What is balanitis?
Balanitis is the medical term for inflammation of the glans penis, also referred to as the head of the penis or tip of the penis. The inflammation often involves the foreskin (prepuce) in uncircumcised men in which case it is known as balanoposthitis. If the foreskin alone is inflamed then it is known as posthitis. However, these conditions are largely similar and is often discussed together. These are common conditions in males and can affect any age group. Balanitis is more common in boys and men who have not been circumcised but does not warrant the need for a circumcision as a preventative measure. Most cases are due to infections and poor personal hygiene is a major risk factor. It is not a life threatening condition but can lead to serious complications if left untreated.
The head of the penis (glans penis) is a mucous membrane and lacks the keratinized protection of skin. The foreskin covers the glans penis, thereby protecting it to some degree, and allows for moisture of the membrane to be retained. Circumcised males, on the other hand, do not have this level of protection and the glans penis is constantly dry. Despite the protection from the foreskin, the penile head is still exposed and in fact the foreskin can contribute to infections of this area. Therefore circumcised males, although having a drier glans penis, are less prone to balanitis.
Meaning of Balanitis
Like any area of the body, the head of the penis is prone to inflammation under certain conditions. Inflammation is a response to injury, whether mechanical, chemical, allergic or infectious. The tip of the penis is covered by the foreskin which can retract when necessary but it also traps debris, dirt and bacteria. The penis itself is kept warmer than other parts of the body due to constant covering with clothing. The moisture on tip of penis further covered by the foreskin, provides an ideal environment for bacteria and even fungi to grow and thrive within. Poor hygiene does not remove remnants or urine, semen, epithelial cells and skin oils which are collectively referred to as smegum. As the invading pathogen grows and multiplies it can reach a stage where it is able to cause serious injury to the tissue of the head of the penis.
Inflammation then sets in. The process of inflammation on the glans penis is marked by swelling, redness, heat and pain. Since the inflammation extends to the foreskin, this area may also be red, swollen and painful. The inflamed foreskin may be unable to retract and this is known as phimosis. Similarly excessive swelling of the head of the penis may trap the foreskin behind it thereby preventing it from returning to its normal position. This is known as paraphimosis. Swelling of the penile tissue and the pressure of the foreskin against it may compress and thereby block the urethra. If balanitis is not treated, it can lead to persistent injury of the urethral opening and distal portion of the urethra. Subsequently scar tissue may form thereby permanently narrowing the urethra – urethral stricture. Although balanitis is almost always caused by an infection, the inflammation of the head of the penis can occur at times with non-infective causes.
Causes of Balanitis
The two main factors that contributes to balanitis is poor hygiene and a tight foreskin (phimosis). Other risk factors include HIV, diabetes mellitus, multiple sexual partners and a history of sexually transmitted infections (STIs).
Balanitis is mainly due to an infection of the head of the penis which may or may not involve the foreskin. Simultaneous infection of the foreskin (balanoposthitis) is not a consideration in circumcised men. The main causative pathogens are bacteria and this includes naturally occurring skin bacteria. Viruses and fungi may also cause balanitis. Fungal infections are more likely in immunocompromised patients as is seen with HIV and poorly controlled diabetes mellitus. Some of the agents include :
- Gonorrhea (Neisseria gonorrhoeae)
- Genital herpes (Herpes simplex virus)
- Human papilloma virus (HPV)
- Syphilis (Treponema pallidum)
- Trichomoniasis (Trichomonal species)
- Borrelia species
The tip of the penis is sensitive and easily injured by mechanical and chemical factors. Mechanical trauma to the tip of the penis is not as common as chemical irritation. The latter may or may not be related to an allergy and can occur with :
- Soaps and disinfectants
- Condoms, lubricants and spermicides
- Washing powders and detergents
Smegum (skin oil, epithelial cells, sweat, urine, dirt) is the most common irritant and can cause balanitis even without an infection. Other non-infectious factors that are unrelated to mechanical or chemical irritants. Skin diseases like psoriasis, eczema and balanitis xerotica obliterans (BXO) may also be a contributing factor. Penile cancer, although rare, is a also a risk factor for balanitis.
Signs and Symptoms of Balanitis
Symptoms of inflammation such as redness, heat, swelling and a burning pain of the tip of the penis are among the first symptoms. It tends to arise within 2 to 3 days after sexual intercourse when balanitis is due to STIs or trauma related to sexual acts. The severity may also depend on the extent of the injury or irritation and whether it is related to infectious factors or not. As the condition worsens, the pain becomes intense and tenderness may be severe enough that even the pressure of underwear can be extremely painful. Itching of the tip of the penis and a foul smelling discharge are other common symptoms. The symptoms are often localized to a portion of the penis head initially.
In more severe cases, it affects the entire head of the penis. At this point there may be other symptoms in uncircumcised men such as an inability to pull the foreskin back (phimosis) or push it forward to its original position (paraphimosis). Urinary symptoms also depends on the severity and duration of balanitis. Burning upon urination is a common symptom even in mild cases but in severe balanitis there may also be signs of urinary obstruction like difficulty urinating or ballooning of the foreskin during urination. Urinary symptoms are more likely to be permanent in long term balanitis with the formation of scar tissue giving rise to urethral strictures.
Other symptoms like penile ulcers and pustules may be related to sexually transmitted infections even in the absence of balanitis. Swelling of the inguinal lymph nodes may also be present but is non-specific for balanitis. Read more on swollen groin lymph nodes.
Treatment of Balanitis
The treatment varies depending on whether there are complications like phimosis or urinary obstruction. In these cases circumcision may be warranted.
- The foreskin is gently retracted and the area is cleaned with warm water.
- Antimicrobial ointments may be applied to the affected area.
- Oral antibiotics or antifungal medication may be necessary.
- Topical corticosteroids may help to reduce the inflammation.
- Application of topical corticosteroid may allow for gentle retraction and the measures mentioned above.
- Circumcision may be necessary if the case is very severe and not responding to the measures above.
Prevention of Balanitis
The main preventative measure is proper hygiene. Uncircumcised men should retract the foreskin gently and wash the area daily. A hypoallergenic soap or an emollient may be used instead of soap if there is sensitivity. Warm water on its own is sufficient to keep the area clean. The area must be dried thoroughly before dressing.
Contamination of the area through fecal material or irritation by chemicals are often introduced to the area by the unwashed hands. Men should avoid touching their genitals unnecessarily and always wash their hands thoroughly before doing so. Regular diaper change in male infants is crucial because fecal matter can contaminate the head of the penis.
Sexual intercourse is a risk factor particularly in uncircumcised men. Sexually transmitted infections need to be prevented with proper condom use. Even infections of the female reproductive system, like vaginal thrush, can cause balanitis in men who are prone. There may be greater trauma to the penis with certain acts like anal intercourse and therefore lubricant use is necessary. Oral sex may also be a risk factor and infectious balanitis may be due to naturally occurring bacteria from the mouth.
Circumcision (removal of the foreskin) is a preventative measure but not for children under 3 years of age. However, it is not necessary in the solitary case of balanitis which can be treated and managed effectively with medication and other conservative measures.