By Gary M. White, MD
Balanitis is inflammation of the glans penis. Balanitis of any cause is more common in uncircumcised men--about 3:1--over circumcised men. This is because the constantly covered skin is hotter and moister, and thus receptive to bacterial and fungal (i.e. candida) overgrowth. This skin occluded with a layer of organisms and their debris is much more prone to inflammation. Poorly controlled blood sugar levels predisposes. Leaving the skin, open, cool and dry promotes healing. Uncircumcised patients are on average less likely to clean the penis well and thus are predisposed to balanitis, but occasionally, a patient will be over-cleansing the area, which can be a trigger as well.
Balanitis alone may cause redness, inflammation and irritation of the penis. When the areas is secondarily infected with Candida, there may be more inflammation accompanied by a white surface material that can be removed. KOH is positive. The patient should be surveyed for other evidence of Candida infection, e.g., thrush, onychomycosis.
For the Candida infection , a topical antifungal agent is appropriate, e.g. clotrimazole, terbinafine for 10 days. Occasionally, oral fluconazole may be needed. In the case of the uncircumcised male, pulling back the foreskin and cleaning well at least once daily is recommended. Recurrences are common and the use of the topical antifungal agent 1-2 weekly may be needed. If there is onychomycosis, it may need to be cultured to rule out Candida onychomycosis and if present, treated.
Once the fungal infection is cleared, some patients may have residual inflammation that represents balanitis by itself, without secondary infection. For those, keeping the area as clean as possible and applying a mild topical steroid may be in order, although the topical steroid can predispose to secondary infection. Rarely, uncircumcised males with chronic, recalcitrant balanitis may opt to undergo circumcision. (For a related condition, see Zoon's balanitis.)
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