What Is Posthitis? 

Introduction 

Posthitis is a condition that causes inflammation of the foreskin. Foreskin is the thin layer of skin on the head of the penis, that protects the head and contributes to sexual pleasure. It is important to know about posthitis, as whilst most individuals recover without treatment, posthitis can return and cause continual issues. Posthitis commonly occurs at the same time as balanitis, which is inflammation of the head of the penis, rather than the foreskin. However, balanoposthitis is when both the foreskin and the head of the penis is inflamed. Posthitis can be caused by a range of factors including infection, allergy, friction and poor hygiene.

What is the foreskin?

The medical term for the foreskin is the prepuce, which is a circumferential flap of highly vascular skin that covers the glans penis. The outer surface of the prepuce is continuous with the skin of the penile shaft and is covered by a glabrous stratified squamous keratinised epithelium. Similar to eyelids, the prepuce marks the boundary between mucosa and skin and provides adequate skin to cover the entire penis during an erection.¹ The role of the foreskin is subject to debate, with some researchers believing that it protects the penis and aids in reproduction through its ability to heighten sexual pleasure, and others believing that it simply increases the likelihood of contracting certain diseases and conditions. Posthitis is one of these conditions that occurs due to the presence of foreskin on the penis.

What causes posthitis? 

Viral, bacterial and fungal infections can all cause posthitis. Commonly, fungi such as Candida albicans can develop around the foreskin through poor hygiene or the use of perfumed soap. Candida albicans is a type of yeast that is naturally found in small amounts on the body, with the balance being controlled by our microbiome. Poor hygiene or perfumed soaps can throw off this vital balance leading to posthitis infections.²

 Bacteria such as Streptococcus and Staphylococcus can both cause posthitis. Streptococcus is usually passed from person to person via respiratory droplets through sneezing, coughing and speaking, but can move to different areas of the body. Staphylococcus is most commonly passed through skin-to-skin contact and is present in small quantities within the nose of most healthy individuals. Much like Candida albicans fungus, levels of staphylococcus in the body can become unbalanced and overgrow, causing infection.

Posthitis can also be caused by sexually transmitted infections such as gonorrhoea, therefore it is vital to wear protection such as condoms when engaging in sexual activities. Moreover, Viral posthitis is less common but can still occur. viruses such as herpes simplex virus and human papillomavirus can both cause symptoms such as inflamed foreskin, and both of these viral infections can be contracted through intercourse with an infected individual. Currently, there is a vaccine available that protects against human papillomavirus, it is recommended for children aged 12 to 13 and those who are at high risk of contracting human papillomavirus.³

One of the main causes of posthitis is poor hygiene. This can cause the development of smegma, which is a combination of oils, skin cells and sweat around the genitals. in addition, Faecal matter that becomes lodged in the foreskin can also occur due to poor hygiene and be the cause of posthitis, therefore it is important to wash the external genital area regularly and to use unscented gentle soaps. Dermatological conditions such as psoriasis, eczema and dermatitis may cause inflammation of the foreskin, and it is best to consult a doctor for issues such as these as they may require ongoing treatment and management. Latex condoms may be an allergen for some individuals and can lead to inflammation, itching and redness. It should be noted that latex-free condoms are available for those with allergies.⁴

Symptoms of posthitis

Symptoms of posthitis can begin with slight pain, swelling and itching. This may become progressively worse and a foul-smelling substance called smegma can develop. The penis may change in colouration, appearing more purple or red than usual. 

Although posthitis can be caused by many different factors, the presentation of symptoms is largely the same and will likely go away on its  own if good hygiene is maintained. If the inflammation persists, or you experience bleeding and difficulty urinating, you should seek medical attention as the inflammation could be becoming more severe.⁵

Diagnosing posthitis

You should always contact a medical professional if you are worried about your foreskin, a doctor can diagnose the condition in many ways. They will likely ask questions about your symptoms and will perform a physical examination of your penis.

 Laboratory tests are not often required to diagnose posthitis, however, a skin test could be gathered by swabbing the foreskin to identify any bacteria or viruses that are present. 

A urethral discharge swab could also help to identify present pathogens, a cotton swab is interested a small way into the urethral opening and is gently rotated to collect this sample. 

Additionally, Urinalysis can examine the visual, chemical and microscopic components of your urine, in which bacteria and high sugar levels will be assessed.⁶

 You may be diagnosed with balanoposthitis rather than posthitis, as balanoposthitis refers to inflammation of the glans penis and the foreskin, whereas posthitis is inflammation of the foreskin alone.

Treatments for posthitis

Posthitis is a very curable condition that is often able to go away on its own, however, treatments can be prescribed by your doctor if this fails to occur. 

Suppose a skin test or urethral discharge swab shows that the condition is caused by a bacterial infection. In that case, antibiotics can be prescribed to kill this bacteria and reduce inflammation. These antibiotics will likely be broad-range antibiotics such as amoxicillin or doxycycline.

 If a fungal infection is found to be the reason for your posthitis your doctor may prescribe antifungal creams such as clotrimazole, econazole and miconazole, which should be applied to the foreskin as directed by your doctor.

 If you have persistent posthitis and believe that it is greatly impacting your life, your doctor may suggest circumcision, which involves the foreskin being surgically removed to expose the end of the penis. Risks of circumcision can include a reduction in sensation in the head of the penis and tenderness around the scar, however, many individuals choose to be circumcised, based on religious beliefs or simply for hygiene and appearance. Circumcision surgeries can be performed in a number of ways, laser circumcision is the most advanced and is minimally invasive, stapler circumcision is slightly more invasive but promotes faster healing, and open circumcision is the conventional and most invasive method of circumcision. You and your healthcare provider can discuss the method that is most suited to you.⁷

Complications of posthitis 

It is possible that the inflamed foreskin could become tight under the head of the penis, and be unable to return to its natural position. In some cases, this can prevent blood from being able to flow to the head of the penis, causing necrosis and further infection. Necrosis occurs when tissue cannot receive enough oxygen and dies, this cannot be reversed. Therefore it is important to seek medical attention if you are worried about your foreskin, as complications such as these are rare but are a possibility. Refractory cases may be indicative of cancerous or precancerous lesions such as squamous cell carcinoma, a wedge biopsy would be required to obtain this diagnosis. If a diagnosis such as this is confirmed, reconstructive surgery, radiation or chemotherapy may be required.⁸

How to prevent posthitis 

Those most likely to develop posthitis are young boys who wear nappies as the faecal matter may get inside of the foreskin, causing infection. Elderly individuals, particularly those who are diabetic may also be affected.

 As posthitis is often caused by sexually transmitted infections, it is important to always use protection such as condoms (latex-free  condoms if you have a latex allergy), and to regularly test for the presence of sexually transmitted infections so that you do not pass one onto another person.

 Moreover, It is important to keep the penis and foreskin clean, through the use of water and unscented soaps in order to prevent the buildup of smegma. Parents and guardians of children wearing nappies should change the nappies regularly to prevent the buildup of urine and faeces. The foreskin of young children does not need to be pulled back in order to be cleaned as this could cause pain or discomfort.⁹

Summary 

Posthitis is an infection of the foreskin (prepuce) that can be caused by pathogens, poor hygiene, allergies and friction. It causes itchy, red and inflamed foreskin that can lead to pain when urinating or engaging in sexual intercourse. Posthitis usually goes away on its own, however, sometimes medical intervention is necessary if the foreskin begins to bleed or inflammation persists. Doctors may prescribe antibiotics or antifungal medications such as amoxicillin or econazole, depending on the cause of your posthitis. Circumcision may be necessary if you get recurrent posthitis, and there are multiple methods of circumcision available such as laser, staple and open circumcision. The condition can be prevented by maintaining good hygiene by washing the foreskin regularly and changing the nappies of children often. Any course of antibiotics prescribed by your doctor should be completed in full to prevent the infection from returning and causing further issues.