Review article

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Balanitis and Balanoposthitis - Review article

S. Arunkumar1, S. Murugan 2, B. Sowdhamani3, R. Sureshkumar 4

Department of STD, Chengalpattu Medical College, Chengalpattu, Tamil Nadu, India.1- Professor & HOD, 2- Assistant Professor,
3&4 Junior Residents.
Submission Date: 18-11-2013, Acceptance Date: 24-11-2013, Publication Date: 31-01-2014
How to cite this article:
Vancouver/ICMJE Style
AS, MS, SB, SR. Balanitis and Balanoposthitis - Review article. Int J Res Health Sci [Internet]. 2014 Jan31;2(1):375-92. Available
from http://www.ijrhs.com/issues.php?val=Volume2&iss=Issue1
Harvard style
A,S., M,S., S,B., S,R. Balanitis and Balanoposthitis - Review article. Int J Res Health Sci. [Online] 2(1). p. 375-92 Available from:
http://www.ijrhs.com/issues.php?val=Volume2&iss=Issue1
Corresponding Author:
Dr. S. Arunkumar, Professor & HOD, Department of STD, Chengalpattu Medical College, Chengalpattu, Tamil Nadu, India.
Email: arunssshc@gmail.com

Abstract
Balanitis is defined as inflammation of the glans penis, which often involves the prepuce (Balanoposthitis). In the
present scenario, where there is a decline in the tropical Sexually Transmitted Diseases ( STDs), balanoposthitis is
the common condition in uncircumcised male patients attending the STD clinic. Candidal balanoposthitis is a
known feature of diabetes mellitus especially in Indian males who are predominantly uncircumcised as the crude
prevalence rate of type II diabetes mellitus in India is 9%. In our hospital, 31% of the newly diagnosed diabetic
patients were presented only with balanoposthitis. The common etiology for balanoposthitis is candida albicans,
but it may be due to a variety of infective and non infective causes. The management of balanoposthitis is given in
a simple and step by step approach for specific and non specific causes.

Keywords: Balanoposthitis; Candidiasis; Circumcision; Diabetes mellitus; Phimosis; Prepuce; STDs

Introduction
Balanitis is defined as inflammation of the

there is a decline in the tropical Sexually Transmitted

glans penis, which often involves the prepuce

Diseases (STDs) balanoposthitis is the common

(Balanoposthitis) [1]. In the present scenario, where

condition in uncircumcised male patients attending

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Arunkumar
et al
Balanitis
the STD
clinic,
whichand
is Balanoposthitis
around 11% [2]. Candidal

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The preputial sac provides lubrication
for

balanoposthitis is a known feature of diabetes

atraumatic vaginal sex. This is aided by the secretion

mellitus especially in Indian males who are

in preputial sac.

predominantly

uncircumcised

crude

The secretions contributed by prostate,

prevalence rate of type II diabetes mellitus in India is

seminal vesicles and urethral glands (Littres)

9%. In our hospital, 31% of the newly diagnosed

moistens male preputial sac. Aerobic organism like

diabetic

group B streptococci, coliforms, corynebacterium,

patients

were

as

presented

the

only

with

balanoposthitis. Risk factors for balanoposthitis are i)

coagulase

uncircumcised, ii) congenital and acquired phimosis

enterococci are seen in subpreputial area normally.

[3], iii) poor genital hygiene, iv) lack of safe sex

Group

practices, v) diabetes mellitus and vi) urinary

heterosexuals

incontinence. Apart from the common etiology

unimportant. The preputial sac is also colonised by

candida albicans, it is due to a variety of infective

Gram negative anaerobes (especially bacteroides

and non infective causes [4-6]. Management of

melaninogenicus). Mycobacterium smegmatis is a

balanoposthitis remains a clinical challenge because

benign commensal organism in the genitalia. This

the cause is frequently undiagnosed as the clinical

organism causes non genital soft tissue infections

features are not specific. Hence we decided to do a

post surgery/ trauma.

review on this topic.

Prepuce:

positive

staph.

streptococci
through

aureus,

causes
sexual

gonococci,

balanitis

in

transmission

is

The langerhans cells or dentritic cells are

important for local mucosal immunity of prepuce.

Prepuce or foreskin is an integral part of

Langerhans cells [8] and squamous epithelial cells

external genitalia that covers the glans penis and

[9] of prepuce secrete cytokines that stimulate the T

clitoris of male and female genitalia respectively. It

helper system.

is a specialised mucosal tissue that marks the

boundary between mucosa and skin [7]. It gives
adequate protection to the genitalia and also
functions as an erogenous tissue. Prepuce is
composed of squamosal mucous epithelium, lamina
propria, dartos muscle, dermis, outer glabrous skin.
The outer epithelium of prepuce internalises glans
penis / clitoris, urethral meatus (male). The inner

Etio pathogenesis
The causes of balanoposthitis is both
infective

and

noninfective

[4].

Infective

balanoposthitis is more common in uncircumcised

male, as a result of poor genital hygiene, lack of
aeration, irritation by smegma, diabetes mellitus and
immune suppression.

epithelium decreases external irritation. The mucosal

epithelium contains langerhans cells which are an
important local defense mechanism. Tysons glands

The causes are broadly classified as:

in lamina propria are often the source of smegma.

Langerhans cells are also found in the outer
epithelium of prepuce.

Infective

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Non Infective

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Arunkumar et al Balanitis and Balanoposthitis

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A. Fungal : Most common cause

(i)
Candida (albicans, krusei )
(ii)
Dermatophytosis
(iii)
Pityriasis versicolor
(iv)
Histoplasma capsulatum
(v)
Blastomyces dermatitidis
(vi)
Cryptococcus neoformans
(vii)
Penicillium marneffi

A. Skin Disorders
(i) Circinate balanitis (Reiters syndrome)
(ii) Lichen sclerosus et atrophicans
(iii) Balanitis xerotica obliterans (BXO)
(iv) Lichen planus/ Lichen nitidus
(v) Zoons balanitis
(vi) Psoriasis
(vii) Seborrhoeic dermatitis
(viii) Pityriasis rosea
(ix) Crohns disease, Ulcerative colitis
(x) Necrobiosis lipoidica
nd
B. Bacterial (2 Most common )
(xi) Hypereosinophilic syndrome
(xii) Xanthomatosis
( i) Haemolytic Streptococci(Group B Streptococci) Most Common
(xiii) Histiocytosis X
(ii) Staphylococci epidermidis / aureus
(xiv) Sarcoidosis
(iii) E.coli
(xv) Porokeratosis
(iv) Pseudomonas
(v) Treponema pallidum
(xvi) Apthous ulcers
(vi) Neisseria gonorrhoea
(xvii) Pyoderma gangrenosum
vii) Haemophilus ducreyi
(xviii) Bullous disorders
vii) Mycoplasma genitalium
(xix) Behcets disease
ix) Chlamydia
(xx) Premalignant Conditions
x) Ureaplasma
Erythroplasia of Queyrat,
xi) Gardnerella vaginalis
Bowens disease
xii) Non specific spirochaetal infection
Bowenoid papulosis
xiii) Citrobacter
Extra mammary Pagets disease
xiv) Enterobacter
(xxi) Malignant conditions
xv) Mycobacterium tuberculosis
Squamous cell carcinoma,
xvi) Anaerobes ( Bacteroides)
Basal cell carcinoma, Melanoma,
xvii) Haemophilus parainfluenzae infection
CLL, Metastasis
xviii) Klebsiella pneumonia
B. Miscellaneous
xix) Leprosy
(i) Trauma
C. Viral
(ii) Poor hygiene
i) Herpes simplex virus (HSV)
(iii) Irritant & Allergic contact dermatitis
ii) Varicella zoster virus (VZV)
(iv) Fixed drug eruption
iii) Human papilloma virus (HPV)
(v) Extra long foreskin
D.Protozoal
(vi) Phimosis
i) Entamoeba histolytica
(vii) Incontinence
ii) Trichomonas vaginalis
(viii) Granulomatous balanoposthitis
iii) Leishmania species
C. Non specific balanoposthitis
E. Parasitic
D. Balanoposthitis simplex
i) Sarcoptes scabiei var hominis
ii) Pediculosis
iii) Ankylostoma species
iv) Creeping eruptions
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Among the infective causes, candida albicans is the most common etiology. It is one of the presenting features of
diabetes mellitus. Apart from candida albicans, other important agents are staphylococcus, streptococcus, anaerobes
and various other organisms may also cause balanoposthitis.
Among the non infective causes irritant balanoposthitis, fixed drug eruption, plasma cell balanitis, circinate balanitis
are the important ones.
Type
Symptoms
Signs
Diagnosis
Treatment
Remarks
Pruritus,
Dry, raised
1) Subpreputial 1) Topical [10] :
First described by
I. Infective
burning
excoriation
discharge
swab
Clotrimazole cream Engman in
A) Fungal
sensation,

Gram
stain,
small irregular
or Econazole cream 1920[11].
Infections
redness
of
KOH
papules and
or Sertaconazole
Normally carried
i) Candida albicans
glans
and
preparation
and
dispersed
vesicles
cream
or
on penis in 14(Also called as
prepuce,
Culture.
with
plaques
of
Miconazole
(2%)
18%. 35% of all
Balanoposthitis
whitish
white cheesy
2) Urine culture. cream or Nystatin
cases of infective
Candidomycetica).
subpreputial
matter.
Cream for 10-14
balanitis.
3) FBS/ PPBS/
discharge.
days bd.
Erythema of glans HbA1C.
Predisposing
and fissuring of
2) Tab. Fluconazole factors:
4) Germ tube
prepuce.
150 mg Stat or
test.
Uncircumcised
Transient
T. Itraconazole
men
urethritis may be
200mg bd for 1day. Antibiotics and
seen.
steroid abuse.
Acute
Immunocompromi
inflammatory
sed
edematous
Poorly controlled
balanoposthitis
DM patients.
associated with
Sexual contact of a
diabetes mellitus.
partner with
vulvovaginal
candidiosis.
No significant
difference between
carriage rate in
uncircumcised/circ
umcised men.
ii) Dermatophyte
infection

iii) Pityriasis versicolor

Circinate, fine,
scaly,
hypopigmented
areas in glans.

Deep Fungal Infections

iv) Histoplasma
capsulatum

Multiple non
tender punched
out ulcers with

History and
clinical
evidence of
dermatophyte
infection in
other sites.
Scraping and
microscopy.
Culture.
Scrapping and
microscopy.
Woods lamp.
Culture.
`

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Topical antifungals.
Oral antifungals.

Topical antifungals.

Surgical
debridement.
Systemic antifungals
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indurated margins.

v) Cryptococcus
neoformans
vi) Penicillium marneffi

Necrotizing ulcer
over the glans.
Ulcers over the
glans.
Ulcers over the
glans.
Nonspecific
erythema without
discharge, rarely
penile edema
(cellulitis).

vii) Blastomyces
dermatitidis
B. Bacterial Infections
i) Group B Streptococci
ii) Group A Beta
haemolytic streptococci
iii) Staph. aureus

iv) Treponema pallidum

( Also known as
syphilitic balanitis of
Follman)

(v) Neisseria gonorrhoea

like Amphotericin
B,
Ketoconazole.
Same.

Primary syphilis:
Multiple circinate
lesions eroded to
form irregular
ulcers at the glans
penis and prepuce.
Secondary
syphilis: Swollen
glans covered
with partially
coalescent white
flat papules,
plaques over glans
penis.

Pain, burning
sensation,
urgency and
frequency of
micturition.
Urethral

Tender ulcers /
pustules on
prepuce and shaft.
Thick creamy,
greenish yellow
purulent

Same.
Same.
Penicillins.
Cephalosporins.

i)
Demonstration
of organism by
dark field
microscope.
ii)
Demonstration
of T. pallidum
by polymerase
chain reaction.
iii) Serology for
syphilis.
iv)Eliminate the
presence[12] of
other organism
like Candida,
Group B
Streptococci,
Anaerobes,
HSV etc.
i) Grams stain:
Intracellular
Gram negative
diplococcic.
ii) Culture

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Caused
asymptomatically
in adult genital
mucosa.
Increased carriage
in heterosexuals.
Sexual
transmission is
unclear.
Commonly
involves children.
Infrequently
occurs.
Toxic Shock
syndrome is a rare
complication.

Benzathine
Penicillin 24 lakh
units IM after test
dose.

Single dose
Ceftriaxone or
Cefixime.
Simultaneous
treatment with
Doxycycline or

Hypopigmentation
of glans penis is a
rare complication.

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Arunkumar et al Balanitis and Balanoposthitis

discharge.

(vi) Haemophilus
ducreyi

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discharge.
Lymphadenopathy
is seen.
Painful shallow
ulcers with ragged
and undermined
edges.

(vii) Mycoplasma
genitalium

Simple erythema.
Circinate lesions
over the glans
penis and prepuce.
Tendency for
bleeding.

(viii) Chlamydia

Irritant balanitis.

(ix) Gardnerella
vaginalis and other
aerobes

Mild
symptoms
Pruritus and
irritation over
Glans penis
and prepuce

Azithromycin for
Chlamydial
infection
Systemic
Antibiotics.
Erythromycin or
Ceftriaxone or
Azithromycin or
Ciprofloxacin.
Tetracyclines.

Tetracyclines.

Diffuse erythema
and mild irritation
over glans penis
and prepuce.
Increased
offensive , fishy
odour in sub
preputial
discharge
(SPD)[14].

Subpreputial
culture
Group A
streptocooci,
staph aureus and
Gardnerella
vaginalis.

As per guidelines
and depending on
the sensitivity of the
organism.
Erythromycin
500mg bd, 2%
fusidic acid cream.

(x) Non specific

spirochaetal infection (
Borrelia infection)

Large,
serpiginous,
superficial, foul
smelling tender.

Dark field
microscopy.
Spirochaetes
demonstrated.

Penicillin and
Metronidazole[15].

(xi) Mycobacterim

Ulcers with

Biopsy ( HPE)

MDT.

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Phimosis and
phagedenic ulcer
are the
complications.

Mycoplasma
causes urethritis
independent of
balanitis.
Increased risk of
HIV transmission
and
susceptibility[13].
D-K serotypes
cause balanitis.
Symptoms occur
within 7 days of
sexual contact.
Most common in
uncircumcised
men.
Congenital
phimosis and
acquired phimosis.
Poor hygiene.
Normally this
organism is
present in glans
penis and prepuce.
Concomitant
anaerobic infection
is common.
Sexually acquired.
Coexists with
other infections.
Aetiology:
Commonly
Treponema
refringens,
Treponema
phagedenis,
Treponema
balanitidis,
Borrelia vincenti.
Common in
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Arunkumar et al Balanitis and Balanoposthitis

leprae and (xii)
Mycobacterim
tuberculosis

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undermined edges
over glans penis.
Involement of
glans penis and
Phimosis[16].
Chronic papular
eruption of glans
penis which may
be ulcerated, and
heals with
scarring[17] .
Superficial
erosion of glans
penis, coronal
sulcus.
Preputial edema.
Tender
lymphadenitis.

shows
tuberculoid
granuloma
formation.

Anti tuberculous
treatment.

(xiii) Anaerobes (
Bacteroides,
nonclostridial
anaerobes). Also known
as erosive bacterial
balanitis.

Foul smelling
discharge.
Swelling of
glans penis.

Diagnosed
clinically and
treated early.

C. Viral
(i) Herpetic balanitis
(HSV)

Prodromal
symtoms
common.
Pain in penis
and inguinal
region.
Dysuria and
urethral
discharge

Multiple tender
papulo vesicles
over the glans
penis and or
prepuce.
Multiple necrotic
ulcers over glans

Serology,
culture in chick
embryo, baby
hamster kidney,
Hep 2 cells.
Biopsy.
Light and
Electron
microscopy

Acyclovir tablets.
5% Idoxuridine [19]
solution in DMSO.

(ii) Human papilloma

virus (HPV)

Redness,
itching,
burning
sensation, pain
and fissuring
of glans penis.

Diffuse or patchy
erythematous
macules or
maculo papules on
the inner aspect of
prepuce.

1) 5% Acetic
acid test- on
application the
lesions become
white- aceto
white.
2) HPE:
Hyperkeratosis
and
parakeratosis.
3) Detection of
types.

1) 5 Fluorouracil
(5FU) cream
application once/
twice weekly.
2) 0.5%
podophyllotoxin self
application.
3) 25% Podophyllin
once a week (under
super vision).
4) 5% Imiquimod
cream twice weekly
for 16 weeks.

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countries with
increased
prevalence of
tuberculosis.
Associated with
positive Mantoux
test.

Transmitted by
Anogenital
contact.
Predisposing
factor: Contact by
mouth or finger,
poor genital
hygiene, phimosis,
uncircumcised.
Causative
agents:[18]
Fusobacterium,
Bacteroides,
Anaerobic cocci
etc.,
Complication:
Gangrenous
balanitis.
Due to HSV1,2.
Predisposing
factors:
Uncircumcised
men,
poor genital
hygiene, orogenital
contact.
Screening for other
STDs is
recommended.
Screen the partner
and Inform the
partner about the
risk of
transmission.
Advise barrier
protection.
Advise for follow
up.

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D. Protozoal
(i) Amoebic balanitis
( Caused by Entamoeba
histolytica)

Pain, dysuria.

Ulcers and
erosions over
glans penis,
edema of prepuce.
Phimosis,
discharge.

Biopsy.
Culture, smear,
wet mount
preparation.

Metronidazole
Circumcision.

(ii) Trichomonas
vaginalis

Copious
frothy
discharge.

Superficial
erosions present
over the glans
penis.
Phimosis.
Mucopurulent
greenish frothy
discharge with
fishy odour.

Wet Mount:
from
subpreputial
discharge demonstration
of the organism.
Culture:
HPE: Dense
lymphocytic
infiltrate in
upper dermis
[21].
Demonstation of
leishmania
amastigotes in
smear / biopsy.

Metronidazole.

(iii) Leishmania
donovani

Ulcers over glans

penis and prepuce.

E. Parasitic
(i) Sarcoptes scabiei var
hominis

Pruritus

Raised, slightly
elongated,
circumscribed
tracts and nodules
over glans penis
and scrotum, shaft
and penis.

(ii) Creeping eruptions (

Cutaneous larva
migrans)

Itching

Erythematous
itchy papules and
linear serpiginous
bizarre tracts.
Shallow, circinate
irregular greyish
white lesions with
raised edges
coalesce to form
geographic
patches with white
margin[23].

II. Non infective

A. Skin
disorders
(1) Circinate balanitis /
Balanoposthitis (
Reiters disease)

Systemic/ local
pentavalent
antimony
compounds.
5% permethrin
cream application.

Described first by
Straub in 1924.
Seen in
uncircumcised
men with poor
hygiene.
Auto inoculation
and intercourse
with infected
partner[20] are the
main modes of
transmission.
Sexually acquired.
Associated with
other infections.
15-50% of men
with trichomonas
infection are
asymptomatic
carriers.
Long prepuce is an
important
predisposing
factor.

Transmitted by
close body contact.
Emphasis on good
local hygiene.
Treatment of
household contacts
and sexual partners
of patient is
mandatory.

Albendazole 400800mg daily for 3

days.
HPE:
Hyperkeratosis,
parakeratosis,
acanthosis,
elongated rete
ridges,
spongiform
pustule in upper
dermis.
Dermal

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Not required usually

Some cases : 1%
hydrocortisone
cream twice daily
application.
Potent steroids.

Common in
Shigella associated
disease[22].
Post infection
syndrome.
Overlap with
Psoriasis, HIV
infection.
HLA B 27 plays a
role.
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capillaries
enlarged,
increased in
number
mononuclear
cell infiltrate.
Extravasation of
RBCs.

2) Lichen Sclerosis et
atrophicans (LSA)

Usually
asymptomatic.
Non
retractable
foreskin.
Pain,
irritation.
Disturbance of
sexual
function.
Urinary
symptoms.

Recurrent painful
vesicles and ulcers
over glans penis.
White plaques on
glans penis and
prepuce.
Thickened non
retractable
prepuce.
Hemorrhagic
vesicles over
plaques.
Cicatricial
shrinkage, urethral
stricture, phimotic
prepuce.

HPE: Epidermis
: ( Early)
Thickened
(Late)
Atrophy,
follicular
hyperkeratosis.
Dermis:
Oedematous
area with loss of
elastic fibres
and alteration in
collagen.
Perivascular
band of
lymphocytic
infiltrate.

3) Balanitis Xerotica
Obliterans ( BXO)

4) Zoons balanitis (
Balanitis circumscripta
plasma cellularis/
Plasma cell balanitis

Usually
indolent and
asymptomatic
mild pruritis.
Irritation,
pain,
SPD, staining
of under

Raised, solitary,
smooth, well
circumcised, redorange shiny[25]
plaques on glans
and prepuce with
pinpoint purpuric
Cayenne
pepper surface

Biopsy : HPE:
Epidermis :
Atrophy,
complete
effacement of
rete ridges.
Diamond
shaped or

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Circumcision
Treatment of
Choice[24] .
Meatotomy for
meatal stenosis.
Topical potent
steroids until
remission then
intermittently once a
week ( for
remission).
Other treatment :
photodynamic
therapy, laser,
testosterone
ointment,
calcipotriol
ointment, topical
Calcineurin
inhibitors.
Neonatal
circumcision.

Circumcision (
Curative).
Topical steroids.
Topical tacrolimus,
Pimecrolimus.
Topical fusidic
acid[26] cream.
CO2 laser/ intra

Screening for
concurrent STIs
especially
Chlamydia
trachomatis.
Triad includes
Conjunctivitis,
Urethritis and
Arthritis.
Circinate balanitis
and Keratoderma
blennorrhagicum
seen.
Commonly seen in
middle aged men
uncircumcised
men.
Predisposing
factors:
Idiopathic, trauma,
autoimmune
disease, genetic
factors, hormonal
factors.
Follow up is
mandatory
annually.

Chronic scarring
balanitis.
Most commonly
caused by LSA,
Chronic nonspecific balanitis.
Associated with
phimosis and
squamous cell
carcinoma.
Described by Zoon
in 1952.
Common in
middle aged and
elderly
uncircumcised
men.
It is an idiopathic

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garments with spotting with

blood.
yellowish hue.
Cosmetic
concern.
Anxiety.

lozenge shaped
keratinocytes in
basal layer.
Watery
spongiosis,
sparse
dyskeratotic
cells.

5) Psoriasis

Soreness,
itching,
change in
appearance.

Crusted, scaly
plaques over glans
penis
(circumcised) red
glazed patches
(uncircumcised).

6) Lichen planus (LP)

Itching,
soreness and
dyspareunia.

Well demarcated,
purple colored,
plaques over
glans, prepuce and
shaft of penis.
Erosions on
mucosal surface

7) Seberrhoeic
dermatitis

Itching

Erythema

HPE:
Hyperkeratosis,
parakeratosis,
regional
acanthosis,
elongated rete
ridges, Munros
micro abscesses,
spongiform
pustule of
Kogoj.
LP lesions over
other sites.
HPE:
Hyperkeratosis,
irregular
acanthosis, focal
wedge shaped
hypergranulosis,
liquefactive
degeneration of
basal cell layer.
Band like
lymphocytic
infiltrate in
dermo
epidermal
Junction.
Fine scaling at
classical sites
like nasolabial
fold, scalp and
ears.

8) Eczema

9) Porokeratosis

Dry, red glazed

Slightly scaling,
itching.
Centrifugally
spreading patches

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lesional interferon .
Oral griseofulvin.

chronic, reactive,
rare penile
dermatosis.
Etiology: Unclear
Predispoing factor:
heat, friction,
chronic irritation
due to
Mycobacterium
smegmatis, poor
genital hygiene,
trauma,
hypospadias, HSV
infection.

Topical steroids,
topical /oral
Cyclosporine,
topical Calcineurin
inhibitors.
Circumcision for
persons with LP at
glans.

Inflammatory
disorder of
unknown etiology
with
immunological
basis with lesions
in skin, genitals
and mucous
membrane.

Antifungal cream
with mild
moderate steroids,
oral steroids.

Due to
Pityriosporum
ovale.

Cryotherapy, CO2
laser, topical -5
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Arunkumar et al Balanitis and Balanoposthitis

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surrounded by
ridge like border
with central
atrophy.
10) Bullous disorders
Pemphigus vulgaris
Bullous pemphigoid
Linear Ig A disease
Cicatricial pemphigoid
Pemphigus vegetans
11) Dermatitis artefacta

fluro uracil,
imiquimod.

Erosions
resembling
balanitis.

Topical and oral

steroids.
Immunosuppression.

Clobetasone
butyrate 0.05% (
Moderately potent
steroid cream).

12) Crohns disease and

Ulcerative colitis
13) Behcets disease

Premalignant Conditions
a) Erythroplasia of
queyrat

b) Pseudo
epitheliomatous
micaceous and keratotic
balanitis

Phimosis

Well defined red

shiny velvety
plaques, patches
with sharp
margins and
granular surface.
If indurated /
keratotic plaques
Rule out
malignancy.

HPE:
Confirmatory
and mandatory
SCC in long
term.

5% 5 FU cream,
Cryotherapy,
Laser,
Excision (
Recommended)
Circumcision.

Thick, dry, white,

yellow mica like
sheets and
keratotic masses
adherent to glans
penis and coronal
sulcus.

HPE: Massive
hyperkeratosis,
acanthosis,
pseudo
epitheliomatous
hyperplasia,
sparse cellular
infiltrate.

Topical 5% 5FU
cream for 6 weeks.
Local surgical
excision.
Others:
Cryotherapy,
X ray irradiation,
Shave biopsy,
Electrocautery,
CO2 laser.

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Chronic relapsing
disease, unknown
etiology, oral
ulcers, arthritis,
genital ulcers and
eye lesions.
It is a
premalignant
condition
described by
Queyrat in
1911[27].
Common in
uncircumcised
men.
Aetiology: exactly
unknown,
smegma, poor
genital hygiene,
trauma, friction,
heat, maceration.
Acquired disease
in elderly.
Predisposing
Factor: Smoking
and tobacco
chewing .
Premalignant.
Locally invasive
low grade
malignant lesion.
Associated with
verrucous
carcinoma of
penis.
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Arunkumar et al Balanitis and Balanoposthitis

c) Bowens disease

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Well defined, red,

discrete, scaly,
erythematous
plaque present
over penile shaft /
prepuce.

d) Bowenoid papulosis

Papules and
plaques over
glans penis.

Malignant Conditions
a) Squamous cell
Carcinoma
b) Basal Cell carcinoma
c) Melanoma
d) Metastasis
e) Leukemia, CLL
B.Miscellaneous
1) Trauma

Ulcer over
glans penis
and
Prepuce[28].

Biopsy.

Simple excision,
5% 5FU cream,
Laser,
Topical imiquimod.

Local excision and

Laser.
Spontaneous
resolution.

Pinpoint
abrasions.
Erythema over
glans penis.

2) Contact Dermatitis (
irritant and allergic)
i) Allergic

Erythema, edema
of penis.

Patch test.

Avoidance of
precipitating factors.
Washing with soaps.
Emollients.

ii) Irritant

Erythematous,
Oozing, crusted
lesions ( Early)
lichenoid plaques
( Late).

Biopsy: Non
specific,
inflammation.

Edema of
prepuce.
Predilection for
glans penis.
Well demarcated,
bullous,
edematous and
ulcerated lesions.
Target lesions.
Erosions.

Rechallenge
with the drug to
confirm the
diagnosis.
Hydropic
degeneration of
basal cell layer.
Spongiosis.

Topical steroids like

1% hydrocortisone
cream once or twice
daily.
Systemic steroids.
Spontaneous fading
without treatment.
Residual
hyperpigmentation.
Rarely topical 1%
hydrocortisone
cream bd until
resolution.
Systemic steroids
for severe lesions.

3) Drug reactions
Fixed drug eruptions
(FDE)
SJS/ TEN

Itching,
burning
sensation.

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Etiology unknown.
Carcinoma in situ,
20% will go for
Squamous Cell
Carcinoma.
Follow up is
important.
Due to HPV
infection.
Carcinoma in situ.

Vigorous sexual
activity, sharp
pubic hair piercing
of frenulum, zip
fastening injury,
teeth bites, beads,
pin prick, self
mutilation.
Etiology: Balsum
of peru, kathon
CG, perfume,
rubber,
spermicidal agents,
smegma, condoms.
Etiology: Topical
antifungals, soaps,
antiseptics,
podophyllotoxin.
Etiology:
Tetracyclines,
NSAIDS,
Sulfonamides,
Dapsone,
Warfarin,
Griseofulvin,
Phenophthalein,
Erythromycin,
Phenacetin,
Metronidazole,
Anti convulsants,
Hypnotics.
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Arunkumar et al Balanitis and Balanoposthitis

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4) Phimosis
5) Granulomatous
balanoposthitis

Multiple painless
firm papules
(glans penis),
edema of prepuce.

6) Nonspecific
balanoposthitis

Chronic
symptomatic
presentation.

7) Balanoposthitis
Simplex

Itching.
Burning
sensation
while
urinating.

Failure to
respond to
conventional
topical
treatment.
Biopsy : Non
specific
histology.
Redness, swelling.

Etiology: Bacterial
infections,
mechanical
irritants,
chemicals.

8) Mild balanoposthitis

Candidal balanoposthitis
Accounts for 35% of cases of balanoposthitis. Mostly
it is acquired sexually. It is commonly seen in patients
with diabetes mellitus. Diabetes mellitus interferes
with both cellular and humoral immunity and suppress
the host defence against infections. Acquired
balanoposthitis can be the first sign of diabetes
mellitus in uncircumcised males. In healthy males,

Circumcision is
curative.

Follow up not
required. Avoid
precipitating
agents.
Common in young
boys
After intra vesical
BCG instillation
therapy[29] for
Carcinoma of
bladder.
Titanium.
Low grade fever.
Etiology :
Unknown
associated with
atopy.

It is
balanoposthitis of
a localised,
inflammatory,
nature with few
non specific
symptoms and a
tendency to
become chronic or
recurrent[30].

candidal balanoposthitis may be a cutaneous marker of

diabetes mellitus. Various studies have shown that
55% of known diabetic patients have candidal
balanoposthitis. The presentation of candidal
balanoposthitis varies according to the age group and
the sexual activity of the patient. In young, sexually
active males, the symptoms include itching, burning
sensation, increased fissuring of the inner part of
prepuce and subpreputial discharge. In elderly males,

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Arunkumar et al Balanitis and Balanoposthitis

who are sexually inactive, itching and moist erythema
of inner aspect of prepuce and glans penis is more
prominent, whereas fissuring is not that much marked
[31]. Though Indian muslim males are usually
circumcised, and Hindu males are usually
uncircumcised, there is no scientific data available that
demonstrates the advantage of circumcision in
prevalence of candidal balanoposthitis. Candidal
posthitis can occur without balanitis. The smegma and
the enzymes in prostatic secretion normally control
and eliminate candidal growth. An acute fulminating
oedematous type of balanoposthits may occur with
ulceration of penis and a swollen fissured prepuce in
undiagnosed diabetics. The appearance of prepuce may
be called volcano like [32]. Diabetics with
balanoposthitis presenting as acquired phimosis was
first reported in 1971 [33]. It is seen in one third of
men with acquired phimosis and it is found that 26%
of patients with acquired phimosis had history of type
II DM [34]. Clinicians and urologists thus should
check the fasting blood sugar of patients with volcano
like appearance of prepuce.
The pathogenesis for fissuring in candidal
balanopostitis is due to the following factors [35].
1) In uncontrolled diabetics with poor glycemic
control, there is accumulation of advanced glycation
end products (AGE) in
foreskin which results in
impaired production of collagen and extra cellular
matrix, which further causes decreased hydroxy
proline content of collagen and alteration of skin
elasticity.
2) Impairment of sebaceous gland function leads to
loss of skin surface lipids which leads to loss of
elasticity and hydration.
3) Decreased hydration in stratum corneum.
4) During urination and sexual intercourse, the
retraction of foreskin produces biomechanical stress
which causes vertical preputial fissures which leads to
fibrosis and subsequent phimosis.
Balanoposthitis in Children:
Balanitis in children affects 4% of boys [36]. It
commonly affects preschool children (2-5 years) and it
is associated with nonretractable prepuce. It is
uncommon in infants and among boys in napkins.
The exact aetiology is not known. It is postulated that
it may be due to poor personal hygiene. Organisms like
group A haemolytic streptococci (commonest), E.coli,
Pseudomonas, Klebsiella, Serratia are implicated in
causing this condition. Autoinoculation from other
sites is usually the mode of infection.
Symptoms include redness, swelling, ulcer over glans
penis, itching, pain, subpreputial discharge (SPD),
dysuria, bleeding, low grade fever and weakness.

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Physical examination reveals phimosis, erythematous

appearance of glans penis, foul smelling subpreputial
discharge and partially or completely non retractable
prepuce.
Ammonia dermatitis, foreskin fiddling are the common
differential diagnosis. Though this condition is usually
self limiting in nature, penicillins or cephalosporins
may be useful in some children. In children with
recurrent balanitis and causing severe distress
circumcision is advised. Above all, investigation for
diabetes mellitus is important, because balanoposthitis
is commonly seen in children with type I diabetes
mellitus.
Smegma and Balanoposthitis
Smegma is the result of desquamated epithelial debris
collected in the sub preputial space & not formed due
to glandular secretions [37]. It contains squalene, beta
cholesterol, long fatty acids, which produces calcium
soaps (Calcium phosphate and Magnesium phosphate).
In chronic inflammation this leads to subpreputial
smegma stones formation.
Smegma stones are seen in uncircumcised men. Such
stones are formed due to poor genital hygiene, lack of
retracting and washing the prepuce, accumulation of
smegma beneath the foreskin [38]. Patients complain
of penile irritation, discharge, pain during and after
coitus. Signs include inflammation, partially
retractable prepuce and purulent SPD.
Circumcision and Balanoposthitis :
Balanitis is uncommon in circumcised men. Balanitis
patients usually have increased risk of carcinoma of
penis. Circumcision thus helps in preventing
carcinoma of penis. Good genital hygiene and safe sex
will definitely help to prevent balanoposthitis. The aim
of treating balanoposthitis is to relieve the symptoms,
to decrease the complications and to restore sexual
function. Treating the associated sexually transmitted
diseases and preventing the route of entry of HIV
infection is also important.
Algorithm I is useful for management of balanitis /
balanoposthitis (European guidelines) [39]
Complications:
Phimosis / Paraphimosis
Meatal stenosis / stricture
Recurrence, relapse and reinfection
Scarring, Depigmentation and hyperpigmentation
Preputial adhesion and perforation
Gangrene
Lymphangitis and lymphedema
Carcinoma of penis

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Arunkumar et al Balanitis and Balanoposthitis

Management of non-specific balanitis [40] (Algorithm
II)

Conclusion
Balanoposthitis is thus a treatable condition in
most of the patients. Persistent recurrent balanposthitis
needs extensive search for the cause and circumcision
may be a best option in some of the cases. Since
prepuce is an immunologically important tissue as well
as an erogenous tissue it should be removed only when
mandatory in certain conditions like BXO. Good
genital hygiene and safe sex will definitely help to
prevent balanoposthitis. The aim of treating
balanoposthitis is to relieve the symptoms, to decrease
complications and to restore sexual function. Treating
associated sexually transmitted diseases and
preventing the entry of HIV infection is also important.
Prevention and precautions for balanoposthitis :
The following instructions and general advice will help
the patients to prevent recurrence of balanoposthitis.
General advice:
1) Avoid frequent washing of genitalia with soaps.
2) Maintaining the genital hygiene by using weak
salt solution or potassium permanganate soaks
(1:8000) or soap free wash.
3) Using lukewarm water to clean penis and prepuce.
4) Drying the foreskin of the penis after washing and
before putting on undergarments.
5) During washing and bathing the foreskin should
be pulled back to expose the glans fully.
6) During urination pulling the foreskin back so that
urine does not collect under the prepuce.
7) After urination dry the penis and prepuce should
be replaced.
8) Washing and drying penis after having sex.
Specific advice:
1) Safe sex practices.
2) Appropriate hygiene.
3) Explain the about the condition and its long term
complications.
4) Advice regarding the effect of condoms if creams
are applied [41].
5) Frequent changing of diapers in children.
6) Examination and treatment of sexual partners
wherever necessary.

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Management of balanitis/ balanoposthitis (European Guidelines) (Algorithm I )

Balanitis / Balanoposthitis

Take history and examine

Prepuce retractable

Ulceration +

Prepuce not retractable

Prepuce scarred

Erythema / SPD+, No Ulcer

Treat as genital ulcer

Foul smell +

No foul smelling

Prepuce swollen

Refer to Surgery

Treat as Genital Ulcer

Metronidazole
400mg bd for 1week

Antifungal +1% Hydrocortisone cream application bd

for 1 week

Review after 1
week

Better, Discharge and Follow up

If no improvement, 1) Reassess or 2) Erythromycin 500mg qid for 1 week or 3) Potent

steroid cream and follow up

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Management of Non specific Balanitis [40]

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(Algorithm II )
Balanitis
Culture for pathogens

No pathogens identified

Pathogens identified, treat

appropriately
Improved

No improvement, try empirical Metronidazole

Good hygiene,
emollients / avoid potential irritants

Improved

Poor hygiene
Advice to improve
genital hygiene

No Improvement

Improved

Hydrocortisone 1% cream bd for 1 week

No improvement and significant balanitis. Advice penile biopsy
Treat as per specific diagnosis in biopsy
Shows inflammatory dermatoses
Consider Circumcision

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