Balanitis - Posthitis - Balanoposthitis

Balanitis is an inflammation+ of the glans (balanus), but is not necessarily an infection*. Balanitis may occur together with posthitis (inflammation of the foreskin), when it is known as balanoposthitis. Balanitis xerotica obliterans (BXO) is a separate and distinct condition. For more information on BXO, visit Balanitis Xerotica Obliterans.

Balanitis can occur in both circumcised and intact (non-circumcised) males.6 Van Howe reported significantly more balanitis in circumcised boys as compared with intact non-circumcised boys.10 Balanitis has a wide variety of causes, including physical trauma, an irritant, or an infection.6,8,13 Infectious balanitis may be caused by yeast, fungus, bacteria, or virus infection.6,8,9,13 Identification of the cause is essential for successful treatment.6,13 Use of the flow chart in the External link National Guidelines PDF link to assist in obtaining a diagnosis and selecting treatment is recommended. If the balanitis is caused by an infectious organism, the organism should be identified and the appropriate medical treatment determined based on the identifed infectious agent.6,8,13 Biopsy may be necessary for proper diagnosis.6,12,13 Treatment without first obtaining a diagnosis is like a shot in the dark - one may hit the target but one is far more likely to miss.

Birley et al. documented that balanitis is associated with excessive washing of the penis, with the use of soap or other irritants, and with fungal or other infections.6 Excessive washing removes normal skin oils and causes non-specific dermatitis (NSD) which is confused with balanitis.6 If the inflammation is caused by NSD, the treatment is to stop washing with soap, apply emollients, and allow natural skin oils to return.6,13 Washing may worsen the condition.

A physical insult may cause balanitis. Inflammation may be caused by External link premature forcible retraction PDF link of the foreskin which may tear the synechial membranes that retain the non-separated foreskin in the young boy.14 The tearing of the synechia creates raw surfaces which may become infected.14

Non-infectious irritants may cause atopic balanitis.4,6,8,13 For example, swimming a in heavily chlorinated swimming-pool is known to cause balanitis. The irritant should be avoided.11 Emollients should be applied.13

The foreskin is designed by nature to protect the body from infection.11 In the young boy, balanitis is best prevented by leaving the prepuce or foreskin alone and allowing it to perform its protective immunological functions.8,11 No attempt should be made to retract or wash underneath the prepuce or foreskin.14

In sexually mature males, accumulated smegma should be washed away periodically.4,8 Soap should be avoided. If soap is used for washing, all residual soap should be rinsed away.4,8 Washing with soap is a cause of balanitis.6,9,13

A few medical doctors advocate circumcision for repeated cases of inflammation of the glans. However, there is no documented medical evidence that circumcision is more effective than proper penile care - which includes leaving a boy's foreskin alone, and avoidance of irritants, such as excessive washing, especially with soap.

Some authorities state that the glans should be kept dry. This advice is founded in ignorance of normal human physiology because the sub-preputial area is normally moist.1,11 Attempts to keep the sub-preputial area dry may be impossible to comply with and may worsen a dermatitis condition. The sub-preputial moisture contains lysozyme - an antibacterial enzyme - which may be protective against infective organisms.1,11 The sub-preputial moisture also contains secretions from sebaceous glands that moisturize, lubricate, and protect the mucosa of the glans penis.11

Zoon's plasma cell balanitis. Plasma cell balanitis is characterized by sub-epithelial infiltration of plasma cells. Baldwin reported successful treatment of Zoon's balanitis with the carbon dioxide laser.3 Kumar reported successful treatment by circumcision.7 In 27 of the 32 cases reported by Kumar the location of the lesions were on the prepuce so the disease was more properly Zoon's plasma cell posthitis. Amputation of the prepuce by circumcision in those 27 men, of course, cured the condition! Carbon dioxide laser vaporization of the lesions is likely to be more satisfactory.3 See Balanitis Xerotica Obliterans for more information on the carbon dioxide laser. More recently, Albertini et al. reported successful use of the Erbium:YAG laser to treat the lesions of Zoon's plasma cell balanitis without circumcision.15 Zoon's balanitis must be distinguished from the similar appearing Erythroplasia of Queyrat, which is a cancerous condition.8

Yeast balanitis. Some diabetic men may have a greater tendency to have candida albicans (yeast) balanitis. Anecdotal evidence suggests that limiting intake of sugar and alcohol and strict control of blood sugar may be helpful in the control of candida balanitis. Yeast infections of the penis may indicate a compromised immune system.12

The Hong Kong Medical Association maintains a very useful and informative External link page on the subject of balanitis.7

The (British) Association for Genitourinary Medicine (External link AGUM PDF link) also has a very good page.

+ Inflammation
A fundamental pathologic process consisting of a dynamic complex of cytologic and chemical reactions that occur in the affected blood vessels and adjacent tissues in response to an injury or abnormal stimulation caused by a physical, chemical, or biologic agent, including: 1) the local reactions and resulting morphologic changes, 2) the destruction and removal of the injurious material, 3) the responses that lead to repair and healing. The so-called cardinal signs are: rubor, redness; calor; heat (or warmth); tumor; swelling; and dolor, pain; a fifth sign, functio laesa, inhibited or lost function is sometimes added. All of the above signs may be observed in certain instances, but no one of them is necessarily always present. [L. inflammo, pp. -atus, fr. in, in, + flamma, flame]
~ Stedman's Medical Dictionary, 26th Edition, 1995.

* Infection
Multiplication of parasitic organisms within the body; multiplication of usual bacterial flora of the intestinal tract is not usually viewed as infection.
~ Stedman's Medical Dictionary, 26th Edition, 1995.

References are indexed in chronological order of publication.

  1. Prakash S, Raghuram R, Venkatesan, et al. Sub-preputial wetness - Its nature. Ann Nat Med Sci (India) 1982; 18(3): 109-112.
  2. Escala JM, and Rickwood AMK. Balanitis. Br J Urol 1989; 63: 196-7.
  3. Baldwin HE, Geronemus RG. The treatment of Zoon's balanitis with the carbon dioxide laser. J Dermatol Surg Oncol 1989;15(5):491-4.
  4. Chow KW. (1990?) Balanitis and other genital conditions. Social Hygiene Handbook, Hong Kong.
  5. Kyriazi NC, Costenbader CL. Group A beta-hemolytic streptococcal balanitis: it may be more common than you think. Pediatrics 1991; 88(1):154-156.
  6. Birley HDL et al. Clinical features and management of recurrent balanitis; Association with atopy and genital washing. Genitourinary Medicine 1993; 69: 400-403.
  7. Kumar B, Sharma R, Ragagopalan M, et al. Plasma cell balanitis: clinical and histological features- response to circumcision. Genitourin Med 1995;71:32-4.
  8. Edwards S. Balanitis and balanoposthitis: a review. Genitourin Med 1996;72(3):155-9.
  9. Au TS, Yeung KH. External link Balanitis, Bacterial Vaginosis and other genital conditions. In: Lo Kuen-kong, Chong Lai-yin, Tang Yuk-Ming, eds., Handbook of Dermatology and Venerology (Social Hygiene Handbook, 2nd Ed.) Hong Kong: Social Hygiene Service, Department of Health, 1997) (ISBN 962 3340303). (link to www.hkmj,org.hk)
  10. Van Howe RS. Variability in penile appearance and penile findings: a prospective study. Brit J Urol 1997;80:776-782.
  11. Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Inf 1998;74:364-367.
  12. Mayser P. Mycotic infections of the penis. Andrologia 1999;31 Suppl 1:13-6.
  13. Edwards S. (for the Clinical Effectiveness Group) External link National guideline on the management of balanitis. PDF link Association for Genitourinary Medicine (U.K.) and the Medical Society for the Study of Venereal Diseases (U.K.). (2001) (link to www.agum.org.uk)
  14. External link Questions About Premature (Forcible) Retraction of Your Young Son's Foreskin PDF link. (Pamphlet) San Anselmo, CA, NOCIRC, 2000.
  15. Albertini JG, Holck DE, Farley MF. Zoon's balanitis treated with Erbium:YAG laser ablation. Lasers Surg Med 2002; 30(2):123-6.
  16. Georgala S, Gregoriou S, Georgala C, et al. Pimecrolimus 1% cream in non-specific inflammatory recurrent balanitis. Dermatology. 2007;215(3):209-12.
  17. Bardazzi F, Antonucci A, Savoia F, Balestri R. Two cases of Zoon's balanitis treated with pimecrolimus 1% cream. Int J Dermatol. 2008;47(2):198-201.

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