1. health and fitness
2. disease

CPG M2
CLINICAL MANAGEMENT OF BALANITIS
GUIDELINE STATUS: FINAL 20/05/2008
REVIEW DATE: 20/05/2009
AUTHOR: MR BUSH, DM LEE
SCOPE OF PRACTICE
TARGET POPULATION
• Male clients presenting with symptoms consistent with balanitis
• Clients who present as asymptomatic with subsequent clinical findings of symptoms
consistent with balanitis
EXCLUSION CRITERIA
• Clients with ongoing dermatological conditions such as lichen sclerosis, lichen planus,
psoriasis, dermatitis, eczema, pre-malignant and malignant conditions, chronic skin
conditions
• Clients presenting with persistent symptoms post treatment
• HIV positive clients who present with non STI associated dermatological symptoms
GUIDELINE OBJECTIVES AND ANTICIPATED OUTCOMES
•
•
•
Provide treatment for symptomatic clients
Identification of individual STI risk and provision of appropriate screening
Identify public health risks to control infections by:
• Provision of STI education and information
• Identification and exploration of sexual risk taking behaviors
• Partner notification and treatment as required
• Test of reinfection/test of cure where appropriate
• Monitoring antimicrobial resistance
BACKGROUND
CONDITION DESCRIPTION
Balanitis is defined as inflammation of the glans penis, often involving the prepuce
(balanoposthitis). It is not sexually transmitted but may occur after sexual contact. 1 Non specific
balanitis is a common presentation. Inflammation has many possible causes, including irritation
by environmental substances, physical trauma, and infection by a wide variety of pathogens,
including bacteria, virus, or fungus, each of which require a particular treatment. Balanitis may
be caused by candida, gardnerella and anaerobic infections. This condition typically causes
pruritus and a red rash with white flat lesions on the glans penis, prepuce, coronal sulcus and
shaft. 1,2
If inflammation continues, men may exhibit shallow ulcerations on the glans penis. 1,2,3 Candida
balanitis occurs more frequently, and causes more symptoms in uncircumcised men. 1,2,3, 3 After
unprotected intercourse with a woman who has Candida vaginitis, a man may experience
transient erythema and burning of the glans penis. 2,4 Balanitis may cause oedema resulting in
phimosis, or inability to retract the foreskin from the glans penis.
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PRESENTING SYMPTOMS
• Localised rash on glans and or
prepuce
• Pruritis
• Soreness
• Itch
• Odour
• Inability to retract foreskin
• Discharge from the glans
Table M2.1: Symptoms of Balanitis
1,2,3,4
(photos courtesy of MSHC)
PRESENTING SIGNS
• Erythema
• Scaling
• Ulceration
• Fissuring
• Crusting Exudate
• Oedema
• Leukoplakia
• Sclerosis
• Odour
• Phimosis
Table M2.2: Signs of Balanitis
1,2,3,4
(photos courtesy of MSHC)
Predisposing factors such as HIV infection and diabetes should be considered. Clients with
symptoms of diabetes, who are over 40 years of age, a family history of diabetes or recurrent
candida balantitis should have a urine test to screen for glycosuria. 3,5,6 In diabetic clients the
presentation may be more severe with oedema and fissuring of the foreskin present. 2,4 Recent
use of oral antibiotics may also contribute to balanitis. 6
Candidal balanitis is considered the most common cause of balanitis usually caused by Candida
albicans. 1,2 Other skin conditions may affect the glans penis, including
•
•
•
•
•
•
•
2,3,4,5
Psoriasis
Lichen planus
Seborrheic dermatitis
Phimosis
Herpes simplex virus
Malignant transformation
Fixed drug reaction
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INVESTIGATIONS AND DIAGNOSIS
Diagnosis includes careful identification of the cause with the aid of a good history, swabs and
cultures. Although the detection of aerobic and anaerobic bacteria does not always imply the
cause of the balanitis, culture for bacteria can exclude an infective etiology and may be helpful.
3,5,6
•
•
•
•
•
Sub preputial swab for Candida (Gonorrhoea Culture plate) and bacterial culture (Horse
Blood Agar plate) may help to exclude an infective cause or super infection of a skin
lesion.
A swab for HSV PCR is warranted if ulceration is present
Gram stain evaluation of sub preputial discharge if present
Dark ground examination for spirochaetes and syphilis serology if ulcer is present and
client’s history indicates epidemiological risk
Screening for other STIs as indicated by the sexual history
DIABETES SCREENING
• Over 40 Years of age
• Overweight
• Family history of diabetes
• History of recurrent balanitis
• Symptoms of diabetes
• Thirst/Frequent urination
• Tiredness or lack of energy
• Blurred vision
• Infections
• Weight loss (in type 1 diabetes)
• Blood glucose or
urine glucose as
required
Table M2.3: Diabetes screening
CANDIDIAL BALANITIS
• Symptoms include erythematous rash with soreness and or itch
• Blotchy erythema with small papules or dull red areas with glazed appearance are seen
on genital examination
• A wet prep preparation of a skin scraping may reveal pseudohyphae or budding yeast
• Microscopy and culture of area may reveal candida infection
TREATMENT AND MANAGEMENT
The aim of treatment is promotion of genital skin hygiene. Educating the client to keep the glans
and foreskin clean and dry produces an environment where organisms are less likely to grow.
GENITAL SKIN HYGIENE1,3,5,6
• Wash with water or a ‘soap alternative’ such as Sorbolene
• Avoid soap
• The area under the prepuce should be kept clean and dry (use hairdryer or fan)
• After washing expose the glands to the air for 10 minutes
• During urination avoid urine under foreskin
• Wash penis as described above after sexual contact
MANAGEMENT1,3,5,6
• Most causes should resolve within one to two weeks
• Clients should avoid spermacides or lubricants if they are implicated as the cause of
balanitis
• Saline baths or Potassium permanganate wash may provide symptom relief
• Avoiding sexual contact may promote resolution of balanitis
• Recurrent or chronic balanitis requires a medical review
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Treatment depends on the identified cause of balanitis. In the absence of an identifiable cause
the diagnosis is nonspecific balanitis. In cases where candidal balanitis is suspected treatment
with a topical imidazole is recommended. 1.4,6 Use of preparations containing 1% hydrocortisone
is useful in clients with marked inflammation and preputial odema. 1,2.
TREATMENT
• CLOTRIMAZOLE CREAM 1% BD FOR 7-14 DAYS or
• HYDROZOLE CREAM 1% BD FOR 7-14 DAYS and
• POTASSIUM PERMANGANATE 1:8000 WASH
•
•
•
Advise about effect on condoms if antifungal creams are being used
Potassium Permanganate 1: 8000 wash can be used for cleansing and deodorising
MO review if symptoms continue post treatment
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CLINICAL ALGORITHM
Client attends with symptoms of
balanitis
Diabetes screening
• >40 Years of age
• Overweight
• Family history of
diabetes
• History of recurrent
balanitis
• Symptoms of diabetes
•
•
•
•
Symptom history
Culture for pathogens
STI screening
Pathogen identified
Other cause
No pathogen identifies
Candidal Balanitis
Refer to
appropriate CPG
Non specific balanitis
Clotrimazole cream
1% bd for 14 days
Potassium permanganate wash and
Hydrozole cream 1% bd for 14 days
Genital skin Hygiene
• No soap
• Genital skin care
• Dry glans post washing
Improvement
No further follow up
No improvement
MO review for further
investigation
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MEDICATION FORMULARY 8
DRUG
INDICATIONS
ROUTE
DOSE
FREQUENCY
Clotrimazole
Balanitis;
balanoposthitis
Topical
1%
Apply small
amount 2-3
times daily for
14 days
Hydrozole Cream
clotrimazole/
hydrocortisone
Candidal
infections
Fungal infected
dermatitis
Tinea infections
Topical
1% in
30g
Apply small
amount 2-3
times daily for
14 days
THERAPEUTIC
CLASS/
Poisons Schedule
Topical antifungal
A
S3
Topical Antifungal
A
CONTRAINDICATIONS
/
INTERACTIONS
Viral tuberculous skin
infections, eye contact,
occlusive dressings,
severe circulation
impairment
PRECAUTIONS/
ADVERSE EFFECTS
Latex products
Local irritation, skin rash,
urinary frequency,
abdominal cramps
Extensive use, non dermal
fungal primary skin
infections,
Psoriasis,
immunocompromised,
pregnancy, lactation,
children
Dermatological effects
Viral tuberculous skin
infections, eye contact,
occlusive dressings,
severe circulation
impairment
Latex products
Potassium
permanganate
1:8000
Acute
inflammatory
dermatoses
Topical
1:8000
b.d. prn
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N/A
Persisting symptoms,
recurrent infection,
diabetes, pregnancy,
lactation, adolescents
Avoid menses
N/A
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REFERENCE
1. McMillan A, Ballard R C. Ulcers and other conditions of the external genitalia.. In: McMillan A,
Young H, Ogilvie M M, Scott G R, editors. Clinical practice in sexually transmissible infections.
London: Saunders; 2002. p 549-566.
2. Aitken S. Penile, epididymal, and testicular conditions. In: Russell D, Bradford D, and Fairley
C, editors. Sexual health medicine. Melbourne: IP Communications; 2005. p. 167-183.
3. Denham I, Bowden F. Genital and sexually transmitted infections. In: Yung A , McDonald M,
Spelmen D, Street A, Johnson P, Sorrell T, McCormack J, editors. Infectious diseases a
clinical approach. 2nd ed. Melbourne: IP Communications; 2005. p. 372-387.
4. Edwards L. Genital dermatoses. In: Holmes K K, Sparling P F, Mardh P A, Lemon S M, Stamm
W E, et al, editors. Sexually transmitted diseases. 3rd ed. New York: McGraw Hill; 1999. p.
893-902.
5. Marrazzo J, Ocbamichael N, Meegan A, Stamm WE, editors. The practitioner’s handbook for
the management of STD’s. 4th ed. Washington: University of Washington; 2007.
6. Venereology Society of Victoria. National management guidelines for sexually transmissible
infections. Melbourne: Venereology Society of Victoria; 2002.
7. Melbourne Sexual Health Centre. Treatment guidelines: Balanitis. Melbourne: Bayside Health;
2005.
8. Therapeutic Guidelines Limited. Therapeutic guidelines antibiotic version 13. Melbourne:
Therapeutic Guidelines Limited; 2006.
9. Queensland Health. Queensland clinical practice guidelines for advanced sexual and
reproductive health nursing officers. Public Health Service Branch. Queensland Government.
2007.
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