Symptoms of balanitis

Balanitis tends to present in acute, recurrent or chronic forms.

Symptoms of balanitis can be present just for a few days or a couple of weeks. Such acute balanitis is often due to infective or irritative causes.

Many patients will have recurrences of balanitis, or balanoposthitis, over a period of months and years, affecting their quality of life. Such chronic balanitis is often caused by chronic fungal infections or underlying skin conditions specific to the genital area (genital dermatosis). Patients have typically tried various antifungal creams prescribed by the GP or bought over the counter, without resolution of their symptoms.

Whilst patients tend to focus on their current symptoms, often there is a history of occurrence of similar symptoms in the past. Some patients may have undergone a circumcision in their childhood to deal with their tight foreskin and may not remember much about it. Whilst the circumcision may have dealt with the tight foreskin, the underlying skin condition can still affect the glans penis years (or decades) later.

The symptoms of balanitis are easily attributed to underlying yeast (fungal) infection and unsuccessfully treated as such. The lack of response should prompt to consider other causes of balanitis.

Changes in the skin – this may include:

• Redness
• Patches (or blemishes)
• Itchiness and irritation
• Soreness
• Swelling (or raised skin)

• Spots
• Scarring (or whitening of the affected area)

It is extraordinary how these changes on a small surface area of mucosa and skin can appear so differently in different patients.

Discharge – There may be a collection of mucus discharge underneath the foreskin. The presence of secondary bacterial or fungal infections in these situations is not uncommon.

Phimosis – In the early stages patients may only notice a subtle change in the movement of pulling back the foreskin, especially when erect. This can gradually progress into frank tightness of the foreskin which may appear as a tight band across the outer aspect of the foreskin.

Such tightness whether subtle or established leads to a sense of soreness after sexual contact and sometimes cuts which can last for days and be so painful that it affects the sex life.

Difficulty in passing urine – Occasionally, there may narrowing of the hole of the waterpipe (urethral meatus) due to scarring which in turn results in narrowing of the urinary stream.

Causes of balanitis

Can balanitis be caused by an STI?

Yes, balanitis can result from the following STIs:

• Chlamydia
• Gonorrhoea
• Trichomonas vaginalis
• Mycoplasma genitalium
• Genital herpes
• Human Papillomavirus (HPV)
• Syphilis (primary and secondary)
• Haemophilus ducreyi
• Scabies

This is why it is essential to rule out STIs when diagnosing the cause of balanitis.

Circinate balanitis & Reiter’s Syndrome
Circinate balanitis is the presence of circular red marks on the glans of the penis with raised margin – this can be seen weeks/months after getting a Chlamydia infection. This is an autoimmune condition, and triggered due to immune reaction to chlamydial antigens. This can occur after the original infection has spontaneously resolved.

Circinate balanitis can be seen in patients with reactive inflammation of joints (SARA), another autoimmune reaction to Chlamydia. Occasionally patients develop circinate balanitis, arthritis and conjunctivitis, and when present together, it is called Reiter’s Syndrome.

What else can cause balanitis?

Allergens or Irritants
The skin of the glans is very sensitive and may become inflamed upon exposure to certain chemicals/irritants including:

• Soaps, shower gels
• Irritation to the skin from over washing and scrubbing
• Latex, lubricants and spermicides used in condoms
• Chemicals on the hands being transferred to the penis
• Washing powders, conditioners and detergents
• Drug side effects or allergies (eg. antibiotics are often linked with cases of candida/thrush which may cause balanitis inflammation)

Stress
It is well recognised that stress can trigger or worsen skin conditions like eczema and psoriasis, and it is true for many genital skin conditions including Lichen sclerosus and Lichen planus which can cause balanitis.

Inadequate personal hygiene
This may be due to a tight foreskin which does not allow the foreskin to be pulled back adequately to clean.

Fungal infection (e.g. Thrush)
Candida albicans, normally a harmless yeast present in our mouth, gut and genitals, can cause balanitis. An overgrowth of this yeast is promoted by warm and moist conditions, as during sexual contact, which in turn can irritate the immune system of the patient, and produce symptoms.

Fungal infections can be triggered by use of antibiotics and steroids.

Bacterial or viral infections (non-sexually transmitted)

• Streptococcus infection
• Anaerobic infection (typically produce smelly discharge as well)
• Gardnerella vaginalis (The organism causes Bacterial Vaginosis (BV) in women but generally without symptoms in men)
• Borrelia vincentii and Borrelia burgdorferi

Genital dermatosis
Certain skin conditions typically tend to affect the penile area, and tend to demonstrate certain classical patterns in some patients where it is easy to identify them with plain examinations. These may include:

• Zoon’s balanitis
• Lichen planus
• Lichen sclerosus et atrophicus (LSA)
• Genital psoriasis
• Genital eczema
• Bowenoid papulosis

However, it is much harder to identify such patterns in mild cases. In some patients, the features of more than one skin condition may be present. A good outcome is expected in most cases after a correct diagnosis has been made.

Sometimes secondary fungal or bacterial infection may complicate the clinical picture, and it may be necessary to re-examine after a course of antifungal medications or antibiotics.

Diabetes
Recurrent balanitis may be a sign of diabetes. Those with poorly controlled (or undiagnosed) diabetes are more likely to have recurrent candida as well as other bacterial infections than those who are non-diabetic.

Penile Intraepithelial Neoplasia (PeIN) is a precancerous condition where single or multiple lesions are seen on any part of penis, but more commonly on the glans penis, and thus can look like other causes of balanitis. Most cases of PeIN are driven by underlying HR-HPV.

Penile cancers are rare, but should be considered in those with suspicious lesions, in cases where the lesion fails to respond to treatment, and in those who have High-Risk HPV. An early diagnosis of penile cancer can lead to successful treatment and cure.

Treating balanitis

How is balanitis treated?

The treatment of balanitis depends entirely on the cause of the problem.

• If the cause is an STI then we will treat the underlying STI.
• If the cause is a bacterial infection then it can be treated with antibiotics. 
• If the cause is a fungal or yeast infection then it can be treated with antifungal cream or oral capsules.

Steroid creams of various strengths are available, and are used in the treatment of balanitis based on the severity of symptoms and the underlying cause.

Rarely, circumcision will be recommended to those who have extreme difficulty retracting the foreskin and have had repeat episodes of balanitis. However this is usually a last resort after non-invasive treatments have been unsuccessful.

What if all my tests are negative?

Non-Specific balanitis describes balanitis in those where no specific cause of the inflammation can be identified and all tests are negative. Such cases of non-specific balanitis are managed on a case by case basis.

Many patients find using a salt water bath, or use of saline wipes over the affected area to improve the symptoms.

Will my partner also need treatment?

This will only be necessary if the cause of balanitis is an STI.

Although fungal infection is not sexually transmitted, occasionally it may be necessary to treat the sexual partner to reduce the recurrence of balanitis.

How can I prevent getting balanitis?

• Wash your penis every day, including under the foreskin
• Dry after washing before getting dressed
• Use latex-free condoms or condoms for sensitive skin
• Wash your hands before going to the toilet/touching your penis
• Avoid soaps or shower gel on the area – highly fragranced products often contain harsh chemicals which are known to irritate the skin