommendation
These recommendations are based on expert advice from review articles [Edwards, 1996; English et al, 1997] and the UK national guideline on the management of balanoposthitis from the British Association for Sexual Health and HIV [BASHH, 2008].
Hygiene advice:
Avoiding soap and/or using a regular emollient resulted in resolution of non-specific balanitis in two case series (approximately 80 men) [Birley et al, 1993; Fornasa et al, 1994].
Testing partners for candidal, streptococcal, and Gardnerella infection:
Testing and treating partners who have a proven candidal or Gardnerella infection will prevent reinfection and recurrent balanitis.
Studies have shown that in men with candidal balanitis, their partner is more likely to have a candidal infection [Davidson, 1977; Mayser, 1999].
Studies have shown that in women with Gardnerella vaginalis, their male partners have high rates of Gardnerella in their urine or urethra [Edwards, 1996].
The primary reservoir for group B beta-haemolytic streptococci is the female genital tract, and sexual transmission is the most likely cause of streptococcal balanitis [English et al, 1997].
Referral
When should I refer an adult with balanitis?
If penile cancer is suspected, refer urgently to dermatology or urology. See the section on Penile cancer in the CKS topic on Urological cancer - suspected.
If ulceration, urethritis, or inguinal lymphadenopathy are present — refer to genitourinary medicine (GUM).
If balanitis is recurrent and associated with inability to retract the foreskin (phimosis) — refer to urology.
If balanitis is recurrent and no underlying cause can be identified, or balanitis persists despite treatment — refer to dermatology, urology, or GUM depending on the most likely underlying cause.
Basis for recommendation
Basis for recommendation
These recommendations are based on expert opinion from review articles [Edwards, 1996; English et al, 1997] and the UK national guideline on the management of balanoposthitis from the British Association for Sexual Health and HIV [BASHH, 2008].
Specific balanitides or neoplasia
A dermatologist or urologist may carry out a biopsy to help confirm or exclude a diagnosis of penile cancer or specific balanitides.
A dermatologist may identify allergic contact dermatitis by patch testing.
Ulceration, urethritis, or inguinal lymphadenopathy
Ulceration, urethritis, or inguinal lymphadenopathy may indicate a sexually transmitted infection and require assessment and management by a specialist in genitourinary medicine (see the CKS topics on Chlamydia - uncomplicated genital, Herpes simplex - genital, and Trichomoniasis) [McCormack and Rein, 1995].
Persistent or recurrent balanitis
Specialist advice should be sought to exclude underlying balanitides and provide advice on further management.
Evidence
Evidence
Supporting evidence
Causes of balanitis
Evidence on the causes of balanitis
Children
Evidence on the causes of balanitis in children
The evidence on the causes of balanitis in children is from small studies carried out in secondary care. CKS found no studies in boys with balanitis presenting in primary care, therefore the causes listed may not accurately represent boys with balanitis in primary care.
A case series of boys (n = 100) with balanitis attending a urology department in the UK showed that of the 32 who presented acutely to the Accident and Emergency department and had a swab taken [Escala and Rickwood, 1989].
47% (n = 15) had no growth of any organisms.
22% (n = 7) had a mixed growth of bacteria.
31% (n = 10) had a pure growth of one organism (five Staphylococcus aureus, four Proteus vulgaris, one Morganella morgagni).
The authors concluded that the aetiology of balanitis in children remains unclear. They suggest there is no single causative pathogen, nor is it proven that the suppurative process is necessarily of bacterial origin. A persistence of preputial adhesions seems to predispose to pathogens lodging beneath the foreskin, and poor hygiene also seems to be an obvious factor. However, further studies are needed to evaluate these potential causes.
In a retrospective survey of uncircumcised (n = 272) and circumcised (n = 273) boys between 4 months and 12 years of age to investigate foreskin problems [Herzog and Alvarez, 1986; Schwartz and Rushton, 1996]:
Balanitis was diagnosed in 5.9% of uncircumcised boys compared with 2.9% of circumcised boys; the difference was not statistically significant.
Poor hygiene or fair hygiene was described in 11% of boys who were uncircumcised and 7% of circumcised boys; there was no statistical difference between the groups.
Adults
Evidence on the causes of balanitis in adults
The evidence on the causes of balanitis in adults is from small studies carried out in secondary care. They vary in their findings due to differences in study populations. Men attending urology departments predominantly have an infectious cause for their balanitis, while men attending dermatology departments often have a dermatosis. CKS found no studies in men presenting to primary care with balanitis, therefore the causes listed may not accurately represent men with balanitis in primary care [Birley et al, 1993; Fornasa et al, 1994; Edwards, 1996; English et al, 1997; Mayser, 1999].
Antifungal treatment
Evidence on antifungal treatment for balanitis
Antifungal treatment compared with placebo
CKS found no placebo-controlled trials of antifungal treatment for balanitis. The recommendation to prescribe antifungal treatment for balanitis is based on evidence of effectiveness of antifungals in the treatment of candidiasis of the skin, toenails, and perineum in infants (see the section on Supporting evidence in the CKS topic on Candida - skin).
Antifungal treatments compared with each other
There is no evidence to suggest that one antifungal is more effective than any other.
CKS identified one comparative trial which showed that oral fluconazole was as effective as topical clotrimazole for candidal balanitis [Stary et al, 1996].
This randomized, open-label, multi-centre study (n = 157), that included men with either mild or moderate balanitis, compared a single dose of fluconazole 150 mg with topical clotrimazole applied twice daily for 7 days.
132 men were assessed after 8–11 days.
Clinical cure (disappearance of all clinical symptoms and signs) or improvement was similar in both groups and was achieved in 92% of men taking fluconazole and in 91% of men using topical clotrimazole.
Mycological cure was achieved in 78% of men receiving fluconazole and 83% of men using topical clotrimazole. This difference was not statistically significant.
Topical corticosteroid treatment
Evidence on topical corticosteroid treatment for balanitis
CKS found no trials evaluating the effectiveness of topical corticosteroids in the treatment of balanitis. Randomized controlled trials of topical corticosteroids compared with placebo suggest a large treatment effect for atopic eczema, and clinical experience suggests that similar benefits occur when topical corticosteroids are used in balanitis. For further information on corticosteroids see the CKS topic on Eczema - atopic.
Antibiotic treatment
Evidence on antibiotic treatment for balanitis
CKS found no trials investigating or comparing the effectiveness of different oral antibiotics in the treatment of balanitis. Randomized controlled trials of oral antibiotics for streptococcal skin infections or Gardnerella infection (bacterial vaginosis) have shown benefit. Clinical experience suggests that similar benefits will occur when oral antibiotics are used in balanitis.
Search strategy
Scope of search
A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on the primary care management of balanitis, with additional searches in the following areas:
topical antifungals
prevalence and causes of balanitis in children
Search dates
Guidelines, Medline, EMBASE: January 2006 – December 2008
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.
balanitis/, balanitis.tw, balanoposthitis.tw, balanatide$.tw, ((exp penis/ or penis.tw or penile.tw or penile diseases/) AND (exp skin diseases/ or exp candidiasis/ or exp candida/ or dermatoses.tw or exp infection/ or exp inflammation/))
Table 1. Key to search terms.| Search commands | Explanation |
|---|---|
| / | indicates a MeSH subject heading with all subheadings selected |
| .tw | indicates a search for a term in the title or abstract |
| exp | indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree |
| $ | indicates that the search term was truncated (e.g. wart$ searches for wart and warts) |
Topic specific literature search sources
British Association of Sexual Health and HIV
Sources of guidelines
National Institute for Health and Clinical Excellence (NICE)
Scottish Intercollegiate Guidelines Network (SIGN)
National Guidelines Clearinghouse
British Columbia Medical Association
Institute for Clinical Systems Improvement
Guidelines International Network
National Library of Guidelines
National Health and Medical Research Council (Australia)
University of Michigan Medical School
Michigan Quality Improvement Consortium
National Resource for Infection Control
NHS Scotland National Patient Pathways
Agency for Healthcare Research and Quality
UK Ambulance Service Clinical Practice Guidelines
RefHELP NHS Lothian Referral Guidelines
Medline (with guideline filter)
Sources of systematic reviews and meta-analyses
Systematic reviews
Protocols
Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
NIHR Health Technology Assessment programme
NHS Economic Evaluations
Health Technology Assessments
Canadian Agency for Drugs and Technologies in Health
International Network of Agencies for Health Technology Assessment
Sources of randomized controlled trials
Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
DynaMed
Central Services Agency COMPASS Therapeutic Notes
Sources of national policy
Health Management Information Consortium (HMIC)
References
ABPI Medicines Compendium (2006) Summary of product characteristics for Lamisil cream. Electronic Medicines Compendium..Datapharm Communications Ltd.www.medicines.org.uk [Free Full-text]
Alsterholm, M., Flystrom, I., Leffsdottie, R. et al. (2008) Frequency of bacteria, Candida and malassezia species in balanoposthitis. Acta Dermato-Venereologica 88(4), 331-336. [Abstract] [Free Full-text]
Barrett, S. (2009) Personal communication. Consultant Medical Microbiologist, Charing Cross Hospital: London.
BASHH (2008) UK national guideline on the management of balanoposthitis. ..British Association of Sexual Health and HIV.www.bashh.org [Free Full-text]
Bhalani, V., Kohler, T.S. and Brannigan, R.E. (2008) Common penile dermatoses. Current Sexual Health Reports 5(3), 124-132.
Birley, H.D., Walker, M.M., Luzzi, G.A. et al. (1993) Clinical features and management of recurrent balanitis: association with atopy and genital washing. Genitourinary Medicine 69(5), 400-403. [Abstract] [Free Full-text]
BNF 56 (2008) British National Formulary. 56th edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain.
Davidson, F. (1977) Yeasts and circumcision in the male. British Journal of Venereal Diseases 53(2), 121-122. [Abstract] [Free Full-text]
Edwards, S. (1996) Balanitis and balanoposthitis: a review. Genitourinary Medicine 72(3), 155-159. [Abstract] [Free Full-text]
English, J.C., Laws, R.A., Keough, G.C. et al. (1997) Dermatoses of the glans penis and prepuce. Journal of the American Academy of Dermatology 37(1), 1-24. [Abstract]
Escala, J.M. and Rickwood, A.M. (1989) Balanitis. British Journal of Urology 63(2), 196-197. [Abstract]
Fornasa, C.V., Calabro, A., Miglietta, A. et al. (1994) Mild balanoposthitis. Genitourinary Medicine 70(5), 345-346. [Abstract] [Free Full-text]
Hay, R.J. and Moore, M.K. (2004)
Herzog, L.W. and Alvarez, S.R. (1986) The frequency of foreskin problems in uncircumcised children. American Journal of Diseases of Children 140(3), 254-256. [Abstract]
Mayser, P. (1999) Mycotic infections of the penis. Andrologia 31(Suppl 1), 13-16. [Abstract]
McCormack, W.M. and Rein, M.F. (1995)
Orden, B., Martin, R., Franco, A. et al. (1996) Balanitis caused by group A beta-hemolytic streptococci. Pediatric Infectious Disease Journal 15(10), 920-921.
Schwartz, R.H. and Rushton, H.G. (1996) Acute balanoposthitis in young boys. Pediatric Infectious Disease Journal 15(2), 176-177.
Singh, S. and Bunker, C. (2008) Male genital dermatoses in old age. Age & Ageing 37(5), 500-504. [Abstract] [Free Full-text]
Stary, A., Soeltz-Szoets, J., Ziegler, C. et al. (1996) Comparison of the efficacy and safety of oral fluconazole and topical clotrimazole in patients with candida balanitis. Genitourinary Medicine 72(2), 98-102. [Abstract] [Free Full-text]
Waugh, M.A. (1998) Balanitis. Dermatologic Clinics 16(4), 757-762. [Abstract]