Balanitis

Contents

What is balanitis

What is balanitis

Balanitis is an inflammation of the head of the penis (the ‘glans’) that can affect men and boys, that causes pain, redness and itchy skin and sometimes a discharge from under the foreskin ¹. In uncircumcised males (the foreskin or “prepuce” is still present) inflammation of both the glans and the foreskin together is called balano-posthitis. Inflammation of the head of the penis (the ‘glans’) or foreskin may cause redness, itching, discomfort, flaking of skin, swelling or soreness. Balanitis is most common in uncircumcised men. Causes include skin disorders, infection, poor hygiene, uncontrolled diabetes and overuse of soaps. Most men should be able to clear balanitis themselves.

Most balanitis is not sexually transmitted. Men do not ‘catch’ balanitis from women with vaginal thrush, or vice versa. Balanitis results from excessive growth of organisms which are normally present on the skin of the glans. Balanitis usually occurs in men who have a foreskin (i.e., have not been circumcised). The environment under the foreskin is warm and moist, and these conditions favor growth of organisms that cause balanitis. This may be more likely to occur if you have not washed for a couple of days, or sometimes after sexual activity (vaginal, oral or anal – with or without a condom).

A common organism associated with balanitis is a yeast called Candida albicans. Balanitis can result from overgrowth of Candida, but it is important to remember that Candida is normally present under the foreskin in small quantities. In normal amounts, it doesn’t cause any problems and does not require treatment.

Sometimes there are underlying conditions, for example diabetes or skin conditions, that make balanitis worse.

Balanitis (inflammation of the head of the penis) and balano-posthitis (inflammation of both the glans and the foreskin together) may be a relatively minor problem or may become a major issue, greatly affecting enjoyment of life. Fear of a sexually acquired infection (STD) or fear of cancer of the penis may be aggravated by inappropriate and incorrect advice offered by family, friends or inexperienced health professionals.

Balanitis can clear up with careful washing and drying of the affected area. Medical treatment is rarely needed.

If you have balanitis, you might notice:

redness and swelling
itching
pain
perhaps a smell and a discharge
a pink or red rash, smooth or scaly, spotty or patchy
discharge or oozing
problems pulling back the foreskin (phimosis)

Balanitis is due to overgrowth of the microorganisms, particularly yeast, normally found on the glans. If you are uncircumcised, the warm moist environment under the foreskin provides ideal conditions for the growth of yeast. It is not as common in men and boys who have been circumcised.

Balanitis can also be caused by allergies, psoriasis, scabies and nappy rash.

Balanitis is not sexually transmitted. Men can’t get it from their partners.

Balano-posthitis (inflammation of both the glans and the foreskin together) in uncircumcised males may cause difficulty in retracting the foreskin, resulting in discomfort and difficulty with erections and sexual activity.

The main aim of balanitis treatment is to keep the head of the penis and foreskin clean and dry. This should prevent infection and thus complications. Daily showering with particular attention to cleaning this area is necessary. Slide the foreskin back towards your body so the head of the penis is exposed. Wash with warm water; do not use soap as this may irritate the area. A nonsoap cleanser such as aqueous cream may be used if desired, then it should be rinsed off.

Figure 1. Balanitis

Balanitis home treatment

You can usually clear up balanitis by looking after your penis well. At least once a day, gently wash the glans with warm water, including the part under the foreskin, and dry it gently. If you have a foreskin, pull it back gently and wash underneath. A bath in salty water might help.

If you don’t wash underneath the foreskin correctly, a cheesy-looking substance called smegma may begin to gather. Smegma is a natural lubricant that keeps the penis moist. It’s found on the head of the penis and under the foreskin. If smegma builds up in the foreskin, it can start to smell, stop you easily pulling your foreskin back, and become a breeding ground for bacteria. This can cause redness and swelling of the head of your penis, called balanitis.

After washing, dry the area thoroughly. Make sure the head of the penis is completely dry before replacing the foreskin.

If you are prone to develop balanitis a few hours after sex, wash the penis shortly after having sex.

You should avoid soap, hot water and vigorous rubbing, which can make the inflammation worse. Your pharmacist will be able to recommend soap-free products.

If the careful washing and drying routine does not work, talk to your doctor or pharmacist about the use of over-the-counter mild steroid or antifungal creams.

For babies, nappy rash cream applied to the tip of the penis can help clear up or prevent balanitis.

Is balanitis an STD?

Balanitis can also be caused by allergies, psoriasis, scabies and nappy rash.

Balanitis is not sexually transmitted. Men can’t get it from their partners.

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.

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. 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.

How long does balanitis last?

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.

When to see a doctor

You should see your doctor if you think you’ve got balanitis just to make sure it isn’t a sign of something more serious like a sexually transmitted disease (STD).

You can also get yourself checked out at a sexual health clinic.

Balanitis causes

Balanitis and balano-posthitis may be caused by many different skin conditions including:

Poor hygiene, leading to a build-up of smegma. Smegma is a natural lubricant that keeps the penis moist. It’s found on the head of the penis and under the foreskin. If smegma builds up in the foreskin, it can start to smell, prevent easy foreskin movement and become a breeding ground for bacteria. This can cause balanitis, which is redness and swelling (inflammation) of the head of your penis.
Irritation under the foreskin caused by urine
Non-infectious skin conditions such as dermatitis (eczema) or psoriasis (flexural psoriasis).
- Dermatitis of various kinds including contact allergy, e.g. to rubber condoms, fragrances or medicament.
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 intraepithelial neoplasia (PIN).
Reiter syndrome.
Scabies

In these conditions, there are usually signs of the skin condition elsewhere. Specific tests may help make the diagnosis. When these are negative, the origin of the balanitis is considered ‘nonspecific’. It is a type of intertrigo.

Nonspecific balanitis appears to be an irritant reaction related to proliferation of bacteria (pseudomonas, anaerobes) and yeasts (candida). These may normally be found in small numbers on healthy skin.

Sexually transmissible diseases (STDs) (e.g., syphilis, chlamydia, gonorrhoea) are only rarely a cause of balanitis or balano-posthitis. Fear of a possible STD often causes anxiety, distress or confusion.

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.

Risk factors for balanitis

Risk factors for developing balanitis include:

Moisture (sweat), which permits the microorganisms to thrive. Nonspecific balanitis nearly always affects uncircumcised men, as the tissue under the foreskin may fail to dry out properly.
Infrequent washing and/or failure to dry the glans after washing
Conversely, over-frequent washing, especially with standard alkaline soap, or drying vigorously with a harsh towel
Diabetes mellitus, which especially increases the likelihood of Candida albicans infection
Sexual partner suffering from vaginal thrush (in which case it’s the partner’s yeasts that cause the irritation rather than a sexually transmitted infection)
Chemical irritants, e.g., lubricating jelly, medicated creams
Minor trauma – this may include friction during sexual intercourse
Obesity

Balanitis in toddler

At birth, the normal foreskin (prepuce) is attached to the glans and has a tight opening (preputial ring) at the distal end. It is not retractable in most newborns.

Foreskin (prepuce) retractability increases with age, with full retraction possible in:

10% of boys at 1 year
50% of boys at 10 years
99% of boys at 17 years

A non-retractable foreskin is a normal variant and needs no intervention. It is different from true phimosis.

The foreskin should never be forcibly retracted for cleaning. Once it becomes freely retractable naturally, then the child should retract it as part of routine bathing, ensuring immediate replacement over the glans to prevent paraphimosis. See care of the normal uncircumcised penis patient information.

Balanitis and inflammation

Minor redness and/or soreness of the tip of the foreskin is common and can be managed with reassurance and avoidance of chemical/physical triggers. More extensive inflammation of the glans penis +/- foreskin is termed balanitis.

Causes include:

Chemical irritation: urine trapping, soiled nappies, soap residue.
Physical trauma: forcible retraction.
Candida nappy rash in infants.

Balanitis Treatment:

Soaking in warm salt water settles swelling and discomfort.
Barrier or 1% hydrocortisone cream (see also Nappy rash).
Antifungal cream (clotrimazole, miconazole) if candida suspected.
Oral analgesia may be needed.
Topical antibiotic ointments and creams are not efficacious.
Preputial retraction during acute inflammation should not be recommended as this can lead to paraphimosis.

Balanitis xerotica obliterans (BXO) is a condition that affects the foreskin in older boys (> 3 years old). The foreskin has a white scarred appearance. Balanitis xerotica obliterans (BXO) may requires circumcision.

Cleaning a child’s penis

Don’t try to forcefully pull back the foreskin of a baby or young boy as this could be painful and cause harm. Their foreskin might still be attached to the head of the penis and will therefore not retract fully. At this stage of their development, there’s no need to clean inside the foreskin.
If the child is still in nappies, change them frequently.
Don’t use baby wipes to clean their penis.

Balanitis prevention

Keeping the penis glans clean and dry is the first line of prevention.

You can also help prevent balanitis by:

washing the penis soon after sex (if balanitis tends to flare up soon after sex)
washing your hands free of chemicals before touching your penis
pulling back your foreskin when weeing and drying any urine before replacing the foreskin.
practising safe sex to avoid an STD
using latex-free condoms if you have a latex allergy

You should see your doctor if you can’t comfortably pull your foreskin back to expose the glans.

Young boys may not yet be able to clean under their foreskin because it may not fully pull back yet. Don’t attempt to pull back a child’s foreskin to clean under it if it’s still fixed, as this can cause damage.

What other problems can occur with balanitis?

Balano-posthitis (in uncircumcised males) is more common than balanitis alone. Balanitis (inflammation of the head of the penis) and balano-posthitis (inflammation of both the glans and the foreskin together) 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 (BXO). 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”. Penile intra-epithelial neoplasia (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.

Balanitis symptoms

Balanitis affects the head of the penis and the foreskin. Balanitis occurs far more often in men and boys who haven’t been circumcised.

The symptoms and signs of balanitis are variable. They may include:

A pink or red rash, which may be smooth or scaly, spotty or patchy
Redness, swelling and tenderness of the glans
Discharge or oozing
Itching and discomfort
In severe cases, it may be difficult to retract the foreskin (phimosis). Phimosis is a constriction of the opening of the foreskin so that it cannot be drawn back over the glans of the penis. Phimosis is a normal occurrence in the newborn boy. Some boys’ foreskin can be retracted as early as infancy, others not until age 5 or 6 years. Once potty trained, the uncircumcised boy should learn to retract his foreskin when he urinates and bathes and then pull it back forward again.

Balanitis may be accompanied by urethritis (inflammation of the urethra) and/or other skin problems.

Balanitis possible complications

The main complication of balanitis is phimosis. This is where the foreskin adheres to the inflamed and swollen glans penis and cannot be retracted. Correction of phimosis requires a surgical procedure, such as a dorsal slit or circumcision (removal of the foreskin).

How is balanitis diagnosed?

A doctor who is knowledgeable and skilled in recognizing 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 recognizing diseases of the male genitalia as most genital disease is disease of genital skin.

Your family doctor 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.

To determine which factors are contributing to balanitis, a swab may be taken for bacterial and yeast culture. Urethral cultures may also be necessary, and occasionally, blood tests for syphilis and diabetes. In persistent cases, a skin biopsy is appropriate to determine whether there is an underlying skin disease or cancer.

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.

Balanitis treatment

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.

How to get rid of balanitis and cure balanitis

Frequently the most useful balanitis treatment is a combination of the following:

Astringent compressess using dilute vinegar (acetic acid 1%), Burow’s solution (aqueous solution of aluminium acetate) or potassium permanganate
Topical antifungal medication
Topical antiseptic or antibiotic
Mild topical steroid

Depending on the results of culture, an oral antifungal medication and/or an oral antibiotic may be prescribed.

The problem may recur, in which case the treatment may be repeated. Potent topical steroids should only be used for a few days, or under careful medical supervision, as they may thin the tissues. Also, withdrawal of topical steroids can result in a flare of symptoms (periorifical dermatitis or steroid dependency).

In refractory cases, circumcision may be necessary to prevent recurrence.

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.