Summary
Common disorders of the glans penis and foreskin include balanitis, balanoposthitis, phimosis, and paraphimosis. Balanitis refers to inflammation of the glans penis, while balanoposthitis refers to inflammation of both the glans penis and the foreskin. Management focuses on optimizing genital hygiene and topical treatments based on the underlying etiology. Phimosis is a congenital or acquired constriction of the foreskin causing inability to retract the foreskin. Physiologic phimosis is common in younger men and resolves with time. Pathologic phimosis is treated with careful genital hygiene and topical steroids, but circumcision may be required. Paraphimosis is a urological emergency in which the foreskin is trapped behind the glans penis in uncircumcised or partially circumcised individuals, causing constriction of the penis. Paraphimosis needs to be manually reduced, but if unsuccessful, surgical management is required to avoid penile necrosis.
Balanitis and balanoposthitis
Definition [1]
- Balanitis: inflammation of the glans penis
- Posthitis: inflammation of the foreskin
- Balanoposthitis: inflammation of both the glans penis and the foreskin
Etiology [1][2][3]
-
Infectious
- Candida (e.g., candidal balanitis, diaper dermatitis)
- Sexually transmitted infections (e.g., gonorrhea, chlamydia, syphillis)
- Human papillomavirus
- Herpes simplex virus
-
Inflammatory [4]
- Irritant balanoposthitis: balanoposthitis due to irritation of the skin (e.g., excessive cleaning with soap)
- Allergic reaction (e.g., contact dermatitis, fixed drug reaction)
- Balanitis xerotica obliterans: lichen sclerosus of the glans penis and foreskin, characterized by pruritic, white plaques with epidermal atrophy and scarring
- Lichen planus
- Psoriasis
- Balanitis circinata: an inflammatory, ulcerating balanitis associated with reactive arthritis
- Zoon balanitis: an inflammatory balanitis that is commonly found in older, uncircumcised men and presents as an erythematous patch on the glans
- Premalignancy
Recurrent candidal balanitis may be caused by undiagnosed diabetes. [5]
Clinical features [1][2][5]
- Pruritus, pain, and edema of the glans penis
- Erythema of the glans and/or foreskin with possible erosions or ulcerative lesions
- Penile exudate and/or discharge
- Associated symptoms (e.g., fever, arthralgias, malaise, lymphadenopathy)
Diagnostics [2]
- Clinical diagnosis
- Additional testing if etiology is uncertain, e.g.:
- Subpreputial swab and KOH test to confirm candida infection
- Subpreputial Gram stain and culture to confirm bacterial or candida infection
- STI testing (e.g., gonorrrhea, chlamydia, syphillis, HSV)
- Biopsy if there is a concern for premalignant lesions
Management [2]
- Optimize hygiene, e.g., daily foreskin retraction and washing.
- Avoid known irritants (e.g., soap, perfumes); consider emollients as an alternative to soap.
- Provide disease-specific treatment such as antibiotics for bacterial infections, topical antifungals (e.g., clotrimazole) for mild fungal infections, and topical steroids for irritant or allergic reactions.
- Manage underlying conditions, e.g., psoriasis, reactive arthritis, diabetes, lichen sclerosus, lichen planus.
- Consult urology for persistent or recurrent episodes. [2]
Disease-specific treatment
-
Candidal infection
- Mild-to-moderate: topical clotrimazole for 7–14 days [2]
- Severe: oral fluconazole (off-label) [2]
- Anaerobic bacterial infection: metronidazole for 1 week [2]
-
Aerobic bacterial infection
- Mild-to-moderate: topical mupirocin for 7–10 days [2]
- Severe: systemic antibiotics, e.g., oral cephalexin for 7 days [5]
- STIs: See “Gonorrhea treatment,” “Genitourinary chlamydia treatment,” “Treatment of HSV infection,” and “Treatment of syphilis.”
-
Irritant balanoposthitis and allergic dermatitis
- Remove inciting trigger.
- Administer hydrocortisone until symptoms resolve. [2]
-
Other inflammatory etiologies (e.g., lichen planus, psoriasis)
- Treatment varies by underlying etiology.
- Consult a specialist (e.g., rheumatology, dermatology).
-
Suspected malignancy
- Consult urology.
- See “Penile cancer” for further management.
Complications [2]
Phimosis
- Definition: a congenital or acquired constriction of the foreskin causing inability to retract it over the glans penis
- Epidemiology: physiologic phimosis occurs in ∼10% of boys at 3 years of age, but decreases to ∼1% of boys by 16 years of age [6]
-
Etiology [6]
- Physiologic phimosis: the inability to retract the foreskin due to preputial adhesions between the glans and foreskin (congenital)
-
Pathologic phimosis refers to the inability to retract the foreskin due to distal scarring caused by, e.g.:
- Recurrent episodes of balanitis or balanoposthitis
- Balanitis xerotica obliterans
- Redundant tissue remaining after circumcision [7][8]
- Trauma
-
Clinical features [6]
- Inability to retract foreskin
- White fibrous ring around the preputial orifice in pathologic phimosis
- Symptoms of underlying etiology (e.g., balanitis, balanitis xerotica obliterans)
- Diagnostics: clinical diagnosis
-
Treatment [6]
- All patients: Optimize foreskin hygiene (e.g., cleansing with soap and water).
- Physiologic phimosis: Provide reassurance (mostly self-limiting).
-
Pathological phimosis and physiological phimosis with recurrent complications (e.g., paraphimosis, UTIs): Consider topical corticosteroids (off-label). [9]
- Options include triamcinolone and betamethasone. [6][10]
- Duration: 4–8 weeks
- Conservative treatment failure: surgical management (e.g., circumcision)
- Complications [5]
Paraphimosis
- Definition: a urological emergency in which the foreskin is trapped behind the glans penis in uncircumcised or partially circumcised individuals, causing constriction of the penis
-
Etiology [11]
- Complications of phimosis (physiological or pathological)
- Iatrogenic (i.e., following genitourinary procedures such as bladder catheterization)
- Trauma (vigorous sexual intercourse, forceful retraction of foreskin while urinating, piercing)
-
Clinical features [11]
- Constricting band of tissue proximal to the glans
- Inability to reduce foreskin
- Edema and pain of the glans penis
- Lower urinary tract obstruction
- Penile ischemia and/or necrosis
- Diagnostics: clinical diagnosis
-
Management [5][12]
-
Perform manual reduction of paraphimosis.
- Provide pain management (e.g., topical anesthetic, dorsal penile block).
- Reduce swelling by applying a compressive elastic dressing and/or ice packs.
- Perform reduction by pressing on the glans with two thumbs while pulling the foreskin over the glans.
- If manual reduction is successful, patients may be discharged.
- Arrange outpatient urology follow-up for definitive management (e.g., circumcision).
- Counsel discharged patients to refrain from retracting their foreskin for a week to avoid recurrence.
- If manual reduction fails, consult urology for surgical managment, e.g.:
- Dorsal slit: an incision made in the foreskin of the dorsal aspect of the penis
- Circumcision as a last resort
-
Perform manual reduction of paraphimosis.
- Complication: glans penis necrosis
Paraphimosis is a urological emergency.
