Brief overview
- Causes and risk factors: Excessive or inadequate personal hygiene and infections, uncircumcised men more frequently affected than circumcised men
- Treatment: Mostly external therapy with baths or ointments, sometimes tablets, rarely surgery
- Symptoms: The most common symptoms of balanitis include pain, itching, rashes, discharge and other changes to the glans penis
- Duration: The course of the disease depends on the cause, but also on the patient’s state of health.
- Diagnosis: Medical history and physical examination, if infectious balanitis is suspected, swab the glans and urethral opening to determine the pathogen
- Prevention: Appropriate intimate hygiene and protection against pathogens transmitted during sexual intercourse
What causes balanitis?
There are many possible causes for the development of balanitis. There is often a combination of several causes. For example, mechanical irritation often favors an infection. In a third of all patients, no clear cause of glans inflammation is identified.
The causes of balanitis can be roughly divided into non-infectious and infectious causes. However, glans inflammation also occurs in the context of other diseases.
Non-infectious causes of balanitis
High levels of mechanical and chemical stress also sometimes provoke balanitis. This can be caused, for example, by excessive washing and disinfectants. In some cases, balanitis is also the result of irritation or an allergic reaction to medication, fragrances or (latex) condoms.
Doctors also refer to inflammation of the glans due to a non-infectious cause as balanitis simplex (simple inflammation of the glans).
Infectious causes of balanitis
The two most common causes of infectious balanitis are bacterial and fungal infections.
Bacterial causes of balanitis include infections with staphylococci, enterococci, streptococci and Mycobacterium tuberculosis, the causative agent of tuberculosis.
The bacterium Gardnerella vaginalis is also a possible cause of balanitis. This germ is often the cause of bacterial vaginitis (vaginosis). During sexual contact, it is possible for the bacteria to be transferred to the penis and trigger glans inflammation.
Balanitis caused by yeast fungi is also known as candidomycetica balanitis. Like bacterial infections, fungal infections are either localized or systemic (i.e. also affecting the rest of the body).
Another fungal infection, namely with Malassezia furfur, is the so-called pityriasis versicolor. This form of skin fungus is relatively rare in Europe, but common in tropical regions. It particularly affects the back, shoulders, neck and chest, sometimes also other parts of the body such as the penis. This fungal infection is characterized by sharply defined, brownish and scaly changes.
Other fungal infections affect the penis even less frequently. These are mainly fungi that settle in the groin and spread continuously to the penis over time.
The glans penis also becomes inflamed more frequently in connection with sexually transmitted diseases. Infections with herpes viruses and human papillomaviruses (HPV) – especially types 6 and 11 – are particularly noteworthy here. HPV in particular leads to protracted balanitis, which is not easy to overcome.
Other possible triggers are trichomonads, gonococci (causative agent of gonorrhea/gonorrhea), Treponema pallidum (causative agent of syphilis) and Haemophilus ducreyi (causative agent of ulcus molle).
Balanitis in the context of other diseases
Various skin diseases promote the development of balanitis or even trigger it. These include seborrhoeic dermatitis, psoriasis and the autoimmune disease pemphigus vulgaris.
As part of reactive or post-infectious arthritis (formerly Reiter’s disease), a non-infectious inflammation, around a quarter of those affected develop balanitis. This disease is characterized by the three symptoms of joint inflammation, urethritis and conjunctivitis. It usually occurs one to four weeks after a urinary tract or gastrointestinal infection and is also known as balanitis circinata.
Balanitis plasmacellularis zoon occurs in older men over the age of 60. The cause of this form of acorn inflammation is unclear. It leads to minor bleeding and deposits of hemosiderin, an iron storage protein. In addition, immune cells infiltrate the glans tissue.
In rare cases, inflammation of connective tissue cords leads to the death of tissue and thus triggers a dangerous balanitis gangraenosa. This requires immediate treatment.
Balanitis in the context of cancer treatment
Risk factors for balanitis
The main risk factor for balanitis is inadequate intimate hygiene. It is important to wash the penis and especially the glans daily with warm water and to remove smegma. Failure to clean, but also overly aggressive cleaning, promotes the development of balanitis.
A constricted foreskin that is difficult or impossible to retract (phimosis) also promotes inflammation of the glans, as this makes it easier for pathogens to attach themselves to the glans and spread. For this reason, circumcision appears to significantly reduce the risk of balanitis.
Statistically, people with certain diseases are more likely to have balanitis than otherwise healthy people. This is particularly true for people with diabetes mellitus. The sugar in the urine of diabetics presumably promotes the development of balanitis. Diabetes patients often have a fungal infection as the cause of balanitis.
Severe obesity and the chronic inflammatory bowel diseases Crohn’s disease and ulcerative colitis are also considered to be risk factors for acorn inflammation.
Treatment of balanitis
In order to treat balanitis itself, daily washing of the genital area with warm water is just as important as good drying. Sitz baths are a good home remedy to support the therapy.
Home remedies have their limits. If the symptoms persist over a longer period of time and do not improve or even get worse, you should always consult a doctor.
Local balanitis treatment
In the case of infectious acorn inflammation, local (external) balanitis treatment is usually sufficient. An ointment containing the antibiotic metronidazole is usually prescribed against bacteria. It has a very broad spectrum of action. Cotrimazole, which is effective against a variety of fungi, is usually used to treat fungi (e.g. candida balanitis). This is usually sufficient to defeat the infection.
If no success is seen after four weeks of antifungal therapy, it is advisable to reconsider the diagnosis. In the case of balanitis of a non-infectious cause, local therapy with a cortisone ointment is usually tried first. The glucocorticoid cortisone reduces the inflammation and thus usually significantly improves the symptoms. However, it should be noted that the symptoms of cancer (precancerous stages) may also improve under cortisone therapy and then recur once the ointment is discontinued.
Balanitis therapy with tablets
In certain situations, the medication must be taken in tablet form. This applies, for example, to diabetes mellitus, severe alcoholism, chemotherapy, AIDS and prolonged use of cortisone. In these cases, there is also an increased risk of the infection recurring.
Surgery
In the case of repeated balanitis and constricted foreskin, the doctor may suggest circumcision as a treatment option. This involves surgically removing the foreskin of the penis. Circumcised men are usually less susceptible to infections. Surgical intervention is often performed to prevent narrowing of the urethra, particularly in cases of lichen sclerosus.
Balanitis therapy for children
There are special treatment recommendations for children that should be followed. Parents or the child itself should consistently perform daily intimate hygiene with the foreskin retracted. After consultation with the pediatrician, he or she will prescribe a suitable ointment if necessary.
If the foreskin is constricted, it should only be pushed back, if at all, in consultation with the treating doctor. This is often very painful and unpleasant. For this reason, the use of local anesthesia with an ointment or the administration of painkillers (possibly also locally) is considered on a case-by-case basis.
The main symptom of balanitis is a more or less painfully reddened and inflamed glans. However, it is usually only the upper layers of the skin that are inflamed and not the deep erectile tissue of the glans. Those affected often report rashes (such as red spots or patches) and unclear changes to the glans. Another frequently mentioned symptom is that the glans burns or itches.
In addition to the red rash, affected men usually also suffer from discharge from the penis. This discharge can be of different colors and foul-smelling. The consistency is often purulent. Pulling back the foreskin is usually difficult and painful.
However, this also happens when the glans swells (edema). This makes urination difficult and painful. In severe cases, this sometimes interferes with the control of the urine stream. Sometimes balanitis is even associated with impotence, even if only temporary.
Clues to the cause of balanitis
In addition, there are a number of signs of balanitis that already provide indications of a possible trigger. Some are listed here as examples:
- When infected with the herpes virus, a large number of grouped blisters form. The infection is usually accompanied by fever and swelling of the inguinal lymph nodes.
- An infection with the human papillomavirus (HPV) triggers condylomas. These are cauliflower-like growths that are often found at the base of the glans.
- The syphilis infection leads to a painful ulcer with a hard edge.
- Raised redness or whitish discoloration with itching are indications of a fungal infection.
- Balanitis in the context of reactive or post-infectious arthritis is characterized by redness with a white border and skin damage on the glans.
- Balanitis plasmacellularis zoon is a chronic inflammation of the glans of unknown cause. It is characterized by smooth, lacquer-like and reddish-brown areas.
How long does balanitis last?
Untreated balanitis sometimes ascends along the urinary tract. Possible consequences are a urinary tract infection, bladder or prostate inflammation. Urinary tract infections are rare in men and need to be treated more consistently than in women.
If balanitis does not improve – despite the correct treatment – this potentially indicates a malignant process. In this case, a biopsy should be performed. In most cases, this is the precursor of a cancer (erythroplasia Queyrat), which in some cases develops into a carcinoma.
In patients with a weakened immune system, infectious balanitis should be monitored particularly closely. On the one hand, it is easy for the infection to spread and affect other parts of the body. On the other hand, balanitis may be the first sign of an existing infection in the body.
In addition, infections in weakened immune systems often take a much more severe course than in healthy people, and there is a risk of severe skin damage with bleeding. Persistent fungal balanitis therefore leads to painful inflammation of blood vessels in some immunocompromised patients.
In rare cases, balanitis results in a narrowing of the foreskin (phimosis).
What is balanitis?
Balanitis is most common in uncircumcised men and occurs almost equally frequently in all age groups, including babies and young children. However, the frequency of the various causes of glans inflammation varies depending on age.
Overall, it is estimated that between three and eleven percent of all men suffer from balanitis each year. However, most studies on glans inflammation have only examined children and sexually active men.
Balanitis: examinations and diagnosis
Which doctor should you see if you have balanitis? Adult men should see a urologist if they suspect glans inflammation. The first step in diagnosing balanitis is a detailed discussion with the patient to take a medical history. The doctor will ask questions such as
- How intensively do you practise intimate hygiene?
- Have you noticed any changes to the glans or penis?
- Do you suffer from pain or itching in or around the glans?
- Do you have problems with urination or sexual intercourse?
- Do you have any known skin conditions or other diseases?
As described in the symptoms section, many causes of balanitis can be identified by typical, visible changes to the glans penis, such as grouped blisters in the case of a herpes infection.
If an infectious inflammation of the glans penis is suspected, a smear should nevertheless be taken from the glans penis and the entrance to the urethra to determine the pathogen. This swab is examined under a microscope. In some cases, the different bacteria or fungi are identified with the help of special stains. If the doctor uses a culture to grow existing pathogens, they can be identified even better.
In very rare cases, particularly with certain types of fungi, the blood of balanitis patients is examined for the pathogen or antibodies against the pathogen. However, the blood test is usually reserved for unclear and severe cases.
A small tissue sample (biopsy) is considered in the case of unclear and complicated balanitis. In the case of infectious balanitis, however, the findings of a biopsy are usually non-specific. In uncertain cases, a biopsy is primarily used to investigate the suspicion of a tumor or skin disease.
If there are problems urinating, the doctor will examine the urethral opening for signs of inflammation. He will ask the patient whether the foreskin “inflates” when urinating. If there is evidence of involvement of the urinary tract, the doctor will perform an ultrasound examination of the bladder to determine whether there is any obstruction to the flow of urine.
It is possible for balanitis to be triggered by several causes at the same time. This means that further investigation may be necessary even after a supposed cause has been identified. For example, it is not unlikely that there is another infection in addition to a wart caused by the human papillomavirus.
Warning signs of a complicated course of balanitis are
- Signs of blood poisoning (sepsis)
- Poorly controlled diabetes mellitus
- Inability to retract the foreskin
- Blockages during urination
Balanitis: prevention
Balanitis is often caused by overly aggressive or inadequate intimate hygiene. Appropriate intimate hygiene is therefore important to reduce the risk of balanitis. Certain risk factors such as chronic inflammatory bowel disease cannot be prevented. However, it is possible to prevent infections in the genital area that increase the risk of balanitis.
