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Balanitis: Etiology, Diagnosis and Therapy

Definition of Balanitis

Balanitis is an infectious or non-infectious inflammation of the glans penis and the prepuce. The accurate medical term for a lesion involving glans and prepuce is balanoposthitis.

Etiology of Balanitis

Balanitis in children:

Balanitis in children usually arises from an infection of the smegma because of phimosis or adhesions of the prepuce.

Balanitis caused by infection:

Candida, bacteria, viruses (herpes). Oral therapy of diabetes mellitus with SGLT-2 inhibitors (e.g., dapagliflozin) leads to chronic glucosuria, which significantly increases the risk of external genital infections.

Balanitis circinata:

Balanitis circinata presents with erosive plaques with slightly raised edges on the glans due to a Reiter syndrome.

1–4 weeks after urogenital infection or intestinal infection patients may develop a Reiter syndrome: fever, malaise, urethritis (95%), prostatitis (50–80%), conjunctivitis (50–90%), arthritis (knee, ankle, ISG in 30–50%), pustular rash developing small hard nodules called keratoderma blennorrhagica (palms, soles, leg, nail involvement). In 20–50% balanitis circinata. See also section non-gonococcal urethritis.

Balanitis in psoriasis:

Manifestation of psoriasis (inversa) of the glans penis.

Gangrenous balanitis:

Fournier gangrene at the glans penis. Untreated disease can lead to organ destruction.

Balanitis plasmacellularis (Zoon balanitis):

Zoon balanitis presents with bright and sharply defined erythema of the glans. The inflammatory lesion of the glans of unknown etiology is relatively asymptomatic. Histology shows a plasmacellular infiltrate. A biopsy is necessary to rule out, e.g., erythroplasia of Queyrat.

Balanitis xerotica obliterans:

Balanitis xerotica obliterans (BXO) is the manifestation of lichen sclerosus on the glans penis. BXO presents with porcelain white spots or papules on the glans with a sharp border. The atrophy leads to phimosis, meatal stenosis, urethral stricture of the fossa navicularis, or, in females, to kraurosis vulvae. Lichen sclerosus is sporadically associated with squamous cell carcinoma.

Differential diagnosis of Balanitis

Non-venereal sclerosing lymphangitis of the penis:

Frequent sexual intercourse or balanitis are risk factors for a lymphangitis of the inner foreskin with cord-like induration.

Behcet disease:

Behcet disease is a chronic vasculitis with stomatitis (90%), iritis or conjunctivitis with hypopyon (30–90%), genital ulcers (60–90%), arthritis (20–60%), thrombophlebitis or erythema nodosum.

Erythroplasia Queyrat:

Squamous cell cancer in situ of the prepuce (or other non-keratinized squamous epithelium) is called erythroplasia of Queyrat. In contrast, squamous cell cancer in situ of the skin is called Bowen disease. Erythroplasia Queyrat is a well-defined bright redness of the glans and prepuce (or vulva, anus, mouth) with fine granulation, slightly vulnerable.

Diagnosis of Balanitis

In doubt of the etiology or resistance to standard care, a microbiological culture and/or biopsy should be obtained.

Treatment of Balanitis

• Penis baths and if necessary oral antibiotics in the acute inflammatory episode of bacterial balanitis
• Clotrimazole ointment for fungal infections.
• Local steroid ointment for non-infectious causes.
• Further treatment according to the underlying disease
• Circumcision is the treatment of phimosis or recurrent balanitis

References

Buechner 2002 BUECHNER, S. A.: Common skin disorders of the penis.
In: BJU Int
90 (2002), Nr. 5, S. 498-506

Schütte 2003 SCHüTTE, B.: Ausgewählte dermatologische Erkrankungen im Genitalbereich.
In: Urologe A
42 (2003), S. 514–522

  Deutsche Version: Balanitis: Entzündung der Eichel.