Balanoposthitis, characterized by the inflammation of the glans penis and prepuce, is a frequently encountered condition in uncircumcised males, spanning both pediatric and adult populations. Its prevalence can reach up to 20%, presenting as inflammation of the foreskin and penile head, leading to considerable discomfort and potential health issues. While typically benign, neglecting balanoposthitis can lead to complications. Common causes include inadequate hygiene, irritants, infections, and, in some instances, sexually transmitted infections. Notably, about one-third of cases lack a definitive etiology even after thorough investigation. Initial management often involves empiric approaches like sitz baths, gentle cleansing, and topical treatments. However, if these initial strategies fail, further examination for unusual infections or underlying malignancies may be necessary. Early and accurate Balanoposthitis Diagnosis, coupled with prompt intervention, is critical in minimizing the impact of this condition, emphasizing the need for comprehensive patient education on hygiene, safe sexual practices, and regular medical evaluations.
For healthcare providers, a detailed understanding of balanoposthitis is crucial for effective patient care. This educational resource aims to provide clinicians with an in-depth knowledge of balanoposthitis diagnosis, evaluation, and the differentiation from other conditions presenting with similar symptoms. It will guide healthcare professionals in developing tailored management plans based on the identified underlying cause, utilizing treatments such as topical antifungal, antibiotic, or corticosteroid therapies as needed. Furthermore, this guide underscores the importance of educating patients to prevent recurrence and improve overall outcomes. An interprofessional team approach is highlighted as essential for enhancing patient care, integrating diverse expertise and perspectives. Through improved communication and collaboration among healthcare team members, we can optimize patient outcomes, reduce complications, and enhance the quality of life for individuals affected by balanoposthitis.
Objectives:
- Recognize the etiology and epidemiology of balanoposthitis to improve diagnostic accuracy and deliver appropriate patient care.
- Differentiate balanoposthitis from other conditions that share similar clinical presentations, ensuring accurate balanoposthitis diagnosis.
- Determine and implement etiology-specific treatments for balanoposthitis as part of a comprehensive patient care strategy.
- Foster effective interprofessional collaboration and communication to improve treatment outcomes, prevent recurrence, and enhance the quality of life for patients diagnosed with balanoposthitis.
Introduction
Balanoposthitis is a prevalent condition, especially among uncircumcised pediatric and adult males, involving inflammation of both the glans penis and the prepuce. The origins of balanoposthitis are diverse, generally categorized as infectious, irritative, or traumatic. It’s important to distinguish balanoposthitis from balanitis, which specifically refers to glans penis inflammation, and posthitis, which indicates prepuce inflammation. This discussion will center on balanoposthitis diagnosis and management. For detailed information on balanitis, refer to the StatPearls’ companion resource on “Balanitis.”[1]
At birth, the prepuce, commonly known as the foreskin, is naturally adhered to the glans. These adhesions are non-pathological and cause physiological phimosis, a reduced ability to retract the foreskin in newborns. Typically, these neonatal adhesions and phimosis resolve by adolescence. Research by Hsieh et al. indicated that 17.1% of boys in first grade exhibited physiologic phimosis, which decreased to 1.2% by seventh grade in a study of healthy children in Taiwan.[2] “Pathologic phimosis,” in contrast, refers to the inability to retract the foreskin due to prepuce scarring.[3]
Etiology
The most frequent underlying cause of balanoposthitis is poor hygiene, often leading to nonspecific balanoposthitis. Other factors include infections, inflammatory skin conditions, trauma, persistent edema, and cancer. Patients with a history of frequent genital washing and recurring issues are more likely to suffer from contact dermatitis. In approximately one-third of balanoposthitis cases, the precise underlying cause cannot be identified.[4] Therefore, accurate balanoposthitis diagnosis often involves ruling out various potential causes.
Infectious agents are the most commonly identified etiology in balanoposthitis diagnosis, with Candida albicans being the most frequently detected pathogen, followed by Streptococcus.[5] Candidal infections are particularly prevalent in children and may also be associated with diaper rash in infants. Other infectious causes include Staphylococcus aureus, Group A Streptococcus, Bacteroides, Gardnerella, anaerobic bacteria, syphilis, and human papillomavirus (HPV).[6][7][8] A thorough balanoposthitis diagnosis will consider these infectious agents, especially when clinical signs point towards an infection.
Inflammatory etiologies include contact dermatitis, reactive arthritis, and lichen sclerosus (balanitis xerotica obliterans.)[[9]](#article-18122.r9] Detailed information can be found in StatPearls’ companion topics “Lichen Sclerosus” and “Balanitis Xerotica Obliterans.”[10][11] Reactions to antiseptic solutions used by patients performing intermittent self-catheterizations have also been documented.[12] In older men, common causes include intertrigo, contact irritants, and fungal infections. Balanoposthitis diagnosis in these cases requires careful consideration of these inflammatory and irritant factors.
Epidemiology
Balanoposthitis is a relatively common condition affecting both children and adults. The prevalence among males of all ages ranges from 12% to 20%.[13] Pediatric patients typically present between 2 to 5 years of age, likely due to a combination of physiologic phimosis and developing hygiene habits. Among adults, uncircumcised men with diabetes mellitus are at the highest risk, with a prevalence around 35%.[14][15] Meta-analyses have demonstrated that circumcision reduces the prevalence of inflammatory conditions of the glans penis by 68%. Understanding these epidemiological factors is important for balanoposthitis diagnosis and risk assessment.
Pathophysiology
The pathophysiologic mechanisms of balanoposthitis are diverse and depend on the underlying cause. These mechanisms can be infectious, autoimmune, trauma-induced, or malignancy-related. Irritants and allergens are also common triggers, causing nonspecific inflammation that leads to erythema and pruritus. Most cases of balanoposthitis begin with moisture, such as urine, sweat, or smegma (natural secretions from genital sebaceous glands and shed epithelial cells), becoming trapped in the preputial space due to adhesions, phimosis, or poor hygiene. This creates an environment conducive to bacterial and fungal growth. Balanoposthitis diagnosis often requires identifying these initiating factors to guide appropriate treatment.
History and Physical
Balanoposthitis can manifest with various symptoms, including penile pain, itching (pruritus), discharge, redness (erythema), rash, or unexplained crying in infants. By definition, balanoposthitis affects only uncircumcised individuals. A key aspect of balanoposthitis diagnosis is recognizing these characteristic signs. The typical examination finding is a moist, erythematous, macular lesion on the glans and foreskin. Erythema is frequently observed and often described as blotchy. Small papules, sometimes eroded, may also be present. In some instances, balanoposthitis can appear as a dull, dry, reddish plaque with a glazed or waxy texture.[16] Yellowish or even black discoloration may occasionally be noted.
Balanoposthitis is more prevalent in patients with poor genital hygiene and can occur with or without phimosis. Depending on the underlying cause and severity, the prepuce may exhibit scarring, the patient might experience difficulty voiding, have a weak urinary stream, present with genital ulcers, phimosis with or without skin splitting, rashes, urethral discharge, and other lesions. A thorough history and physical examination are crucial components of balanoposthitis diagnosis.
Evaluation
In the majority of balanoposthitis cases, a detailed medical history and physical examination are sufficient for balanoposthitis diagnosis and to establish a treatment plan. The history should cover symptom duration, hygiene practices, potential infectious exposures, allergens, and sexual behaviors. The physical examination should focus on general hygiene, the presence of phimotic or urethral discharge, urinary retention, erythema, edema, tenderness, scarring, inguinal lymphadenitis, and testicular edema or tenderness.
Physiologic preputial smegma can be mistaken for urethral discharge. True discharge is typically more exudative, may have a foul odor, and is often associated with erythema and tenderness. When indicated in balanoposthitis diagnosis, fungal (Candida) and bacterial cultures should be collected from under the foreskin.[16] Culturing for group A beta-hemolytic Streptococcus may be necessary in both adult and pediatric patients.
Penile ulcers, vesicles, urethral discharge, and other lesions suggest sexually transmitted infections as the cause, necessitating appropriate testing. If a sexually transmitted disease is suspected in balanoposthitis diagnosis, cultures and nucleic acid amplification tests (NAATs) for gonorrhea and chlamydia should be performed for definitive diagnosis. NAATs for Trichomonas vaginalis should also be considered, especially in cases unresponsive to initial treatment.[16] If ulcers are present, NAATs or similar tests for herpes simplex virus and syphilis testing are warranted.
For children without suspicion of sexual abuse, and in the absence of lesions or discharge, empirical management is appropriate without further testing. Otherwise, additional evaluation should be guided by other symptoms and exposure history. In new balanoposthitis cases, particularly fungal etiologies in older children, diabetes evaluation is essential as it may be an initial sign of hyperglycemia and glycosuria.[14] While most cases respond to improved hygiene or empiric treatment, patients with recurrent or treatment-resistant symptoms after 4 weeks may require a biopsy to further investigate the etiology and pathology, and potentially circumcision.[16][[17]](#article-18122.r17] Therefore, a systematic approach to evaluation is key to accurate balanoposthitis diagnosis.
Treatment / Management
Most balanoposthitis cases improve with enhanced hygiene or empiric treatment. Ideally, balanoposthitis treatment should be based on identifying the specific causative agent. When this is not possible, empiric therapy should target the most likely etiologies and follow general therapeutic principles.
General empiric therapy for balanoposthitis typically includes:
- Avoiding irritants: Eliminate exposure to known or potential penile irritants. Soap, even gentle baby soap, can be irritating and should not be used under the foreskin. Antibacterial and fragranced soaps, as well as those with unnecessary chemicals, should be avoided.
- Eliminating potential irritating agents: Avoid detergents, perfumes, talc powder, bubble baths, alcohol, adult or baby wipes, antiseptics, sexual lubricants, spermicides, moisturizers, ointments, and creams unless specifically prescribed.
- Caution with topical agents: Creams or ointments containing parabens and neomycin should be avoided as they may cause inflammatory reactions in some individuals.
- Abstinence from sexual activity: Refrain from sexual activity until balanoposthitis is fully resolved.
- Gentle cleaning: Cleanse the area passively with warm sitz baths two to three times daily, or more frequently for severe cases. Sitz baths are also anti-inflammatory. A dilute salt solution is recommended.
- Careful cleansing under the foreskin: If needed, gently clean beneath the foreskin using a cotton swab and water.[18]
- Irrigation for phimosis: If phimosis prevents access to the glans, gentle irrigation with warm water can be performed using a small 5 or 8-French straight catheter or feeding tube inserted through the foreskin lumen.[19]
- Proper hygiene education: Educate patients on proper foreskin hygiene. Routine cleaning should be done with water, and the area should be thoroughly dried before replacing the foreskin over the glans. Full retraction for cleaning should only be attempted if it is easy and painless.
Topical empiric treatments for balanoposthitis include antibiotics (bacitracin, metronidazole, mupirocin, or bacitracin/polymyxin B), antifungals (clotrimazole 1% cream), and low-potency corticosteroids (1% hydrocortisone).[20][21] Metronidazole is effective against anaerobic bacteria, fungi, and protozoa.[22] In cases presenting with phimosis severe enough to cause urinary obstruction, urgent catheterization is necessary. If catheterization is not possible, more invasive interventions like a dorsal slit may be required. Circumcision can be postponed until preputial edema and inflammation subside.[23][24] Appropriate treatment strategies are determined following balanoposthitis diagnosis.
Malignant and premalignant penile lesions, such as Buschke-Lowenstein tumor (giant condyloma), cutaneous penile horn, leukoplakia, lichen sclerosus, and pseudoepitheliomatous keratotic and micaceous balanitis, are detailed in StatPearls’ companion topic “Penile Cancer.”[25] Penile intraepithelial neoplasia (previously known as Bowen disease, bowenoid papulosis, Erythroplasia of Querat, and squamous cell carcinoma in situ of the penis), HPV-related premalignant lesions, are also discussed in the “Penile Cancer” StatPearls resource.[25] Differential balanoposthitis diagnosis must exclude these malignant conditions.
Guideline for Etiology-Specific Balanoposthitis Treatment
Amebiasis: Though rare, amebiasis should be considered in balanoposthitis resistant to initial antibiotic therapy, particularly in men who have sex with men and immunocompromised individuals. Diagnosis is by biopsy, as clinical presentation is nonspecific. Microscopic examination of the biopsy specimen revealing trophozoites is diagnostic. Treatment is with metronidazole, with emetine as an alternative for metronidazole failures (though no longer available in the US due to toxicity).[26][27] Accurate balanoposthitis diagnosis guides targeted treatment.
Anaerobic bacterial infections: Suspect anaerobic infections in cases with erythema, edema, and foul-smelling exudate or discharge. Superficial erosions may be present, and severe cases may involve lymphadenopathy. Diagnosis is confirmed by culturing the exudate or discharge. Mild cases respond to topical metronidazole, while severe cases require oral antibiotics (metronidazole 400 mg to 500 mg twice daily or 15 to 35 mg/kg per day in divided doses) for 7 days. Amoxicillin-clavulanate or clindamycin are acceptable alternatives. Circumcision may be considered for recurrent or resistant cases.[16] Identifying the etiology is crucial for effective balanoposthitis diagnosis and treatment.
Bacterial balanoposthitis: Suspect bacterial balanoposthitis with intense erythema and transudative or exudative preputial discharge. Definitive diagnosis relies on culture. Erythema and edema can vary in severity.[16] Streptococcus pyogenes and Staphylococcus aureus are common aerobic bacterial causes. Mild cases can be treated with topical antibiotics like mupirocin 2% cream three times daily for 7 to 14 days. Severe cases, or when phimosis hinders topical treatment, require oral antibiotics for at least a week, such as cephalexin or erythromycin, or based on culture results.[20] Concomitant group A Streptococcal pharyngitis is treated as pharyngitis with a beta-lactam. Balanoposthitis diagnosis directs appropriate antibiotic selection.
Balanitis circumscripta plasmacellularis (Zoon balanitis, plasma cell balanitis): This benign condition presents as well-defined, shiny, orange-reddish areas on the glans and inner foreskin surface, often with symmetrically distributed tiny red spots and associated with other skin pathologies.[16][28] Primary treatment is circumcision, but alternatives include:
- Circumcision (typically resolves and cures the lesion)
- General hygiene measures
- Laser ablation
- Topical antibiotic cream (Mupirocin 2% ointment) twice daily
- Topical calcineurin inhibitor cream (pimecrolimus 1%) twice daily (potential malignancy risk)
- Topical high-potency steroids (clobetasone)
- Treatment of underlying dermatoses[29][30][31][32][33][34][35][36][37] Balanoposthitis diagnosis differentiates Zoon balanitis from other inflammatory conditions.
Candidal infections: The most common cause of balanoposthitis, particularly in children.[16] Often linked to diaper rash in infants (see StatPearls’ “Diaper Dermatitis”).[38] Classic presentation: erythematous rash with satellite lesions tender to palpation. In adults, it may be associated with diabetes mellitus, older age, immunosuppression, or broad-spectrum antibiotic use.[16][39] Potassium hydroxide (KOH) slide preparation aids in direct visualization and diagnosis; fungal culture can further guide treatment. Topical therapy includes 0.25% miconazole cream at diaper changes for 7 days in infants. In adults, clotrimazole 1% or miconazole 2% cream twice daily for 2 to 4 weeks is preferred.[16] Nystatin cream 100,000 u/gram three times daily for 2 weeks is another topical option. Low-potency topical steroid cream (hydrocortisone 1%) twice daily can be added for significant inflammation. Severe cases may require oral fluconazole 150 mg in addition to topical therapy.[16][40] Balanoposthitis diagnosis of candidiasis informs antifungal treatment choices.
Circinate balanitis: Can occur alone, with HIV, or with reactive arthritis.[16] About 20% to 40% of uncircumcised men with reactive arthritis develop it. Appearance: whitish-grayish pale macules with white margins on the glans, possibly coalescing into a single irregular lesion with a white margin. Usually associated with eye, joint, and skin problems, but not always required.[16][41] (See StatPearls’ “Reactive Arthritis”).[41] Differential balanoposthitis diagnosis should include reactive arthritis and STIs like syphilis.[42][[43]](#article-18122.r43] Positive human leukocyte antigen B27 blood test supports reactive arthritis diagnosis.[41][44] Treatment involves managing underlying conditions and mild to moderate topical steroids, such as 1% hydrocortisone twice daily for 1 to 2 weeks.[16]
Fixed drug eruptions: Uncommon on the penis, appearing after using certain medications (tetracyclines, phenolphthalein, phenacetin, paracetamol, NSAIDs, barbiturates, sulfa drugs) or intercourse with a partner on these medications.[45][46][47] Lesions are typically round, erythematous patches darkening with or without edema and vesicles.[45] Common locations are genitals or oral mucosa. Fixed drug eruptions resolve after discontinuing the medication and recur in the same location upon re-exposure. Drug challenge can confirm diagnosis (with allergist/dermatologist consultation due to potential severity). Skin testing is suggested before drug challenge.[16][48] Treatment: discontinue offending medication, mild to moderate potency steroid cream (hydrocortisone 1%) twice daily for 1 to 2 weeks. Severe eruptions may rarely need systemic steroids.[16] Balanoposthitis diagnosis in these cases involves a detailed medication history.
Irritative balanoposthitis: More common in atopic dermatitis patients, often due to frequent or aggressive washing with soap.[9] Presents as mild erythema with or without pruritus. Managed by avoiding strong soaps and using emollients like petroleum jelly multiple times daily. Investigate and avoid potential allergens (latex condoms, lubricants, detergents). Topical hydrocortisone 1% is an option, applied thinly twice daily for 1 to 2 weeks. Balanoposthitis diagnosis focuses on identifying irritants and managing symptoms.
Lichen planus: Inflammatory skin disorder, idiopathic etiology, possibly T-cell-mediated autoimmune, linked to hepatitis C and drugs (ACE inhibitors, beta-blockers, NSAIDs, thiazide diuretics). Presentation: purplish plaques or scales with defined margins on penile exterior epithelium; mucosal surfaces may show annular or erosive lesions.[16][49] Exterior epithelial dermatoses usually resolve spontaneously in 18 months, but mucosal lesions tend to be intermittent and recurrent.[16] Lichen planus is benign, rarely premalignant.[50] Initial therapy: high-potency topical steroids, or calcineurin inhibitor creams. Cyclosporine may be considered for erosive lesions.[16][49][51][52][53][54][55][56] Steroids and circumcision can be considered in severe cases.[16][56][57] Balanoposthitis diagnosis includes differentiating lichen planus from other skin conditions.
Lichen sclerosus: Inflammatory skin condition of male genitalia, worsened by prolonged urine contact in uncircumcised males.[58] Common cause/contributor to childhood balanoposthitis. Predisposing factors: male genital abnormalities (hypospadias), obesity, urological surgery.[16] Rare in neonatally circumcised men.
Lichen sclerosus begins as itchy white discoloration on foreskin/glans mucosa, initially mottled/diffuse, then coalescing. Skin loses elasticity, becoming sore and brittle.[59] Symptoms: adhesions around corona, coronal sulcus changes, frenulum abnormalities, hemorrhagic blisters, hyperpigmentation of preputial skin edges/meatus, itching, lichenoid/Zoonoid inflammation, meatal stenosis/thickening, post-void dribbling, scarring, skin splitting, soreness, urinary problems.[10][11][16][60]
Lichen sclerosus is linked to urethral strictures, meatal stenosis, phimosis, paraphimosis, penile intraepithelial neoplasia, and penile cancer (along with HPV).[11][16] Biopsy is suggested due to squamous cell carcinoma link.[59] Balanoposthitis diagnosis in lichen sclerosus cases often requires biopsy for confirmation.
Treatment includes:
- High-potency (clobetasone) topical steroid cream twice daily for up to 30 days. If unsuccessful/recurrent, circumcision is recommended over prolonged/intermittent steroid use (caution in genital warts history due to relapse risk).
- Regular topical skin barrier to urine (petroleum jelly).
- Remove genital jewelry.
- Wash without irritating soap.
- Weight loss.
- Meatotomy or meatal dilation.
- Circumcision, especially for intractable/recurrent cases.[16][59]
(See StatPearls’ “Lichen Sclerosus” and “Balanitis Xerotica Obliterans”).[10][11]
Nonspecific balanoposthitis: Most common type in children, usually due to poor hygiene. May have preputial discharge, but no urethral drainage, ulcers, or discrete lesions. Urethral discharge assessment via milking urethra from base to glans.
Diagnosis of exclusion: unresponsive to antifungals/high-potency topical steroids, negative tests for bacteria, candida, chlamydia, gonorrhea, herpes simplex, HPV, syphilis, trichomonas. Biopsy histology nonspecific.
Treatment: gentle cleaning 2 to 3 times daily. Avoid forceful prepuce retraction in physiologic phimosis. If foreskin easily retractable, clean gently with cotton swab. Proper hygiene usually resolves symptoms in 5 to 7 days. If not, circumcision is definitive therapy.[16] Balanoposthitis diagnosis of nonspecific type is made after ruling out other causes.
Sexually transmitted infections: May present with urethral drainage when milking penis. Prompt evaluation and treatment for STIs (gonorrhea, chlamydia).[18] Consider sexual abuse in children with urethral discharge or STI diagnosis.
Neisseria gonorrhea or Chlamydia trachomatis treatment: single dose ceftriaxone 250 mg IM and single oral 1-gram azithromycin. Painless ulcer suggests syphilis, treated with benzathine penicillin G 50,000 units/kg up to 2.4 million units IM once. Trichomonas vaginalis diagnosed by NAAT, treated with metronidazole 2 grams oral single dose.[61][62] Balanoposthitis diagnosis should include STI screening in relevant cases.
Viral balanoposthitis: Includes herpes simplex virus and human papillomavirus (HPV).
Herpes simplex: erythematous base with overlying vesicles that may rupture. Diagnosis by NAAT or similar testing. First episode treated with oral acyclovir for 7 to 10 days; recurrent episodes need 5-day treatment.[63][[64]](#article-18122.r64] HPV: may present as diffuse erythema. Lichenification, genital warts, irregular borders suggest HPV, often associated with balanoposthitis. 5% acetic acid solution gauze pad for 3-5 minutes turns HPV-infected tissues white (sensitive and specific test).[65] Treatment: topical podophyllotoxin 0.5% gel twice daily for 3 days, weekly for up to 4 weeks. Alternatives: topical imiquimod, sinecatechins 15% ointment, trichloracetic acid, oral isotretinoin. Surgery, laser therapy, photodynamic therapy, cryotherapy also options. (See StatPearls’ “Genital Warts”).[[66]](#article-18122.r66] Circumcision considered for intractable/recurrent cases.[16] Viral studies are part of the comprehensive balanoposthitis diagnosis.
Differential Diagnosis
The most critical differential diagnosis in balanoposthitis is squamous cell carcinoma of the penis. Squamous cell carcinoma initially presents as a painless, asymmetrical, irregular ulcer or nodule, which may become painful or tender later.[25] Definitive diagnosis requires biopsy. (See StatPearls’ “Penile Cancer”).[[25]](#article-18122.r25] Balanoposthitis diagnosis must always consider and rule out penile cancer.
Penile intraepithelial neoplasia is often associated with HPV.[25] (See StatPearls’ “Penile Cancer”).[[25]](#article-18122.r25]
Additional differential diagnoses for balanoposthitis include:
- Balanitis
- Balanitis circumscripta plasmacellularis (Zoon balanitis, plasma cell balanitis)
- Circinate balanitis
- Contact dermatitis
- Diaper dermatitis
- Discoid (nummular) eczema
- Fixed drug eruption
- Human papillomavirus
- Intertrigo
- Lichen planus
- Lichen sclerosus, also known as balanitis xerotica obliterans
- Mondor phlebitis (disease) of the penis
- Penile intraepithelial neoplasia (Bowen disease, bowenoid papulosis, Erythroplasia of Queryat, squamous cell carcinoma in situ)
- Psoriasis
- Reactive arthritis
- Squamous cell carcinoma
- Stevens-Johnson Syndrome
- Urethritis
Prognosis
The prognosis for balanoposthitis is generally favorable. Most patients without a clear infectious cause respond to hygiene changes and empiric emollient therapy within one to two weeks.[67] However, about 10% of patients experience symptom recurrence, necessitating further evaluation and targeted management.[9] Accurate balanoposthitis diagnosis is key to a good prognosis.
Complications
Patients with recurrent or treatment-resistant symptoms after four weeks, especially with pathologic phimosis or urinary obstruction, should be considered for biopsy to further investigate the condition. Circumcision or a 1 cm wedge biopsy of the affected area is needed for pathologic diagnosis and histologic grading. Refractory cases may indicate cancerous or precancerous lesions, including balanitis xerotica obliterans, amebiasis, or squamous cell carcinoma.[68][[69]](#article-18122.r69] These can be missed without histopathologic examination.[70] Timely balanoposthitis diagnosis and follow-up can prevent serious complications.
Deterrence and Patient Education
Clinicians and healthcare staff must educate patients and families on proper preputial hygiene for both prevention and treatment of balanoposthitis.
Proper hygiene includes gentle cleaning 2 to 3 times daily. Avoid forceful prepuce retraction in physiologic phimosis. For retractable foreskins, clean with a cotton swab. Strong or scented soaps should be avoided due to irritation.
Investigating and avoiding other potential irritants can also significantly improve symptoms.
Circumcision is considered a prophylactic measure against balanoposthitis.[13][16][[71]](#article-18122.r71] Patient education is an integral part of balanoposthitis diagnosis and management.
Pearls and Other Issues
Prevention
Balanoposthitis prevention starts with establishing good hygiene, including routine washing, avoiding forceful foreskin retraction, aggressive scrubbing under the prepuce in young boys with physiologic phimosis, and avoiding strong soaps and detergents.
Circumcision is another preventive measure. While neonatal circumcision recommendations are debated, research shows it prevents penile dermatosis, UTIs, penile cancer, and STIs like HIV, HPV, and syphilis.[69][72][[73]](#article-18122.r73] (See StatPearls’ “Circumcision”).[[73]](#article-18122.r73]
Conflicting data exists on whether circumcision prevents balanitis versus balanoposthitis in uncircumcised patients.[72][[74]](#article-18122.r74] However, meta-analysis indicates inflammatory glans penis conditions are 3.1 times more prevalent in uncircumcised males.[75]
Avoiding high-risk sexual behavior can prevent balanoposthitis by reducing STI risk (syphilis, herpes simplex virus, HPV).
Disposition
Most patients without infectious etiology improve with hygiene changes and empiric emollients within one to two weeks. About 10% will have recurrent symptoms, needing further evaluation and targeted management.[9] Cases not resolving with standard therapy after 30 days warrant further evaluation, such as NAAT testing for herpes and trichomonas, candidal cultures, and serum syphilis screening. If negative, biopsy or circumcision should be considered for possible malignancy, amebiasis, etc. Patients with recurrent or refractory symptoms after four weeks, and pathologic phimosis or urinary obstruction, need biopsy and/or circumcision.
Biopsy is warranted for refractory cases to investigate potential malignancy or premalignant lesions.[16] These may include squamous cell carcinoma, Erythroplasia of Queryat, Bowen disease, or penile intraepithelial neoplasia.[25][68][[69]](#article-18122.r69] Histopathologic examination is crucial as these can often be missed clinically.[25][70] Appropriate disposition and follow-up are essential after balanoposthitis diagnosis.
Circumcision or a 1 cm wedge biopsy of the affected area should be performed to obtain pathologic diagnosis and histologic grade.[69]
Enhancing Healthcare Team Outcomes
Effective balanoposthitis management requires an interprofessional healthcare approach to improve patient outcomes and safety. Strong communication within the team is crucial. Detailed documentation improves communication and reduces redundant testing, unnecessary antibiotics, and loss of follow-up.
Nurses can enhance patient education, clarify hygienic care, prescriptions, and the importance of follow-up. Pharmacists verify proper dosing, administration, and medication compatibility, review prescriptions, check for drug interactions, and counsel patients and families.
Early urological consultation may be needed in refractory or urgent cases to minimize complications.
The interprofessional team includes primary care physicians, pediatricians, general and pediatric urologists, dermatologists, infectious disease specialists, nurses, and pharmacists, with the patient and family as integral members.
Clear explanation of diagnosis, likely causes, treatment options, complications, follow-up importance, and detailed home management instructions improves compliance, patient care, outcomes, and quality of life. Effective interprofessional collaboration is vital for optimal balanoposthitis diagnosis and management.
Review Questions
Figure
Candidal balanoposthitis in a diabetic, penis Contributed by Dr. Shyam Verma, MBBS, DVD, FRCP, FAAD, Vadodara, India
References
1.Wray AA, Velasquez J, Leslie SW, Khetarpal S. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 31, 2024. Balanitis. [PubMed: 30725828]
2.Hsieh TF, Chang CH, Chang SS. Foreskin development before adolescence in 2149 schoolboys. Int J Urol. 2006 Jul;13(7):968-70. [PubMed: 16882064]
3.McGregor TB, Pike JG, Leonard MP. Pathologic and physiologic phimosis: approach to the phimotic foreskin. Can Fam Physician. 2007 Mar;53(3):445-8. [PMC free article: PMC1949079] [PubMed: 17872680]
4.Fornasa CV, Calabrŏ A, Miglietta A, Tarantello M, Biasinutto C, Peserico A. Mild balanoposthitis. Genitourin Med. 1994 Oct;70(5):345-6. [PMC free article: PMC1195281] [PubMed: 8001949]
5.Lisboa C, Ferreira A, Resende C, Rodrigues AG. Infectious balanoposthitis: management, clinical and laboratory features. Int J Dermatol. 2009 Feb;48(2):121-4. [PubMed: 19200183]
6.Mainetti C, Scolari F, Lautenschlager S. The clinical spectrum of syphilitic balanitis of Follmann: report of five cases and a review of the literature. J Eur Acad Dermatol Venereol. 2016 Oct;30(10):1810-1813. [PubMed: 27421838]
7.Norimatsu Y, Ohno Y. Streptococcus pyogenes balanoposthitis. IDCases. 2020;21:e00832. [PMC free article: PMC7248656] [PubMed: 32477873]
8.Burdge DR, Bowie WR, Chow AW. Gardnerella vaginalis-associated balanoposthitis. Sex Transm Dis. 1986 Jul-Sep;13(3):159-62. [PubMed: 3490001]
9.Edwards SK, Bunker CB, Ziller F, van der Meijden WI. 2013 European guideline for the management of balanoposthitis. Int J STD AIDS. 2014 Aug;25(9):615-26. [PubMed: 24828553]
10.Chamli A, Souissi A. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 31, 2023. Lichen Sclerosus. [PubMed: 30855834]
11.Carocci K, Leslie SW, Hughes EC, McIntosh GV. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Oct 29, 2024. Balanitis Xerotica Obliterans (Male Penile Lichen Sclerosus) [PubMed: 33620847]
12.Satoji Y, Tobu S, Matsushita K, Udo K, Noguchi M. Benzalkonium chloride induced corrosive balanoposthitis in a man requiring clean intermittent catheterization. IJU Case Rep. 2021 Mar;4(2):101-103. [PMC free article: PMC7924081] [PubMed: 33718817]
13.Morris BJ, Krieger JN. Penile Inflammatory Skin Disorders and the Preventive Role of Circumcision. Int J Prev Med. 2017;8:32. [PMC free article: PMC5439293] [PubMed: 28567234]
14.Verma SB, Wollina U. Looking through the cracks of diabetic candidal balanoposthitis! Int J Gen Med. 2011;4:511-3. [PMC free article: PMC3150172] [PubMed: 21845057]
15.Bromage SJ, Crump A, Pearce I. Phimosis as a presenting feature of diabetes. BJU Int. 2008 Feb;101(3):338-40. [PubMed: 18005214]
16.Edwards SK, Bunker CB, van der Snoek EM, van der Meijden WI. 2022 European guideline for the management of balanoposthitis. J Eur Acad Dermatol Venereol. 2023 Jun;37(6):1104-1117. [PubMed: 36942977]
17.Guliani A, Kumar S, Aggarwal D, Kumaran MS. Genital Lichen Sclerosus Et Atrophicus: A Benign Skin Disorder With Malignant Aftermath. Urology. 2018 Jul;117:e7-e8. [PubMed: 29729359]
18.Schwartz RH, Rushton HG. Acute balanoposthitis in young boys. Pediatr Infect Dis J. 1996 Feb;15(2):176-7. [PubMed: 8822297]
19.Leslie JA, Cain MP. Pediatric urologic emergencies and urgencies. Pediatr Clin North Am. 2006 Jun;53(3):513-27, viii. [PubMed: 16716794]
20.Pandya I, Shinojia M, Vadukul D, Marfatia YS. Approach to balanitis/balanoposthitis: Current guidelines. Indian J Sex Transm Dis AIDS. 2014 Jul-Dec;35(2):155-7. [PMC free article: PMC4553848] [PubMed: 26396455]
21.Waugh MA, Evans EG, Nayyar KC, Fong R. Clotrimazole (Canesten) in the treatment of candidal balanitis in men. With incidental observations on diabetic candidal balanoposthitis. Br J Vener Dis. 1978 Jun;54(3):184-6. [PMC free article: PMC1045486] [PubMed: 656891]
22.Weir CB, Le JK. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jun 26, 2023. Metronidazole. [PubMed: 30969550]
23.Thiruchelvam N, Nayak P, Mostafid H. Emergency dorsal slit for balanitis with retention. J R Soc Med. 2004 Apr;97(4):205-6. [PMC free article: PMC1079370] [PubMed: 15056750]
24.Wiswell TE, Tencer HL, Welch CA, Chamberlain JL. Circumcision in children beyond the neonatal period. Pediatrics. 1993 Dec;92(6):791-3. [PubMed: 8233738]
25.Engelsgjerd JS, Leslie SW, LaGrange CA. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Sep 2, 2024. Penile Cancer and Penile Intraepithelial Neoplasia. [PubMed: 29763105]
26.Hejase MJ, Bihrle R, Castillo G, Coogan CL. Amebiasis of the penis. Urology. 1996 Jul;48(1):151-4. [PubMed: 8693642]
27.Rafael Ríos-Burgueño E, Velarde-Félix JS, Flores García A. Penile amebiasis mimicking penile squamous cell carcinoma. Int J Dermatol. 2017 May;56(5):573-575. [PubMed: 28083900]
28.Bunker CB. Zoon balanitis-does it exist? J Eur Acad Dermatol Venereol. 2020 Mar;34(3):e116-e117. [PubMed: 31660645]
29.Tang A, David N, Horton LW. Plasma cell balanitis of Zoon: response to Trimovate cream. Int J STD AIDS. 2001 Feb;12(2):75-8. [PubMed: 11236107]
30.Weyers W, Ende Y, Schalla W, Diaz-Cascajo C. Balanitis of Zoon: a clinicopathologic study of 45 cases. Am J Dermatopathol. 2002 Dec;24(6):459-67. [PubMed: 12454596]
31.Cohen PR. Topical mupirocin 2% ointment for diagnosis of Zoon’s balanitis and monotherapy of balanitis circumscripta plasmacellularis. Int J Dermatol. 2019 Jun;58(6):e114-e115. [PubMed: 30604433]
32.Bari O, Cohen PR. Successful Management of Zoon’s Balanitis with Topical Mupirocin Ointment: A Case Report and Literature Review of Mupirocin-Responsive Balanitis Circumscripta Plasmacelluaris. Dermatol Ther (Heidelb). 2017 Jun;7(2):203-210. [PMC free article: PMC5453920] [PubMed: 28382428]
33.Roé E, Dalmau J, Peramiquel L, Pérez M, López-Lozano HE, Alomar A. Plasma cell balanitis of zoon treated with topical tacrolimus 0.1%: report of three cases. J Eur Acad Dermatol Venereol. 2007 Feb;21(2):284-5. [PubMed: 17243988]
34.Bardazzi F, Antonucci A, Savoia F, Balestri R. Two cases of Zoon’s balanitis treated with pimecrolimus 1% cream. Int J Dermatol. 2008 Feb;47(2):198-201. [PubMed: 18211499]
35.Kuiper JG, van Herk-Sukel MPP, Castellsague J, Pottegård A, Berglind IA, Dedman D, Gutierrez L, Calingaert B, Hallas J, Sundström A, Gallagher AM, Kaye JA, Pardo C, Rothman KJ, Perez-Gutthann S. Use of Topical Tacrolimus and Topical Pimecrolimus in Four European Countries: A Multicentre Database Cohort Study. Drugs Real World Outcomes. 2018 Jun;5(2):109-116. [PMC free article: PMC5984609] [PubMed: 29736842]
36.Retamar RA, Kien MC, Chouela EN. Zoon’s balanitis: presentation of 15 patients, five treated with a carbon dioxide laser. Int J Dermatol. 2003 Apr;42(4):305-7. [PubMed: 12694501]
37.Albertini JG, Holck DE, Farley MF. Zoon’s balanitis treated with Erbium:YAG laser ablation. Lasers Surg Med. 2002;30(2):123-6. [PubMed: 11870791]
38.Benitez Ojeda AB, Mendez MD. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 3, 2023. Diaper Dermatitis. [PubMed: 32644493]
39.Lisboa C, Santos A, Dias C, Azevedo F, Pina-Vaz C, Rodrigues A. Candida balanitis: risk factors. J Eur Acad Dermatol Venereol. 2010 Jul;24(7):820-6. [PubMed: 20002652]
40.Stary A, Soeltz-Szoets J, Ziegler C, Kinghorn GR, Roy RB. Comparison of the efficacy and safety of oral fluconazole and topical clotrimazole in patients with candida balanitis. Genitourin Med. 1996 Apr;72(2):98-102. [PMC free article: PMC1195616] [PubMed: 8698375]
41.Cheeti A, Chakraborty RK, Ramphul K. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jan 2, 2023. Reactive Arthritis. [PubMed: 29763006]
42.Kishimoto M, Mor A, Abeles AM, Solomon G, Pillinger MH, Lee MJ. Syphilis mimicking Reiter’s syndrome in an HIV-positive patient. Am J Med Sci. 2006 Aug;332(2):90-92. [PubMed: 16909057]
43.Tudor ME, Al Aboud AM, Leslie SW, Gossman W. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 17, 2024. Syphilis. [PubMed: 30521201]
44.Parameswaran P, Lucke M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 4, 2023. HLA-B27 Syndromes. [PubMed: 31855367]
45.Zhang J, Yang F, Wang M, Yang A, Zhang F, Xiao Y, Guan Y, Yu X. Fixed drug eruption-induced balanoposthitis: a case report. Int J Impot Res. 2024 Sep;36(6):553-555. [PubMed: 38145981]
46.Andreassi L, Bilenchi R. Non-infectious inflammatory genital lesions. Clin Dermatol. 2014 Mar-Apr;32(2):307-14. [PubMed: 24559568]
47.Flowers H, Brodell R, Brents M, Wyatt JP. Fixed drug eruptions: presentation, diagnosis, and management. South Med J. 2014 Nov;107(11):724-7. [PubMed: 25365443]
48.Maatouk I, Moutran R, Fahed M, Helou J. A “sexually transmitted” fixed drug reaction. Sex Transm Dis. 2014 Oct;41(10):626-7. [PubMed: 25211260]
49.Arnold DL, Krishnamurthy K. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Oct 29, 2024. Lichen Planus. [PubMed: 30252382]
50.Kristiansen S, Svensson Å, Drevin L, Forslund O, Torbrand C, Bjartling C. Risk Factors for Penile Intraepithelial Neoplasia: A Population-based Register Study in Sweden, 2000-2012. Acta Derm Venereol. 2019 Mar 01;99(3):315-320. [PubMed: 30426132]
51.Cheng S, Kirtschig G, Cooper S, Thornhill M, Leonardi-Bee J, Murphy R. Interventions for erosive lichen planus affecting mucosal sites. Cochrane Database Syst Rev. 2012 Feb 15;2012(2):CD008092. [PMC free article: PMC10794897] [PubMed: 22336835]
52.Husein-ElAhmed H, Gieler U, Steinhoff M. Lichen planus: a comprehensive evidence-based analysis of medical treatment. J Eur Acad Dermatol Venereol. 2019 Oct;33(10):1847-1862. [PubMed: 31265737]
53.Ioannides D, Vakirlis E, Kemeny L, Marinovic B, Massone C, Murphy R, Nast A, Ronnevig J, Ruzicka T, Cooper SM, Trüeb RM, Pujol Vallverdú RM, Wolf R, Neumann M. European S1 guidelines on the management of lichen planus: a cooperation of the European Dermatology Forum with the European Academy of Dermatology and Venereology. J Eur Acad Dermatol Venereol. 2020 Jul;34(7):1403-1414. [PubMed: 32678513]
54.Volz T, Caroli U, Lüdtke H, Bräutigam M, Kohler-Späth H, Röcken M, Biedermann T. Pimecrolimus cream 1% in erosive oral lichen planus–a prospective randomized double-blind vehicle-controlled study. Br J Dermatol. 2008 Sep;159(4):936-41. [PubMed: 18647310]
55.Petruzzi M, De Benedittis M, Pastore L, Grassi FR, Serpico R. Peno-gingival lichen planus. J Periodontol. 2005 Dec;76(12):2293-8. [PubMed: 16332242]
56.Jemec GB, Baadsgaard O. Effect of cyclosporine on genital psoriasis and lichen planus. J Am Acad Dermatol. 1993 Dec;29(6):1048-9. [PubMed: 8245246]
57.Porter WM, Dinneen M, Hawkins DA, Bunker CB. Erosive penile lichen planus responding to circumcision. J Eur Acad Dermatol Venereol. 2001 May;15(3):266-8. [PubMed: 11683298]
58.Bunker CB, Patel N, Shim TN. Urinary voiding symptomatology (micro-incontinence) in male genital lichen sclerosus. Acta Derm Venereol. 2013 Mar 27;93(2):246-8. [PubMed: 23093304]
59.Pugliese JM, Morey AF, Peterson AC. Lichen sclerosus: review of the literature and current recommendations for management. J Urol. 2007 Dec;178(6):2268-76. [PubMed: 17936829]
60.Singh JP, Priyadarshi V, Goel HK, Vijay MK, Pal DK, Chakraborty S, Kundu AK. Penile lichen sclerosus: An urologist’s nightmare! – A single center experience. Urol Ann. 2015 Jul-Sep;7(3):303-8. [PMC free article: PMC4518363] [PubMed: 26229314]
61.Garcia MR, Leslie SW, Wray AA. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Apr 20, 2024. Sexually Transmitted Infections. [PubMed: 32809643]
62.Schumann JA, Plasner S. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jun 12, 2023. Trichomoniasis. [PubMed: 30521247]
63.Saleh D, Yarrarapu SNS, Sharma S. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 28, 2023. Herpes Simplex Type 1. [PubMed: 29489260]
64.Mathew Jr J, Sapra A. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Mar 13, 2024. Herpes Simplex Type 2. [PubMed: 32119314]
65.Kumar B, Gupta S. The acetowhite test in genital human papillomavirus infection in men: what does it add? J Eur Acad Dermatol Venereol. 2001 Jan;15(1):27-9. [PubMed: 11451317]
66.Leslie SW, Sajjad H, Kumar S. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): May 30, 2023. Genital Warts. [PubMed: 28722914]
67.Zundel S, Ellerkamp V. Balanoposthitis in children: Analysis of treatment diversity and development of a treatment proposal. J Pediatr Urol. 2024 Jun;20(3):480.e1-480.e6. [PubMed: 38461077]
68.Gargollo PC, Kozakewich HP, Bauer SB, Borer JG, Peters CA, Retik AB, Diamond DA. Balanitis xerotica obliterans in boys. J Urol. 2005 Oct;174(4 Pt 1):1409-12. [PubMed: 16145451]
69.Micali G, Nasca MR, Innocenzi D, Schwartz RA. Penile cancer. J Am Acad Dermatol. 2006 Mar;54(3):369-91; quiz 391-4. [PubMed: 16488287]
70.Naji H, Jawad E, Ahmed HA, Mustafa R. Histopathological examination of the prepuce after circumcision: Is it a waste of resources? Afr J Paediatr Surg. 2013 Apr-Jun;10(2):164-6. [PubMed: 23860069]
71.Mallon E, Hawkins D, Dinneen M, Francics N, Fearfield L, Newson R, Bunker C. Circumcision and genital dermatoses. Arch Dermatol. 2000 Mar;136(3):350-4. [PubMed: 10724196]
72.Tobian AA, Serwadda D, Quinn TC, Kigozi G, Gravitt PE, Laeyendecker O, Charvat B, Ssempijja V, Riedesel M, Oliver AE, Nowak RG, Moulton LH, Chen MZ, Reynolds SJ, Wawer MJ, Gray RH. Male circumcision for the prevention of HSV-2 and HPV infections and syphilis. N Engl J Med. 2009 Mar 26;360(13):1298-309. [PMC free article: PMC2676895] [PubMed: 19321868]
73.Warees WM, Anand S, Leslie SW, Rodriguez AM. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): May 2, 2024. Circumcision. [PubMed: 30571057]
74.Schoen EJ, Colby CJ, To TT. Cost analysis of neonatal circumcision in a large health maintenance organization. J Urol. 2006 Mar;175(3 Pt 1):1111-5. [PubMed: 16469634]
75.Morris BJ, Waskett JH, Banerjee J, Wamai RG, Tobian AA, Gray RH, Bailis SA, Bailey RC, Klausner JD, Willcourt RJ, Halperin DT, Wiswell TE, Mindel A. A ‘snip’ in time: what is the best age to circumcise? BMC Pediatr. 2012 Feb 28;12:20. [PMC free article: PMC3359221] [PubMed: 22373281]
Disclosure: Oswald Perkins declares no relevant financial relationships with ineligible companies.
Disclosure: Stephen Leslie declares no relevant financial relationships with ineligible companies.
Disclosure: Sara Cortes declares no relevant financial relationships with ineligible companies.
