Pediatric Balanitis and Balanoposthitis

It’s never comfortable and is often very distressing to have skin problems and infections, such as intertrigo, folliculitis, panniculitis, omphalitis, or even preseptal or periorbital cellulitis.  It’s even more distressing when the skin problem affects the penis.  While summer is starting to wind down, and Summer Penile Syndrome is less likely to occur, we must still be vigilant for penile problems that can occur all year long.  Paraphimosis, phimosis, and priapism can be painful pediatric penile problems that need prompt perusal and procedures to prevent problems with peeing.  (Phew!)  Now let’s consider another penile and skin problem that is quite common – Pediatric Balanitis and Balanoposthitis. 

Balanitis and Balanoposthitis – Basics 

  • Terminology [Assim 2022, Dynamedex 2024, Perkins 2024] 
    • Balanitis– Inflammation of the glans penis 
    • Posthitis– Inflammation of the foreskin (prepuce) 
    • Balanoposthitis– Inflammation of both (ouch!) 
  • Most often occurs in uncircumcised males [Assim 2022] 
    • Buildup of sloughed and dead skin, microorganisms, and secretions between the foreskin and the glans 
  • Incidence in children shown to range from 0.05% up to 20% [Kayaba 1996, Hsieh 2006] 
    • Between 6% and 20% in uncircumcised men [Assim 2022, Perkins 2024] 
    • Pediatrics usually presents between 2y and 5y of age, likely from physiologic phimosis and hygiene [Perkins 2024] 
  • Risk factors 
    • Lack of circumcision 
    • Poor hygiene 
    • Phimosis 
    • Using soaps or lotions with allergens or irritants 
    • Latex condoms, lubricants with propylene glycol, spermicides, or corticosteroids [Dynamedex 2024] 
    • Some antibiotics and medications become concentrated in the urine, are retained in the preputial space after urinating, and can cause irritation balanitis 
    • Diabetes – glucosuria can predispose to yeast and other microbial growth

Balanitis and Balanoposthitis – Etiology 

  • Can be infectious, nonspecific, inflammatory, trauma, or even pre-malignant [Assim 2022, Dynamedex 2024, Perkins 2024] 
    • In children, it’s most often infectious or inflammatory 
    • Candida albicans, 20-35% of cases, most common infectious cause [Lisboa 2009, Dynamedex 2024] 
    • Streptococcus species second most common infectious cause (groups A, B, D) [Lisboa 2009, Dynamedex 2024] 
    • Also caused by [Lisboa 2009, Dynamedex 2024, Perkins 2024] 
      • Gardnerella vaginalis 
      • Staphylococcus species 
      • Chlamydia trachomatis 
      • Pseudomonas aeruginosa  
      • Mycoplasma genitalium 
      • HSV 
      • HPV 
      • Trichomonas vaginalis 
      • Treponema pallidum 
  • Can indicate or be associated with underlying inflammatory dermatoses [Dynamedex 2024, Perkins 2024] 
    • Lichen sclerosis (balanitis xerotica obliterans) – most often in adults but be vigilant for this in adolescents 
      • Chronic mucocutaneous problem 
    • Lichen planus – autoimmune 
    • Psoriasis – chronic and inflammatory 
    • Circinate balanitis – associated with reactive arthritis, or even with chlamydia, HIV, or syphilis infections 
    • Eczema, contact dermatitis, seborrheic dermatitis, or atopic dermatitis 
    • Stevens-Johnson syndrome or other drug eruptions or allergic reactions 
    • Insect bites 
    • Erythema multiforme, pemphigus and other immunobullous disorders 
  • Can even just be non-specific 

Balanitis and Balanoposthitis – Presentation and Exam  

  • History [Dynamedex 2024, Perkins 2024] 
    • Itching or pain in the groin/genitals 
    • Redness and swelling of the penis and/or foreskin 
    • Discharge 
    • Dysuria  
    • Difficulty or inability to urinate, weak stream 
    • May have bullae or plaques on the glans 
    • Eroded pustules 
    • Foul smell 
    • Ask about 
      • Relapsing/remitting 
      • Any chronic underlying conditions – diabetes, lichen sclerosis, sexual activity and exposures, new chemicals/soaps/condoms/lubricants, hygiene practices 
      • Medication history – NSAIDs, antibiotics, acetaminophen 
  • Physical exam [Dynamedex 2024, Perkins 2024] 
    • Phimosis 
    • Erythema 
    • Creamy or curd-like discharge 
    • Swelling/edema of glans and/or foreskin 
    • Preputial fissuring or erosions 
    • Inguinal lymph node swelling 
    • When evaluating for STIs, look for erosions, painless ulcers, grouped vesicles, genital warts, or fleshy papules 
    • When evaluating for underlying systemic causes, look for plaques, eczematous patches, insect bites, scaly patches, circinate balanitis areas with white or gray “geographical” margins 
    • Don’t forget your otherwise thorough exam looking for other systemic findings, skin and oral exams, and your perineal and anal exams 

Balanitis and Balanoposthitis – Diagnosis  

  • Most often based on history and physical examination alone 
  • In pre-pubertal children, likely no testing needed unless refractory symptoms 
  • Could do a sub-preputial swab to evaluate for yeast or bacterial infection if necessary 
  • In adolescents, especially if they are sexually active, testing should be done for sexually transmitted infections, including HIV, syphilis, gonorrhea, chlamydia, trichomonas, and HSV 
  • Consider testing for diabetes or causes of immunosuppression if symptoms are refractory or severe [Dynamedex 2024] 
  • Biopsies are rarely necessary but could be helpful if concerned for malignancy, refractory cases, or systemic inflammatory/autoimmune cause 
  • Up to 1/3 of cases cannot find a definitive cause [Perkins 2024]

Balanitis and Balanoposthitis – Treatment  

  • Supportive care, proper hygiene, saline or sitz baths, avoidance of irritants [Assim 2022, Dynamedex 2024, Perkins 2024] 
    • Avoid creams/ointments with parabens and neomycin, which can be irritating 
  • For candidal infections (IUSTI/WHO recommendations) 
    • Topical- clotrimazole 1% cream twice daily for 7-14 days  
      • Also miconazole 2% cream 
      • Nystatin cream 100,000 units/g (if antifungal resistance or imidazole allergy) 
      • Can combine topical cream with 1% hydrocortisone if very inflamed 
    • Oral (for severe symptoms)- fluconazole 150 mg orally 
  • For bacterial infections (IUSTI/WHO recommendations) 
    • Topical 
      • Mupirocin ointment 2-3 times daily for 7-10 days 
      • Clobetasone butyrate with nystatin and oxytetracycline cream 1-2 times daily for 7-10 days 
    • Oral  
      • Metronidazole oral twice daily for one week (anaerobic) 
      • Amoxicillin/clavulanate (250/125) oral three times daily for one week (anaerobic alternative) 
      • Penicillin for 10 days for Group A Strep infections 
      • Otherwise use an antibiotic based on culture and sensitivity of organism 
  • For sexually transmitted infections, use current specific guidelines for treatment of underlying infection. 
    • Should abstain from sexual activity until symptoms resolve 
  • Treatment of other systemic or underlying causes gets complicated and is beyond the scope of this discussion today but there are some great resources available for your review 
  • May need circumcision eventually.  This can reduce inflammatory causes by 68% [Perkins 2024] 
  • Consider a referral to a specialist if cases are recurrent or refractory to treatment [Dynamedex 2024] 
  • Treatment of sexually transmitted infections in those at risk or who test positive 
  • Urology referral for persistent/refractory cases, for persistent phimosis, failed medical treatments, or concern for malignancy 

Balanitis and Balanoposthitis – Complications 

  • Secondary phimosis 
  • Penile bleeding 
  • Scarring 
  • Meatal or urethral stricture 
  • Complications from sexually transmitted infections 
  • For uncomplicated yeast or bacterial balanitis, the complication rate is low

Moral of the Morsel

  • Beware the painful penis! There are plentiful painful problems in penises, including balanitis and balanoposthitis. 
  • Let’s keep it clean, now! Hygiene and topical irritants are the most common causes of non-infectious balanitis. Instruct parents and parents how to maintain proper hygiene for uncircumcised penises.  
  • To treat to not to treat? Treatment with supportive care or medications depends on the underlying cause. Don’t forget to test for and treat STIs in adolescents and sexually active juveniles, and to evaluate for underlying systemic conditions. 

References: 

Assim AJ, Powell K, Awad K. Guideline review NICE clinical knowledge summary: Balanitis in children. Archives of Disease in Childhood.Education and Practice Edition. 2022;107(2):131-132. https://wake.idm.oclc.org/login?url=https://www.proquest.com/scholarly-journals/guideline-review-nice-clinical-knowledge-summary/docview/2640428169/se-2. doi: https://doi.org/10.1136/archdischild-2020-321303.  

DynaMedex. Balanitis/Balanoposthitis. EBSCO Information Services. Accessed August 1, 2024. https://www.dynamedex.com/condition/balanitis-balanoposthitis 

Perkins OS, Leslie SW, Cortes S. Balanoposthitis. [Updated 2024 May 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553050/  

Kayaba H, Tamura H, Kitajima S, Fujiwara Y, Kato T, Kato T. Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol. 1996;156(5):1813-1815.  

Hsieh TF, Chang CH, Chang SS. Foreskin development before adolescence in 2149 schoolboys. Int J Urol. 2006;13(7):968-970. doi:10.1111/j.1442-2042.2006.01449.x 

Lisboa C, Ferreira A, Resende C, Rodrigues AG. Infectious balanoposthitis: management, clinical and laboratory features. Int J Dermatol. 2009;48(2):121-124. doi:10.1111/j.1365-4632.2009.03966.x 

Author

Christyn Magill
Christyn Magill
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