Balantis

What is Balanitis? Balanitis/ Balanoposthitis (Infection of the glans and/or foreskin)

You have just been diagnosed with balanitis by your physician...let's review together what you discussed in the office. Balanitis simply means a swelling or inflammation of the end of the penis (glans or head). Inflammation most often presents as a redness and/or a blotchy rash of the glans, sometimes with a discharge (this is quite rare). The condition may be accompanied by an itchy or uncomfortable sensation but often feels completely normal

Posthitis is a similar inflammation of the prepuce (foreskin) and is treated the same way. The two may occur simultaneously - balanoposthitis.

What are the symptoms of Balanitis?

The inflammation may present as distinct red spots or dots, red plaques or may affect the entire head of the penis/prepuce. At times the irritation can be so great as to include small breaks in the surface of the skin (fissures). These open wounds are often very sensitive to touch, particularly when soaps or detergents come into contact with affected skin. Itchiness is quite common. Pain is fortunately infrequent.

What causes Balanitis?

Balanitis can be broken down into several different causes; bacterial infection, fungal infection (thrush), chemical irritation (allergic dermatitis) or eczema/psoriasis. Fungal infections are by far the most frequent, followed by chemical irritations.

Fungal infections are most commonly due to the presence of Candida Albicans - Candidiasis (kandidi´esis)- a normal skin habitant that grows out of control and causes your symptoms. Poor hygiene or poor cleaning under the foreskin of the uncircumcised male can cause or exacerbate the problem. However, excessive cleaning with soaps under the foreskin can have the same effect. This will be discussed in greater detail further on. Read on...

How is Balanitis spread? Where did it come from?

One of the most common and real concerns that we hear at l'Actuel is; "can I transmit this to my partner" or "is my partner at risk"? Balanitis is not a sexually transmitted disease. It results from an overgrowth of organisms (typically yeast or fungi) which are normally present on the skin of the glans. These yeast are present in both circumcised and uncircumcised men. This being said, the condition most commonly becomes problematic in men who have a foreskin (i.e. have not been circumcised). The environment under the foreskin is warm and moist, and these conditions often favour the growth of the organisms that cause balanitis. In fact, skin candida albicans or mushrooms prefer growth environments that are similar to those ideal to grow edible mushrooms, that is; warmth, humidity and darkness. Obviously, the uncircumcised penis is fertile ground for the occurrence of balanitis. Candida can cause vaginal thrush in women; therefore balanitis in men is sometimes called thrush. However, candida is normally present in both men and women and a man will not automatically develop balanitis if he has intercourse with a woman with thrush.

These organisms are especially likely to multiply and cause inflammation if moisture is allowed to persist under the foreskin. This may occur if you have not washed for a couple of days, or sometimes after sexual activity (vaginal, oral or anal - with or without a condom).

Frequently, the delicate balance between your normal populations of skin bacteria, yeast and the local pH or acidity are thrown off by one or more of these activities, with the result being a loss of control over the populations of yeast and/or bacteria. Your partner's vaginal secretions may cause a local imbalance and subsequent symptoms. In contrast to poor hygiene, improper or overly zealous cleaning may be the problem... harsh/caustic soaps, detergents, shampoos or other body care products may irritate this environment. It is important to evaluate YOUR environment in an attempt to determine the cause in YOUR case.

How many people have Balanitis?

Balanitis is quite frequent, has no age restriction and frequently occurs in the absence of sexual relations. Once again, this is not a sexually transmitted or venereal disease.

How is Balanitis diagnosed? This is NOT a painful procedure!

Most cases of Balanitis will be diagnosed based on the physical examination that will be performed in the clinic. Remember, it is important to exclude other causes of serious or transmissible skin diseases. When balanitis is the cause, the diagnosis is often quick and reassuring. At times, in an attempt to confirm the diagnosis your physician may swab a sample from the surface (not inside the urethra) of the glans of your penis and visualize the specimen under the microscope for the presence of yeast and or bacteria. This is a short and simple procedure...no pain involved! On rare occasions when your balanitis is recurrent, and before more drastic measures are contemplated, your physician may send a swab to be grown in the laboratory in an effort to identify resistant bugs (this may help to choose the appropriate successful therapy when standard treatments fail)

Is there a cure for Balanitis? What is the treatment?

The treatment depends on the cause. This is where consultation with one an expert is recommended.

Bacterial infections are treated with antibiotics. These will be prescribed.

Thrush or Candida (the most common cause) is treated with an antifungal cream that may/may not be combined with a cortisone-based cream. The treatment decision often depends on the severity of your condition. In severe cases of balano(posthitis) we may prescribe a medication to be taken by mouth - let an expert treat you appropriately.

Allergy/dermatitis (chemical) is simply treated by the avoidance of those products that caused the allergy or inflammation. The culprit may take time to identify by the use or avoidance of products in your environment. In moderate to severe cases, a mild steroid or cortisone cream may be prescribed.

On rare occasions the penis may swell so that urine cannot be passed. This is a case where you should see a doctor as soon as possible. You may need referral to a hospital for care.

Similarly, recurrent balanitis that is not responding to prescribed treatment should probably be seen by a specialist. This may include a consultation with a dermatologist or at times an evaluation by a urologist so as to evaluate the need for circumcision or removal of the foreskin.

Balanitis is not sexually transmitted, but sexually transmitted diseases may be mistaken for balanitis and so if there is any doubt see your doctor.

Part of the treatment for balanitis involves cleaning the penis correctly...so,

How can I avoid getting Balanitis?

Hygiene

All children over the age of 3 and men should clean their penises at least once per day. It is important to learn how to do so if you do not know how. The aim is to make it difficult for organisms to grow under the foreskin by keeping the glans and the foreskin clean and dry.

The best place and time to do this is in a warm bath or shower that does not contain soap. If soap must be used, prefer soaps that have a neutral pH, and that are perfume or fragrance free. Gently retract the foreskin back towards your body until the glans is completely uncovered (Figures 1a and 1b) and allow the sensitive foreskin and tip beneath to be washed by the flow of water. Do not use any force. If there is any resistance or discomfort, check with a doctor. You can add a half cup of salt (125ml) to your bath if you wish. If you do not have access to a bath, a bowl of clean warm water (1.0L) in which you disolve a teaspoon of salt (5 ml) will suffice. Do not fully retract a foreskin in a child under the age of three.

After washing, dry the end of the penis and foreskin thoroughly. Also remember if you are drying a penis to dab and not to rub. If convenient, sit with your glans exposed to the air and light for 10 minutes or more. More thorough drying can be achieved by using a fan or hair dryer - not too hot! (Figure2).

After drying, replace the foreskin (Figure 3).

What if I don't treat my Balanitis? Is Balanitis dangerous?

Balanitis is not dangerous as such. If you are symptomatic with balanitis, then treatment is in your interest. Early treatment will help to ensure that your irritation/infection does not progress and cause greater problems. Untreated, a simple balanitis may resolve or may progress to a more advanced painful and symptomatic stage. Why suffer needlessly?

How does Balanitis affect pregnancy?

It doesn' t affect pregnancy. There is NO risk to the unborn fetus. Balanitis is not a sexually transmitted disease. See the chapter on Vaginitis/Thrush for more information.

I have recurrent Balanitis...what do I do?

In recurrent infection you will be given advice about genital hygiene and the use of soaps and bubble baths which can exacerbate this condition. Referral may be considered if there is no improvement or if there is an associated phimosis (narrowing of the foreskin and inability to fully retract your foreskin). Most often, when the response is poor and your problem persists, your physician will refer you to a dermatologist or at times a urologist for a second opinion and ultimate management. There are several conditions that are not caused by bacteria, yeast or chemical irritants that may mimic a balanitis.

Do I need to be circumcised?

There are several infrequent problems that may be a reason for us to discuss circumcision as the appropriate treatment option.

• Symptomatic phimosis (narrowing of the foreskin and difficulty retracting your foreskin and exposing your glans)
• Paraphimosis
• Recurrent balanitis/ balanoposthitis
• Suspicion or evidence of carcinoma or cancer - RARE
• Selected recurrent urinary tract infections in children (normally referred by a paediatrician)
• Dermatological diseases (e.g. lichen planus or eczema) unresponsive to other treatment - we will refer you.
• Balanitis xerotica obliterans - we will refer you.

A review of what's new!

Oral medications, or medications taken by mouth may be prescribed in the case of moderate to severe or resistant to treatment balanitis. These medications are well-tolerated and extremely effective when combined with our preventive and hygiene measures.

Text by Dr. Robert O'Brien