Introduction

Balanitis and posthitis, inflammation of the glans penis and foreskin respectively, can cause discomfort and complications if left untreated. Balanitis is the term used for pain and inflammation (swelling and irritation) of the glans (head) of the penis. It happens most often in uncircumcised people assigned male at birth (AMAB). Circumcision is a procedure that removes the foreskin from the head of the penis (glans). Yeast infections typically cause balanitis but bacterial infections, viral infections and some skin conditions can also cause balanitis.^1,2

Posthitis is the term for painful or uncomfortable inflammation of the foreskin. Posthitis can result from a fungal infection like candidiasis if a person doesn't practice good hygiene. Using fragrant soaps increases the risk of developing a fungal infection along with poor hygiene. Infections, skin problems, or inadequate hygiene can be the causes of developing posthitis.

Regular medical check-ups are essential for early detection and management of any underlying medical conditions that may predispose individuals to balanitis and posthitis. Education and awareness about proper genital hygiene and risk factors can empower individuals to take proactive measures to prevent these conditions. 

Causes of posthitis and balanitis

• Phimosis or tight foreskin
• Bacterial infections like those caused by Staphylococcus epidermidis, Haemophilus parainfluenzae, Klebsiella and Streptococcus
• Fungal infections such as candidiasis (Candida albicans infections)
• Illnesses spread by sexual contact, such as gonorrhoea
• Psoriasis
• Dermatitis
• Rashes
• Allergies to spermicides, latex condoms, lubricants, corticosteroids, and other substances
• Reactive arthritis is particularly seen as a risk factor in some cases of balanitis¹

Clinical presentation of balanitis

Balanitis symptoms might arise quickly or gradually. They may consist of:

• Pain and inflammation on the head of the penis
• Discolouration 
• Glossy or white areas on the penis
• Smegma, or white discharge beneath the foreskin
• An unpleasant odour
• Pain on urination
• Blisters or sores on the head of the penis
• People over 60 years of age can also be affected by a rare type of balanitis called pseudoepitheliomatous keratotic and micaceous balanitis (PKMB)³

Clinical presentation of posthitis

• Pain, itching and irritation over the penis
• Oedema, or swelling near the foreskin area
• Foul-smelling secretions
• Localised red, purple, or somewhat darker-than-normal skin discolouration that could resemble a rash
• Difficulty urinating

Types of balanitis

There are mainly three types of balanitis:

• Zoons balanitis
• Circinate balanitis
• Pseudoepitheliumatous keratotic and micaceous balanitis (PKMB)

Zoons balanitis 

It involves Inflammation of the glans penis and foreskin and usually affects uncircumcised people assigned male at birth (AMAB) in their middle to advanced years.⁴

Circinate balanitis

Circinate balanitis is associated with a condition called reactive arthritis. It is typified by tiny, superficial, painless ulcerative lesions on the glans penis. A biopsy may reveal upper epidermal pustules that resemble pustular psoriasis. Serpiginous annular dermatitis is another possibility. It frequently has a greyish-white granular look with a white border.^5,6

Pseudoepitheliomatous keratotic and micaceous balanitis

Pseudoepitheliomatous keratotic and micaceous balanitis is typified by scaly, wart-like skin lesions on the head of the penis.³

Diagnosis

Balanitis is diagnosed visually based on the appearance of lesions and clinical presentation. A more thorough assessment could be necessary to ascertain the physical findings and history.⁷

Testing may be carried out for the presence of other conditions:

• Scabies 
• Vesicular or ulcerative sores 
• Syphilis
• Herpes simplex virus (HSV)
• Mycoplasma genitalium 
• Trichomonas (when urethritis is present) 

Other tests carried out are:

• Skin test to identify bacteria or viruses. A cotton swab will be gently rubbed over your foreskin by your healthcare provider. The cotton swab will thereafter be sent to a lab for examination
• A urethral discharge swab can help diagnose viruses and bacteria. A cotton swab is inserted and gently rotated into the urethral aperture. The cotton swab is then sent to a laboratory for analysis
• Urinalysis looks at your urine's appearance, composition, and microbiology. A urine sample is sent for analysis at a laboratory

Treatment

• Antifungal treatments
• Steroids
• Circumcision

Antifungal treatment

The most effective treatment for most individuals with balanoposthitis is topical antifungals, usually for one to three weeks. The first line of treatment is typically an imidazole, such as miconazole 1% or clotrimazole 1% applied twice daily (bid). For individuals who are allergic to imidazoles, nystatin cream is an option.

Steroids

When inflammation is more severe, adding fluconazole 150 mg or combining a topical imidazole with a topical steroid with low potency, like hydrocortisone 0.5% bid, frequently results in resolution. If concurrent infections or cellulitis is a problem, treatment with a first-generation cephalosporin is indicated.

Circumcision

For people with diabetes and immunocompromised conditions in particular, experts advise circumcision for repeated and uncontrollable bouts. According to data from research, men who have had their circumcisions have a 68% lower prevalence of balanitis than men who have not had their circumcisions, and having balanitis increases the risk of penile cancer by 3.8 times.¹

Prevention

The primary goals of diagnosis and treatment should be to rule out sexually transmitted infections (STIs), reduce issues with urological and sexual function, and lower the risk of penile cancer.

• Practise proper hygiene with frequent washing and drying off of the prepuce
• To lessen the reservoir of infection, female partners of males with balanitis should be offered empirical treatment or candida testing⁵
• Avoid wearing tight pants and underwear. Heat and moisture are trapped around your groin by tight underwear and pants. Fungi thrive best in environments that are warm and damp
• Make use of a gentle laundry detergent when washing your garments, especially your underwear and pants
• Dry the foreskin and the skin beneath it after urinating

Complications

The development of discomfort, inflammatory lesions of the glans/foreskin, phimosis, paraphimosis, urethral stricture, balanitis xerotica obliterans and malignant transformation of premalignant lesions are among the complications linked to balanitis.^1,2

Phimosis

Chronic inflammation and oedema of the foreskin cause phimosis, an abnormal narrowing of the opening in the foreskin that prevents retraction over the glans penis. Phimosis development frequently makes urinating, cleanliness and sexual function more difficult. Forcible retraction of the foreskin by the patient or medical personnel may result in paraphimosis or foreskin entrapment.

In an emergency, phimosis can be treated by dilatation using a surgical clamp and analgesics. Should this prove unsuccessful, a urologist can temporise the issue with a dorsal slit circumcision. When it comes to elective procedures, total circumcision is the definitive treatment.

Balanitis xerotica obliterans

Balanitis xerotica obliterans (BXO) is the result of hardening and dry, white plaque formation on the glans. The hard tissue can make it difficult or impossible for urine and semen to pass through the urethra. Another name for this condition is penile lichen sclerosus. 

Summary

Balanitis and posthitis, inflammation of the glans penis and foreskin respectively, often result from poor hygiene, infection or underlying medical conditions. Treatment typically involves improved hygiene, topical antifungal or antibacterial medications and sometimes oral antibiotics for bacterial infections. In severe cases or recurrent infections, circumcision may be recommended to prevent future episodes.

Prevention is key in managing balanitis and posthitis. Maintaining good genital hygiene, including regular cleaning and drying of the penis and foreskin, can significantly reduce the risk of inflammation. Using gentle cleansers and avoiding harsh chemicals or irritants is important for sensitive genital skin. Additionally, practising safe sex and avoiding exposure to sexually transmitted infections can also help prevent infectious causes of balanitis and posthitis.

By adopting a comprehensive approach that combines hygiene practices, medical treatment, and preventive strategies, individuals can effectively manage balanitis and posthitis, promoting genital health and overall well-being.