Balanitis, balanoposthitis and paraphimosis in the adult

Balanitis in a child: see

Inguinal and genital skin problems: see

Essentials

• The aetiology is determined critically (avoid overdiagnosing candidiasis)
• Most often the treatment is symptomatic, and sometimes directed to the cause.
• Paraphimosis must be treated without delay to avoid the risk of necrosis of the glans.
• Consider circumcision in severe cases.

Definitions

• Balanitis can be defined widely to include all inflammatory dermatoses in the glans. In the following, some of these are defined separate from the concept of balanitis.
• Balanitis means inflammation of the epithelium of the glans (picture ).
• Usually also the inner surface of the foreskin is inflamed; in this case the accurate term is balanoposthitis.
• Paraphimosis ("Spanish collar"; picture ) occurs when a tight foreskin is retracted and the resulting stasis causes marked swelling of the distal foreskin).

Aetiology

• Possible causes of balanitis
  • Irritants, neglecting hygiene, tight foreskin, irritation by smegma or by soap
  • Seborrhoeic dermatitis; check scalp, the skin behind the ears, and skin folds (picture )
  • Candida; a positive culture result does not yet prove causality. Candidiasis is overdiagnosed.
  • Contact allergy
    • Latex and additives used in rubber manufacture
    • Constituents of skin care products (used by the patient and his partner)
  • Diabetes and overweight are predisposing factors.
  • Lichen sclerosus (balanitis xerotica obliterans, BXO; pictures ) increases the risk of phimosis, urethral obstruction and penile carcinoma.
  • Balanitis circinata (picture ): a rare skin manifestation associated with Reiter’s syndrome
    • Are there other signs of Reiter's disease – arthritis, conjunctivitis?
    • The patient seeks medical care primarily due to the articular symptoms; detection of balanitis supports the diagnosis.
  • Balanitis plasmacellularis Zoon (rare)
• Other possible diseases in the same location as balanitis
  • Lichen (ruber) planus – it is more common in the glans than is generally believed (picture )
  • Psoriasis (picture ) – check other typical locations of psoriasis
  • Erythema fixum (particularly caused by tetracyclines; picture )
  • Erythroplasia Queyrat (a variant of Bowen's disease in the glans), which is a carcinoma in situ

Investigations

• Interpret the results of bacterial and fungal cultures critically. Contamination is common, and candida is the real cause in every fifth case at the most.
• Fasting blood glucose especially when a young person presents with his first balanitis
• If there is urethral discharge, take samples for chlamydia and gonorrhoea. STDs may be associated with intense balanitis – the urethral discharge ending up under the foreskin causes skin irritation. Also HSV and HPV infections may be associated with balanitis.
• Patch tests (in cases of suspected allergy): refer to a dermatologist.
• A punch biopsy of the glans can be taken by a GP.

Treatment

• Relevant treatment against specific aetiology (bacteria, candida)
• Potassium permanganate bath ("tea cup bath") is nearly always beneficial.
  • A water-soluble tablet is available (Permitabs^®).
• Glucocorticoid creams (from mild to moderate potency) for eczema
• Refer a patient with lichen sclerosus (BXO) readily to a dermatologist or urologist
• A patient with lichen ruber or psoriasis is referred to a dermatologist if needed.
• Treat phimosis by circumcision. If the foreskin of an adult man cannot be retracted in the sulcus of the glans after the balanitis has cured a circumcision is indicated.
• Paraphimosis should be treated by immediate reposition. Use lidocaine gel and squeeze the tip of the glans long enough to reduce swelling so that the foreskin can be liberated.
  • If reposition is not successful, an immediate dorsal slit of the foreskin must be made. A small amount of lidocaine is injected under the constricting band of skin, and a superficial longitudinal incision of 1–2 cm in length is made in the skin. The wound can usually be left open.
  • A general practitioner may perform the procedure as an emergency, and the possible circumcision can be performed in a later phase.

Related resources

• Clinical guidelines