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Balanitis, Phimosis, and Paraphimosis

- Paraphimosis: - Uncircumcised - Pain - Drainage - Voiding difficulty

- 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

- 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

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  • 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 ringAcquired: 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 foreskinMorbid obesityPoor hygieneDiabetes; probably most commonNursing home environmentCondom cathetersChemical irritantsEdematous conditions: CHF, nephrosis
  • Phimosis:Poor hygieneDiabetes by repeated balanitisFrequent diaper rash in infantsRecurrent posthitis
  • Paraphimosis:Presence of foreskinInexperienced health care provider (leaving foreskin retracted after catheter placement)Poor education about care of the foreskin

GENERAL PREVENTION

  • Balanitis:Proper hygiene and avoidance of allergensCircumcision
  • Phimosis/Paraphimosis:If the patient is uncircumcised, appropriate hygiene and care of the foreskin are necessary to prevent phimosis and paraphimosis.

DIAGNOSIS

HISTORY

  • Balanitis:PainDrainageDysuriaOdorBallooning of foreskin with voidingRedness
  • Phimosis:Painful erectionsRecurrent balanitisForeskin balloons when voidingInability to retract foreskin at appropriate age
  • Paraphimosis:UncircumcisedPainDrainageVoiding difficulty

PHYSICAL EXAM

  • Balanitis:ErythemaTendernessEdemaDischargeUlcerationPlaque
  • Phimosis:Foreskin will not retract.Secondary balanitisPhysiologis phimosis-preputial orifice appears normal and healthyPathologic phimosis-preputial orifice has fine white fibrous ring of scar
  • Paraphimosis:Edema of prepuce and glansDrainageUlceration

DIFFERENTIAL DIAGNOSIS

  • Balanitis:LeukoplakiaLichen planusPsoriasisReiter syndromeLichen sclerosus et atrophicusErythroplasia of QueyratBXO: 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 reactionsPenile tourniquet syndrome: foreign body around penis, most commonly hairAnasarca

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% BIDNystatin (Mycostatin) BID-QIDFluconazole: 150 mg PO single dose
  • Antibacterial:Bacitracin QIDNeomycin-polymyxin B-bacitracin (Neosporin) QIDIf cellulitis, cephalosporin or sulfa drug PO or parenteral:Dermatitis: topical steroids QIDZoon 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 BID0.1% 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 glansDorsal slit with delayed circumcision, if reduction is not possibleOperative 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.