Overview
Balanitis
1. Clinical Overview
Summary
Balanitis is inflammation of the glans penis; balanoposthitis includes inflammation of the prepuce (foreskin). It is common, affecting up to 11% of adult men and 3% of boys. Causes include candidal infection, bacterial infection, dermatoses (e.g., lichen sclerosus, psoriasis), and irritant/allergic contact dermatitis. Candidal balanitis is strongly associated with diabetes mellitus. Management depends on aetiology: antifungals for candida, antibiotics for bacterial causes, and topical steroids for dermatoses. Recurrent balanitis may require circumcision.
Key Facts
- Prevalence: 3% of boys; 11% of men
- Most common causes: Candida albicans, bacterial, dermatoses
- Key risk factor: Uncircumcised (intact foreskin), diabetes mellitus
- Red flag: Recurrent candidal balanitis → check HbA1c for diabetes
- Management: Treat underlying cause; hygiene; consider circumcision if recurrent
Clinical Pearls
Think Diabetes: Recurrent candidal balanitis is often the first presentation of diabetes. Always check HbA1c.
Avoid Soap: Advise patients to wash with water only or emollients. Soap causes irritation and exacerbates symptoms.
Lichen Sclerosus (BXO): White, scarring lesions on glans/prepuce. May cause phimosis. Require regular review (small malignancy risk).
Why This Matters Clinically
Balanitis is usually straightforward but may indicate underlying disease (diabetes, STIs). Chronic or atypical cases require investigation to exclude cancer, sexually transmitted infections, or dermatological conditions.
2. Epidemiology
Incidence & Prevalence
- Children: Affects ~3% of uncircumcised boys
- Adults: Up to 11% of men
- Setting: More common in GUM/urology clinics
Demographics
| Factor | Details |
|---|---|
| Age | All ages; peaks in childhood and middle age |
| Circumcision | Higher rates in uncircumcised men |
| Geography | Global; rates correlate with circumcision practices |
Risk Factors
| Factor | Impact |
|---|---|
| Uncircumcised | Inability to retract foreskin → poor hygiene |
| Diabetes mellitus | Candidal overgrowth |
| Immunosuppression | HIV, steroids |
| Poor hygiene | Or over-washing with soap |
| Condom allergy | Latex sensitivity |
| Sexual activity | STIs (HSV, Trichomonas) |
3. Pathophysiology
Aetiology
| Cause | Details |
|---|---|
| Candidal | Most common infective cause; associated with diabetes |
| Bacterial | Staphylococcus, Streptococcus, anaerobes |
| STI-related | HSV, Trichomonas, syphilis |
| Dermatoses | Lichen sclerosus (BXO), psoriasis, eczema, lichen planus |
| Irritant/Allergic | Soap, latex condoms, spermicides |
| Zoon's balanitis | Plasma cell balanitis; benign; elderly men |
Mechanism
Candidal Balanitis:
- Candida albicans overgrowth (normal commensal in small numbers)
- Favoured by moisture, warmth, high glucose (diabetes)
Lichen Sclerosus (BXO):
- Autoimmune inflammatory process
- Causes phimosis, urethral stricture
- Small risk of squamous cell carcinoma
Zoon's Balanitis:
- Benign plasma cell infiltration
- Unknown aetiology; typically elderly, uncircumcised
4. Clinical Presentation
Symptoms
Signs by Cause
| Cause | Typical Signs |
|---|---|
| Candida | Erythema, white patches/curd, satellite lesions |
| Bacterial | Erythema, purulent discharge, oedema |
| Lichen sclerosus | White, atrophic, scarring; may cause phimosis |
| Zoon's | Well-demarcated orange/red glazed patch |
| Psoriasis | Red plaques, may lack scale |
| Contact dermatitis | Erythema, oedema, vesicles |
Red Flags
[!CAUTION] Red Flags — Urgent assessment if:
- Rapidly spreading erythema, pain, necrosis (Fournier's gangrene)
- Foreskin stuck in retracted position (paraphimosis)
- Non-healing lesion (possible carcinoma)
- Recurrent candida (check diabetes)
Penile soreness, itching, or burning
Common presentation.
Redness of glans
Common presentation.
Discharge (white/curd-like in candida)
Common presentation.
Painful urination
Common presentation.
Difficulty retracting foreskin
Common presentation.
5. Clinical Examination
Structured Approach
Inspection:
- Erythema, oedema, discharge
- Ulceration, erosions
- White plaques (candida, BXO)
- Glazed appearance (Zoon's)
- Satellite lesions (candida)
- Phimosis (cannot retract foreskin)
Palpation:
- Inguinal lymphadenopathy (infection, malignancy)
Associated:
- Signs of diabetes (obesity, acanthosis nigricans)
- Other skin lesions (psoriasis elsewhere)
6. Investigations
First-Line
| Test | Purpose |
|---|---|
| Clinical diagnosis | Often sufficient |
| Swab (microscopy and culture) | If discharge present; identify candida, bacteria |
| HbA1c / Fasting glucose | If candidal or recurrent |
| STI screen | If sexually active with risk factors |
Further Investigations
| Test | Indication |
|---|---|
| Biopsy | Non-healing lesion; atypical appearance (rule out cancer, lichen sclerosus) |
| Patch testing | Suspected allergic contact dermatitis |
7. Management
Management Algorithm
BALANITIS
↓
┌─────────────────────────────────────────┐
│ 1. Identify Cause │
│ - History, examination, swab │
│ - Check HbA1c if candidal │
└─────────────────────────────────────────┘
↓
┌─────────────────────────────────────────┐
│ 2. Treat Underlying Cause │
├─────────────────────────────────────────┤
│ Candidal → Clotrimazole cream ± PO │
│ Bacterial → Co-amoxiclav or Fluclox │
│ Dermatosis → Topical steroid │
│ Contact → Remove irritant │
└─────────────────────────────────────────┘
↓
┌─────────────────────────────────────────┐
│ 3. General Measures │
├─────────────────────────────────────────┤
│ - Wash with water only / emollient │
│ - Dry glans carefully │
│ - Treat sexual partners if STI │
└─────────────────────────────────────────┘
↓
┌─────────────────────────────────────────┐
│ 4. Recurrent Balanitis │
│ - Exclude diabetes │
│ - Consider circumcision │
└─────────────────────────────────────────┘
Treatment by Cause
| Cause | Treatment |
|---|---|
| Candida | Clotrimazole 1% BD for 2 weeks (± Fluconazole 150mg PO single dose) |
| Bacterial | Co-amoxiclav 625mg TDS for 7 days or Flucloxacillin |
| Lichen sclerosus | Potent topical steroid (Clobetasol 0.05%); urology follow-up |
| Zoon's | Potent topical steroid; consider circumcision (curative) |
| Psoriasis | Mild topical steroid or calcineurin inhibitor |
| Contact dermatitis | Remove allergen; mild steroid |
General Advice
- Avoid soap; wash with water or soap substitute
- Dry glans and prepuce thoroughly
- Retract foreskin to clean (in those with retractable foreskin)
- Treat sexual partners if STI
Surgical
| Indication | Procedure |
|---|---|
| Recurrent balanitis | Circumcision |
| Phimosis | Circumcision or preputioplasty |
| Lichen sclerosus (BXO) | Circumcision +/- meatotomy if meatal stenosis |
8. Complications
| Complication | Details |
|---|---|
| Phimosis | Scarring and inability to retract foreskin |
| Paraphimosis | Emergency; foreskin stuck retracted |
| Urethral stricture | From lichen sclerosus |
| Malignancy | SCC risk in chronic lichen sclerosus |
| Recurrence | Especially if diabetes uncontrolled |
9. Prognosis & Outcomes
Outcomes
| Variable | Outcome |
|---|---|
| Candidal | Excellent with treatment |
| Bacterial | Excellent with antibiotics |
| Lichen sclerosus | Requires long-term follow-up; SCC risk ~5% |
| Zoon's | Benign; circumcision curative |
Recurrence
- Common if underlying cause (diabetes) untreated
- Circumcision prevents recurrence in most cases
10. Evidence & Guidelines
Key Guidelines
- BASHH UK National Guideline on the Management of Balanitis (2018) — British Association for Sexual Health and HIV.
- EAU Guidelines on Penile Diseases — European Association of Urology.
Key Evidence
| Intervention | Level | Evidence |
|---|---|---|
| Topical antifungals for candida | 1b | RCTs |
| Circumcision for recurrence | 2b | Cohort studies |
| Topical steroids for BXO | 2b | Case series |
11. Patient/Layperson Explanation
What is Balanitis?
Balanitis is inflammation of the head of the penis (glans). It can cause redness, soreness, itching, and sometimes discharge.
What causes it?
- Thrush (yeast infection): Common, especially if you have diabetes
- Bacterial infection: Less common
- Skin conditions: Such as eczema or lichen sclerosus
- Irritation: From soaps, shower gels, or condoms
How is it treated?
- Antifungal cream: For thrush (e.g., clotrimazole)
- Antibiotics: For bacterial infections
- Steroid cream: For skin conditions
- Good hygiene: Wash with water only (no soap); dry carefully
When to see a doctor
- Symptoms not improving with treatment
- Recurrent infections (you may need a diabetes test)
- You cannot pull back your foreskin
- A sore that doesn't heal
Can it be prevented?
- Keep the area clean and dry
- Avoid soap on the penis
- If you have foreskin, pull it back gently to wash
- Treat diabetes well if you have it
12. References
Primary Guidelines
- Clinical Effectiveness Group, BASHH. UK National Guideline on the Management of Balanitis. 2018. bashh.org
Key Studies
- Edwards S. Balanitis and balanoposthitis: a review. Genitourin Med. 1996;72(3):155-9. PMID: 8698355
- Bunker CB. Lichen sclerosus. Dermatol Clin. 2021;39(4):599-611. PMID: 34474874
Further Resources
- NHS Balanitis: nhs.uk/conditions/balanitis
Last Reviewed: 2025-12-24 | MedVellum Editorial Team
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.