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Balanitis, Phimosis, and Paraphimosis

Basics

  • Balanitis: inflammation of glans penis
  • Posthitis: inflammation of foreskin
  • Balanoposthitis: inflammation of both glans and foreskin
  • Balanitis xerotica obliterans (BXO): lichen sclerosus of glans penis (rare)
  • Phimosis: tight foreskin unable to retract; physiologic (normal in children) or pathologic
  • Paraphimosis: foreskin retracted behind glans, cannot be reduced; emergency with risk of necrosis

Epidemiology

  • Balanitis affects 3-11% of males, predominately adults
  • Phimosis common in boys (8% at 6 years), rare in men >16 years (1%)
  • Paraphimosis occurs mainly in infancy and adolescence, rare in adults, risk increases with age

Etiology and Pathophysiology

  • Balanitis causes: allergic reactions (latex, soaps), infections (Candida albicans, Borrelia vincentii, streptococci, Trichomonas, HPV), drug eruptions, plasma cell infiltration (Zoon balanitis), autodigestion by pancreatic enzymes
  • Phimosis: physiologic at birth, resolves by 2-3 years; acquired from repeated inflammation, trauma, infections
  • Paraphimosis: usually iatrogenic or due to improper foreskin care after catheterization or cleaning

Risk Factors

  • Balanitis: foreskin presence, poor hygiene, diabetes (most common), obesity, condom catheter use, chemical irritants, edema from CHF/nephrosis
  • Phimosis: poor hygiene, diabetes, frequent diaper rash, recurrent balanitis/posthitis
  • Paraphimosis: presence of foreskin, poor education or care, inexperienced healthcare provider

Diagnosis

History

  • Balanitis: pain, discharge, dysuria, odor, ballooning foreskin during urination, redness
  • Phimosis: painful erections, recurrent balanitis, ballooning foreskin, inability to retract at expected age
  • Paraphimosis: uncircumcised, pain, discharge, voiding difficulty

Physical Exam

  • Balanitis: erythema, tenderness, edema, discharge, ulcers, plaques
  • Phimosis: foreskin nonretractile; physiologic (normal orifice), pathologic (white fibrous ring)
  • Paraphimosis: edema of glans and foreskin, discharge, ulceration

Differential Diagnosis

  • Balanitis: leukoplakia, lichen planus, psoriasis, reactive arthritis, lichen sclerosus, erythroplasia of Queyrat, BXO
  • Phimosis/Paraphimosis: penile lymphedema, penile tourniquet syndrome (hair strangulation), anasarca

Diagnostic Tests

  • Microbiologic culture, wet mount
  • Syphilis serology
  • Serum glucose, ESR (if reactive arthritis suspected)
  • STI and HIV testing
  • Biopsy if persistent or suspicious lesions

Treatment

General Measures

  • Circumcision for recurrent balanitis or paraphimosis
  • Warm compresses or sitz baths
  • Local hygiene

Medications

  • Balanitis:
  • Allergic/irritant: Hydrocortisone 1% BID
  • Antifungal: Clotrimazole 1% BID, Nystatin BID-QID, Fluconazole 150 mg PO single dose
  • Antibacterial: Bacitracin QID, Neomycin-polymyxin-bacitracin QID; oral cephalosporins or sulfa for cellulitis

  • Dermatitis or Zoon balanitis: topical steroids QID

  • Phimosis:

  • 0.05% fluticasone propionate daily for 4-8 weeks with gradual foreskin traction

  • 1% pimecrolimus BID for 4-6 weeks (not in children <2 years)

  • Paraphimosis:

  • Manual reduction under sedation with gentle pressure and traction
  • Osmotic agents (granulated sugar) to reduce edema
  • Multiple punctures with 21G needle to drain edema fluid
  • Dorsal slit procedure if reduction unsuccessful

  • Circumcision after edema resolves

  • BXO:

  • 0.05% betamethasone BID
  • 0.1% tacrolimus BID

Issues for Referral

  • Recurrent infections
  • Development of meatal stenosis
  • Surgical emergencies: unreducible paraphimosis

Surgery and Procedures

  • Circumcision for recurrent balanitis and phimosis
  • Paraphimosis: urgent dorsal slit if manual reduction fails
  • Hair removal cream or operative exploration if penile tourniquet syndrome suspected

Admission Criteria

  • Uncontrolled diabetes
  • Sepsis
  • Condom catheter hygiene management

Ongoing Care

Follow-Up

  • Every 1-2 weeks until cause is established for balanitis
  • Biopsy persistent balanitis to exclude malignancy or BXO
  • Monitor phimosis resolution

Diet

  • Weight reduction if obese

Patient Education

  • Proper hygiene and foreskin care
  • Avoid allergens (soaps, latex)
  • Abstain from sexual activity 2-3 weeks post-circumcision

Prognosis

  • Usually resolves with appropriate treatment
  • Complications: meatal stenosis, premalignant changes, UTIs, acquired phimosis, gangrene from unreducible paraphimosis

Clinical Pearls

  • Forced retraction of physiologic phimosis leads to scarring and pathologic phimosis
  • Biopsy is essential if recurrent infections or plaques develop
  • Circumcision remains definitive treatment when hygiene and topical therapy fail