‘Balanitis’ describes inflammation of the glans penis, and ‘posthitis’ describes inflammation of the prepuce (foreskin). In practice, both areas are often affected, and the term ‘balanoposthitis’ is then used. Balanitis can be acute lasting a few days, persisting (lasting for more than a few weeks) or recurrent.

Causes may present similarly and may co-exist.

  • Non-specific dermatitis with possible candida or bacterial secondary infection or trauma (foreskin fiddling). This is the most common cause in young boys.
  • Other infections including anaerobes and sexually transmitted infections (if relevant)
  • Skin conditions such as contact dermatitis, seborrheic dermatitis, psoriasis, lichen planus or lichen sclerosis.

History:

  • Penile soreness and itch
  • Bleeding from the foreskin and /or odour, which usually develops over a few days
  • Dysuria, difficulty passing urine and/or dyspareunia in older boys

On examination:

  • Redness and swelling of the glans penis with exudate
  • Tightening of the foreskin or meatal stenosis
  • Phimosis

Assessment:

  • Hygiene practices – exposure to potential irritants, allergens and new drugs, trauma
  • Consider a swab for candida and bacterial culture
  • Consider safeguarding concerns and follow the usual safeguarding procedures if you are concerned

Encourage good hygiene practices and advise to stop any suspected triggers (such as bubble bath, soaps or creams). Use regular emollient and for use as a soap substitute.

  • If inflammation is causing discomfort prescribe topical hydrocortisone 1% cream or ointment once a day until symptoms settle or for up to 14 days
  • Suspected or confirmed candidal balanitis- prescribe topical imidazole e.g. Clotrimazole cream until symptoms settle or for up to 14 days
  • For suspected or confirmed bacterial balanitis, please prescribe oral flucloxacillin for 7 days (or oral clarithromycin if known penicillin allergy).
  • If symptoms are not improving after 7 days of initial treatment stop topical hydrocortisone (if using) and take a swab, then treat accordingly.
  • For children who are struggling to pass urine due to pain, the following may be helpful: simple analgesia may help eg: paracetamol or ibuprofen, suggest sitting in a warm saline bath which may help the child to relax and pass urine, or taking a warm shower may also help.

If the child is unable to pass urine despite the measures described above, and you are concerned he is in urinary retention, please refer for same day paediatric assessment via switchboard (0208 546 7711) which will be to a phone during the day and registrar bleep out of hours. 

Please refer to Paediatric surgical team if persistent or recurrent balanitis via ERS (there is a Paediatric urology clinic held here). 

Nice guidelines

NHS patient advice

Most uncircumcised baby boys have a foreskin that will not pull back (retract) because it’s still attached to the glans. By around the age of 2, the foreskin should start to separate naturally from the glans. The foreskin of some boys can take longer to separate, but this does not mean there’s a problem – they usually detach at a later stage in these cases.  It is important that parents understand that they should not try to force a boy’s foreskin back before it’s ready because it may be painful and damage the foreskin.

Assessment

Phimosis is not usually a problem unless it causes symptoms such as redness, soreness or swelling, or ballooning of the foreskin when urine is passed – this may be painful or cause local infection

It can also be caused by a number of different skin conditions, including eczema, psoriasis, lichen planus and lichen sclerosis (scarring condition of the foreskin that’s probably caused by urinary irritation in susceptible men and boys).

Management

Topical steroids are sometimes prescribed to treat a tight foreskin. They can help soften the skin of the foreskin, making it easier to retract. Surgery may be needed if a child has severe or persistent balanitis or balanoposthitis that causes their foreskin to be painfully tight. Circumcision may be considered if other treatments have failed, but it carries risks such as bleeding and infection. Alternatively, surgery to release the adhesions (areas where the foreskin is stuck to the glans) may be possible. This will preserve the foreskin but may not always prevent the problem recurring.

Assessment

Paraphimosis is where the foreskin cannot be returned to its original position after being retracted. The glans may become painful and swollen and require emergency medical treatment to avoid serious complications, such as increased pain, swelling and restricted blood flow to the penis.

Management

Gentle compression with a saline-soaked swab followed by pulling the foreskin back over the glans is usually successful. It may be possible to reduce the pain and inflammation by applying a local anaesthetic gel to the penis and pressing on the glans while pushing the foreskin forward.

If simple methods don’t work then emergency referral is needed to preserve blood flow to the penis. Please arrange an urgent referral for surgical review via switchboard (0208 5467711) and ask for surgeons on call.  In children under 3 years of age, this will need to be referred urgently to Paediatric Surgeons at St George’s Hospital.

Supporting Information

British Association of Urological Surgeons patient advice 

NHS patient advice