Balanitis: causes, treatment and when circumcision is considered

Balanitis is inflammation of the glans, the rounded tip of the penis. When the foreskin is inflamed too, the term balanoposthitis is used, and NICE Clinical Knowledge Summaries say that in practice both areas are often affected and the single word balanitis is generally used for both. It can be short-lived (acute), long-lasting (chronic) or recurrent.

The NHS describes a head of the penis that is swollen, itchy and sore, and usually red, though redness can be less obvious on brown or black skin. Other symptoms can include pain when peeing, a thick discharge from under the foreskin, bleeding around the foreskin, an unpleasant smell, and difficulty pulling back the foreskin. In young children a tight foreskin is normal, so difficulty retracting alone is not a sign of balanitis in that age group.

Balanitis is a description rather than a single disease. NICE CKS says it may be caused by several conditions affecting penile skin that can look similar and sometimes exist together. The NHS list of causes includes not washing the penis properly, a very tight foreskin that stops a young boy cleaning underneath, thrush, sexually transmitted infections such as gonorrhoea or chlamydia, irritation from soap, shower gel or condoms, and diabetes, because high sugar in urine can encourage thrush.

The NHS says a doctor or nurse will look at the penis and ask a few questions, may swab the head of the penis for infection and, if symptoms are severe, may suggest a blood test for conditions that can lead to balanitis such as diabetes. NICE CKS adds that clinicians should ask about hygiene practices, irritants, new medicines, existing skin conditions, sexual history and anything that weakens immunity, and may arrange swabs from under the foreskin, an STI screen, and blood tests for HbA1c and HIV if balanitis is severe or persistent.

Adults do not have to wait for a GP slot. The NHS notes that sexual health clinics assess genital problems, many take walk-ins, and they often return test results sooner than GP surgeries. Children are assessed by their GP, and the NHS says to speak to a GP if a child has symptoms.

Treatment follows the cause. The NHS says a GP may prescribe a mild steroid cream or ointment, an antifungal cream or ointment, or antibiotics. NICE CKS pairs them to the likely cause: a steroid or imidazole preparation for non-specific dermatitis, an imidazole or oral antifungal plus a steroid for candida, antibiotics plus a steroid for bacterial balanitis, and trigger avoidance, a steroid and a regular emollient for contact dermatitis. Most episodes improve once the cause is identified and treated.

• Wash the penis every day with just water or an emollient, gently pulling back the foreskin and drying afterwards (adults).

• Avoid soap and shower gel on the area; if you use condoms, choose ones made for sensitive skin.

• For a child, wash gently with warm water, change nappies often, avoid soap, bubble bath and baby wipes, and do not pull back a foreskin that is fixed in place.

• Wash your hands before peeing or touching the penis.

NICE CKS recommends specialist referral for diagnostic uncertainty, persistent or recurrent balanitis that does not respond to primary care treatment, persistent phimosis, suspected allergic contact dermatitis, lichen sclerosus or Zoon's balanitis, and any suspected pre-malignant or malignant lesion. Complications it names include phimosis, paraphimosis, narrowing of the urethral opening, sexual dysfunction and, rarely, penile cancer.

The NHS says circumcision may be considered when balanitis keeps coming back and medicine has not helped. The Birmingham and Solihull ICB policy page lists three documented episodes of balanoposthitis (inflammation of the head of the penis) as a funded indication for circumcision. Documenting each episode, ideally with swabs and a note of the treatment given, is therefore part of building the clinical picture. A surgeon will normally also look for an underlying skin condition, because circumcision treats scarring and tightness but does not replace treating an inflammatory skin disease.

See a GP if balanitis symptoms appear in you or your child, or if treatment has not worked. The NHS says that if the foreskin has been pulled back and cannot be returned over the end of the penis, call 999 or go to A&E, because this paraphimosis is a medical emergency. A sore ulcer, lump or thickened patch that does not settle is also a reason to be seen promptly, as the NHS lists these as things to look for in people with lichen sclerosus.