para />
Recurrent infection and irritations (condom catheters) can lead to phimosis.
Recurrent balanitis, either chemical or infectious, can lead to an acquired phimosis.
Inappropriate forced reduction of a physiologic foreskin can lead to chronic scarring and acquired phimosis. Unfortunately, many times done due to instructions from health care providers.
EPIDEMIOLOGY
- Balanitis: predominant age: adult; predominant gender: male only
- Phimosis/paraphimosis: predominant age: infancy and adolescence; unusual in adults; risk returns in geriatrics; predominant sex: male only
Incidence
Balanitis: will affect 3-11% of males
Prevalence
Phimosis: in the United States: 8% of boys age 6 years and 1% of men >16 years of age (1)
ETIOLOGY AND PATHOPHYSIOLOGY
- Balanitis:
- Allergic reaction (condom latex, contraceptive jelly)
- Infections (Candida albicans, Borrelia vincentii, streptococci, Trichomonas, HPV)
- Fixed-drug eruption (sulfa, tetracycline)
- Plasma cell infiltration (Zoon balanitis)
- Autodigestion by activated pancreatic transplant exocrine enzymes
- Phimosis:
- Physiologic: present at birth; resolves spontaneously during the first 2 to 3 years of life through nocturnal erections, which slowly dilate the phimotic ring
- Acquired: recurrent inflammation, trauma, or infections of the foreskin
- Paraphimosis:
- Often iatrogenically or inadvertently induced by the foreskin not being pulled back over the glans after voiding, cleaning, cystoscopy, or catheter insertion
Geriatric Considerations
Condom catheters can predispose to balanitis.
Pediatric Considerations
Oral antibiotics predispose male infants to Candida balanitis. Inappropriate care of physiologic phimosis can lead to acquired phimosis by repeated forced reduction of the foreskin.
RISK FACTORS
- Balanitis:
- Presence of foreskin
- Morbid obesity
- Poor hygiene
- Diabetes; probably most common
- Nursing home environment
- Condom catheters
- Chemical irritants
- Edematous conditions: CHF, nephrosis
- Phimosis:
- Poor hygiene
- Diabetes by repeated balanitis
- Frequent diaper rash in infants
- Recurrent posthitis
- Paraphimosis:
- Presence of foreskin
- Inexperienced health care provider (leaving foreskin retracted after catheter placement)
- Poor education about care of the foreskin
GENERAL PREVENTION
- Balanitis:
- Proper hygiene and avoidance of allergens
- Circumcision
- Phimosis/Paraphimosis:
- If the patient is uncircumcised, appropriate hygiene and care of the foreskin are necessary to prevent phimosis and paraphimosis.
DIAGNOSIS
HISTORY
- Balanitis:
- Pain
- Drainage
- Dysuria
- Odor
- Ballooning of foreskin with voiding
- Redness
- Phimosis:
- Painful erections
- Recurrent balanitis
- Foreskin balloons when voiding
- Inability to retract foreskin at appropriate age
- Paraphimosis:
- Uncircumcised
- Pain
- Drainage
- Voiding difficulty
PHYSICAL EXAM
- Balanitis:
- Erythema
- Tenderness
- Edema
- Discharge
- Ulceration
- Plaque
- Phimosis:
- Foreskin will not retract.
- Secondary balanitis
- Physiologis phimosis-preputial orifice appears normal and healthy
- Pathologic phimosis-preputial orifice has fine white fibrous ring of scar
- Paraphimosis:
- Edema of prepuce and glans
- Drainage
- Ulceration
DIFFERENTIAL DIAGNOSIS
- Balanitis:
- Leukoplakia
- Lichen planus
- Psoriasis
- Reiter syndrome
- Lichen sclerosus et atrophicus
- Erythroplasia of Queyrat
- BXO: atrophic changes at end of foreskin; can form band that prevents retraction
- Phimosis/paraphimosis:
- Penile lymphedema, which can be related to insect bites, trauma, or allergic reactions
- Penile tourniquet syndrome: foreign body around penis, most commonly hair
- Anasarca
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
- Microbiology culture
- Wet mount
- Serology for syphilis
- Serum glucose; ESR (if concerns about Reiter syndrome)
- STD testing
- HIV testing
- Gram stain
Diagnostic Procedures/Other
Biopsy, if persistent
Pathologic Findings
Plasma cells infiltration with Zoon balanitis
TREATMENT
GENERAL MEASURES
- Consider circumcision for recurrent balanitis and paraphimosis.
- Warm compresses or sitz baths
- Local hygiene
MEDICATION
- Balanitis:
- Antifungal:
- Clotrimazole (Lotrimin) 1% BID
- Nystatin (Mycostatin) BID-QID
- Fluconazole: 150 mg PO single dose
- Antibacterial:
- Bacitracin QID
- Neomycin-polymyxin B-bacitracin (Neosporin) QID
- If cellulitis, cephalosporin or sulfa drug PO or parenteral:
- Dermatitis: topical steroids QID
- Zoon balanitis: topical steroids QID
- Phimosis:
- 0.05% fluticasone propionate daily for 4 to 8 weeks with gradual traction placed on foreskin (2)[B]
- 1% pimecrolimus BID for 4 to 6 weeks. Not for use in children <2 years (3)[C].
- Paraphimosis:
- Manual reduction, if possible (should be done with the patient sedated). Place the middle and index fingers of both hands on the engorged skin proximal to the glans. Place both thumbs on glans and, with gentle pressure, push on the glans and pull on the foreskin to attempt reduction. If unsuccessful, a dorsal slit will be necessary, with eventual circumcision after the edema resolves.
- Osmotic agents: granulated sugar placed on edematous tissue for several hours to reduce edema
- Puncture technique: Multiple punctures of foreskin with a 21-gauge needle will allow edematous fluid to escape and thus allow reduction.
- Dorsal slit; done by surgeon or urologist
- BXO:
- 0.05% betamethasone BID
- 0.1% tacrolimus BID
ISSUES FOR REFERRAL
Recurrent infections or development of meatal stenosis
SURGERY/OTHER PROCEDURES
- Balanitis and phimosis: consider circumcision as preventive measure.
- For paraphimosis:
- Represents a true surgical emergency to avoid necrosis of glans
- Dorsal slit with delayed circumcision, if reduction is not possible
- Operative exploration if the possibility of penile tourniquet syndrome cannot be eliminated. Hair removal cream can be applied if a hair is thought to be the cause of the tourniquet.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Uncontrolled diabetes
- Sepsis
Nursing
Appropriate hygiene if condom catheters are used
Discharge Criteria
Resolution of problem
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
Balanitis:
- Every 1 to 2 weeks until etiology has been established
- Persistent balanitis may require biopsy to rule out malignancy or BXO.
- Evaluation for resolution of phimosis
DIET
Weight reduction, if obese
PATIENT EDUCATION
- Need for appropriate hygiene
- Appropriate foreskin care
- Avoidance of known allergens
- No sexual activity for 2 to 3 weeks after circumcision
PROGNOSIS
Should resolve with appropriate treatment
COMPLICATIONS
- Meatal stenosis
- Premalignant changes from chronic irritation
- UTIs
- Acquired phimosis
- Unreducible paraphimosis can lead to gangrene
- Posthitis (inflammation of the prepuce)
REFERENCES
11 Oster J. Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child. 1968;43(228):200-203.22 Zavras N, Christianakis E, Mpourikas D, et al. Conservative treatment of phimosis with fluticasone proprionate 0.05%: a clinical study in 1185 boys. J Pediatr Urol. 2009;5(3):181-185.33 Georgala S, Gregoriou S, Georgala C, et al. Pimecrolimus 1% cream in non-specific inflammatory recurrent balanitis. Dermatology. 2007;215(3):209-212.
ADDITIONAL READING
- Kiss A, Csontai A, Pir ³t L, et al. The response of balanitis xerotica obliterans to local steroid application compared with placebo in children. J Urol. 2001;165(1):219-220.
- Palmer LS, Palmer JS. The efficacy of topical betamethasone for treating phimosis: a comparison of two treatment regimens. Urology. 2008;72(1):68-71.
- Pandher BS, Rustin MH, Kaisary AV. Treatment of balanitis xerotica obliterans with topical tacrolimus. J Urol. 2003;170(3):923.
- Stary A, Soeltz-Szoets J, Ziegler C, et al. Comparison of the efficacy and safety of oral fluconazole and topical clotrimazole in patients with candida balanitis. Genitourin Med. 1996;72(2):98-102.
SEE ALSO
Reactive Arthritis (Reiter Syndrome)
CODES
ICD10
- N48.1 Balanitis
- N47.1 Phimosis
- N48.0 Leukoplakia of penis
- N47.2 Paraphimosis
- N47.7 Other inflammatory diseases of prepuce
ICD9
- 607.1 Balanoposthitis
- 605 Redundant prepuce and phimosis
- 607.81 Balanitis xerotica obliterans
SNOMED
- 44882003 Balanitis (disorder)
- 449826002 Phimosis (disorder)
- 198033005 Balanitis xerotica obliterans
- 13758004 paraphimosis (disorder)
- 44318002 posthitis (disorder)
CLINICAL PEARLS
- Balanitis is an inflammation of the glans penis. Posthitis is an inflammation of the foreskin. BXO is lichen sclerosus of the glans penis.
- With recurrent infections and a plaque, a biopsy should be done to rule out BXO or malignancy.
- If there is a true phimosis that interferes with appropriate hygiene, treat the phimosis with steroids or circumcision to help with hygiene.