What is Balanoposthitis?
Balanoposthitis is a condition that primarily affects uncircumcised men and boys. It causes inflammation of the head of the penis (glans penis) and the skin that covers it (prepuce). The inflammation can be due to many factors, typically infection, irritation, or injury. It’s important to understand that balanoposthitis is not the same as balanitis, which only involves inflammation of the glans penis, and posthitis, which refers to inflammation of the prepuce only.
To better understand this, consider the foreskin of a baby boy, also known as the prepuce. When a child is born, the foreskin is firmly stuck to the head of his penis. It’s completely natural for baby boys to have a foreskin that doesn’t pull back (physiologic phimosis). But as boys grow up, their foreskin usually starts to move more freely. Research indicates nearly 17% of first-grade boys still have their foreskin stuck, but by the seventh grade, this number drops to just over 1%. Although, the inability to retract the foreskin because of scarring is referred to as ‘pathologic phimosis’.
What Causes Balanoposthitis?
Balanoposthitis, or inflammation of the head of the penis and the foreskin, can be caused by various factors. The most common cause is poor hygiene, which can often result in nonspecific balanoposthitis. Other causes can include infection, skin conditions that cause inflammation, injury, chronic swelling conditions, and cancer. Those with a history of excessive cleaning of the genital area and recurring issues are likely to develop contact dermatitis, a type of skin irritation. However, in about a third of balanoposthitis cases, one cannot pinpoint a specific cause.
When a cause can be identified, it’s usually an infection. Candida albicans, a type of yeast, is the most frequently found microorganism, followed by the Streptococcus bacteria. Yeast infections caused by Candida are the most common in children and can also coexist with diaper rashes in babies. Other possible infections could be due to Staphylococcus aureus, Group A Streptococcus, Bacteroides, Gardnerella, certain anaerobic bacteria, syphilis or the human papillomavirus (HPV).
Contact dermatitis, reactive arthritis and lichen sclerosus — also known as balanitis xerotica obliterans — are a few inflammation-related causes. Some people have shown reactions to antiseptic solutions used during self-catheterization. In older men, groin rashes, exposure to substances causing skin irritation, and fungal infections are common causes.
Risk Factors and Frequency for Balanoposthitis
Balanoposthitis is a condition that affects both children and adults. It’s most common in males, with around 12% to 20% of all males experiencing it at some point. When it comes to children, it typically shows up between the ages of 2 and 5, most likely due to natural bodily changes and personal hygiene habits. For adult males, those who aren’t circumcised and have diabetes are at the highest risk, with about 35% of them developing balanoposthitis. A meta-analysis has also shown that circumcision can reduce the chances of having an inflammatory condition of the glans penis by 68%.
- Balanoposthitis is common in both children and adults.
- About 12% to 20% of all males are affected.
- In children, it’s mostly seen between ages 2 and 5, likely due to natural bodily changes and cleaning habits.
- Non-circumcised adult males with diabetes are at the highest risk, with a prevalence of around 35%.
- Circumcision has been found to lower the risk of developing this condition by 68%.
Signs and Symptoms of Balanoposthitis
Balanoposthitis is a condition that affects the head of the penis and the foreskin. It’s exclusively seen in uncircumcised individuals and can cause pain, itching, discharge, redness, rashes, or in infants, uncontrollable crying. If you look at the affected area, you might notice a moist, red, flat lesion on the head of the penis and foreskin. This redness is often patchy. You may also see small bumps that might look like they are eroding. Balanoposthitis can also present as a dull, dry, red patch with a glossy or waxy appearance, and areas of yellow or even black discoloration can also appear.
This condition is more common in those who do not maintain good genital hygiene. It can occur with or without a condition called phimosis, where the foreskin can’t be retracted. Depending on what exactly caused it and how severe it is, further symptoms may include:
- Scarring of the foreskin
- Difficulty in urinating
- Weak urine flow
- Presence of genital ulcers
- Phimosis along with skin splitting
- Rashes
- Discharge from the urethra
- Presence of other lesions
Testing for Balanoposthitis
In most cases, diagnosing and determining the treatment for balanoposthitis, an inflammation of the foreskin, involves understanding the patient’s history and conducting a physical exam. The doctor will ask about the length of time the patient has had symptoms, their personal hygiene habits, if they have been exposed to any infections, any possible allergies, and their sexual practices.
During a physical exam, the doctor will evaluate the patient’s overall hygiene, look for any signs of inflammation or swelling (like redness, tenderness or swelling of the skin), any discharges, urinary retention, any signs of scarring, testicular edema or tenderness and also swollen lymph nodes in the groin area.
It should be noted that naturally occurring ‘smegma’, a substance found under the foreskin, can sometimes be mistaken for a discharge from the urethra. However, an actual discharge usually has a more liquid-like appearance, may have an unpleasant smell, and could be accompanied by symptoms like redness and tenderness.
If appropriate, the doctor might collect samples for testing. These could include bacterial and fungal (yeast infection) cultures from beneath the foreskin. In some cases, testing for Streptococcus, a type of bacteria, may also be recommended.
If there are signs of sexually transmitted infections, such as ulcers, vesicles, or any form of discharge, the doctor will order suitable tests. For instance, if gonorrhea or chlamydia are suspected, cultures and swabs for identifying the presence of the bacteria causing these infections will be conducted. If ulcers are visible, tests for herpes simplex virus or syphilis might also be necessary.
But in kids, if there’s no suspected sexual abuse and no visible discharge or lesions, additional tests may not be required. Their treatment can be derived from the symptoms and their history of exposure to any infections or allergens. However, in older kids, if balanoposthitis appears for the first time and is suspected to be caused by a fungus, the doctor might consider testing for diabetes, as this could be an early indicator of high blood sugar levels and the presence of sugar in the urine.
While most cases get better with improvements in personal hygiene or general treatment, if symptoms don’t improve after four weeks, further investigation may be necessary. This could include a biopsy to understand the root cause and the exact nature of the problem. A circumcision might also be considered in such circumstances.
Treatment Options for Balanoposthitis
Most cases of balanoposthitis, an inflammation of the head of the penis, improve with hygiene or generic treatments. Optimal treatment involves figuring out the specific cause, but when this isn’t possible, general treatment protocols are used.
General treatment usually involves avoiding any known irritants that can worsen the condition. For example, soap should not be used to clean under the foreskin as it can be irritating. If soap is needed, baby soap is preferred as it has fewer irritating ingredients. You should also stay away from antibacterial soaps, fragrances, and other unnecessary chemicals. Other potential irritants such as creams, antiseptics, and adult or baby wipes should be avoided unless a healthcare professional recommends them.
Patients are also advised to abstain from sexual activity until the balanoposthitis has completely cleared. When cleaning the area, sitting in a warm sitz bath 2 to 3 times a day can help. If needed, the area under the foreskin can be gently cleaned with a cotton swab and water. Routine cleaning should be done with water, and the area should be thoroughly dried before covering it with the foreskin.
Topical treatment options for balanoposthitis include antibiotics, antifungals, and low-strength corticosteroids. If a patient is unable to pass urine due to severe foreskin tightening, they may need additional treatment options such as catheterization or surgery.
Different treatments are recommended depending on the cause of balanoposthitis. For example, if the inflammation is due to an infection with a particular bacteria, fungi, or protozoa, an appropriate antibiotic, antifungal, or antiprotozoal medication may be prescribed. In more severe cases, stronger antibiotics taken by mouth might be necessary. For recurrent or resistant cases, circumcision might be recommended.
Some underlying conditions might cause balanoposthitis. For instance, the condition can be associated with diabetes mellitus, old age, immunosuppressive disorders, or the use of broad-spectrum antibiotics. In such instances, controlling the underlying condition can help manage balanoposthitis.
Patients presenting with balanoposthitis due to sexually transmitted infections need to have these infections diagnosed and treated. The recommended treatment in these cases usually involves antibiotics. Balanoposthitis can also occur due to irritating substances, the use of certain drugs, or overly aggressive cleaning methods. In these cases, stopping the use of the offending substance or changing the cleaning method may help relieve inflammation.
In brief, managing balanoposthitis involves good hygiene habits, avoiding irritants, and using the appropriate medication based on the cause of the inflammation. Severe or recurrent cases might require more invasive treatments such as circumcision.
What else can Balanoposthitis be?
When a doctor is trying to diagnose balanoposthitis, which is swelling of the foreskin and head of the penis, there are many different conditions they need to consider as possibilities. The most important condition a doctor needs to rule out is squamous cell carcinoma of the penis. This type of cancer often starts as a painless, uneven, odd-shaped sore or growth, which sometimes becomes painful later on. The only way to confirm this diagnosis is with a biopsy.
Another condition that’s often linked to balanoposthitis is penile intraepithelial neoplasia, which is commonly associated with the human papillomavirus (HPV).
There are also many other conditions that can have similar symptoms to balanoposthitis including:
- Balanitis (inflammation of the head of the penis)
- Zoon balanitis or plasma cell balanitis
- Circinate balanitis
- Contact dermatitis (a skin rash caused by contact with a certain substance)
- Diaper dermatitis (diaper rash)
- Discoid eczema (round-shaped patches of eczema)
- Fixed drug eruption (skin reaction to a drug)
- Intertrigo (skin irritation in folds of skin)
- Lichen planus (itchy rash)
- Lichen sclerosus (skin condition that affects the genitals)
- Mondor disease (blood clot in the penis)
- Bowenoid papulosis, Bowen disease and Erythroplasia of Queyrat (all various types of penile intraepithelial neoplasia)
- Psoriasis (an autoimmune condition causing red, itchy skin patches)
- Reactive arthritis
- Squamous cell carcinoma (as previously mentioned)
- Stevens-Johnson Syndrome (a severe skin disorder)
- Urethritis (inflammation of the urethra)
Correctly diagnosing the condition is critical for determining the best treatment plan.
What to expect with Balanoposthitis
The outlook for people with balanoposthitis is typically positive. Most patients, where the cause of the condition isn’t clearly due to an infection, will improve with better hygiene practices and treatment with moisturizers within a week or two. However, about one in ten of these patients might see their symptoms return, which would need more examination and specific treatment.
Possible Complications When Diagnosed with Balanoposthitis
People with symptoms that continue despite four weeks of treatment, and who also have pathologic phimosis or trouble urinating, might need a biopsy to learn more about their health issue. To understand the nature and seriousness of this issue, a procedure like a circumcision or a small biopsy from the affected area is usually performed. This procedure allows medical professionals to closely analyze tissue samples for signs of disease. It’s important to conduct this test, as some conditions that don’t respond to the treatment could be indicative of cancerous or precancerous growths. These lesions could include disease conditions such as xerotic obliterans balanitis, amebiasis, or squamous cell carcinoma. Doctors may overlook these conditions without conducting a proper tissue examination.
Preventing Balanoposthitis
It’s crucial for doctors and other healthcare workers to educate patients and their families about how to clean the foreskin properly. This important step can help prevent and treat most instances of balanoposthitis, a condition that causes inflammation of the penis.
Cleaning the area correctly involves gently washing it 2 to 3 times a day. If the foreskin is tight and can’t be pulled back, it’s important to avoid trying to force it. For those who can pull back the foreskin, a cotton swab can be used to clean the area. Strong, fragrant soaps should be avoided as they can irritate the penis.
Part of the guidance may also involve identifying other possible elements that may cause irritation and advice on how to stay clear of them, which can help reduce symptoms significantly.
It’s worth mentioning that circumcision, the surgical removal of the foreskin, is seen as a preventive step for balanoposthitis.
