The case

A male toddler presents with a red and swollen penis. He is uncircumcised and working on potty training. Over the past two days the penis has become more tender with wiping, and the foreskin and head of the penis are red and tender to the touch. Otherwise he is well, with no fever, vomiting, diarrhea, or other symptoms.

The diagnosis

Based on the description this is likely balanitis. First, some definitions, since inflamed penis parts have different clinical names.

Balanitis is inflammation of the glans penis.

Posthisis is inflammation of the foreskin and is generally only seen in uncircumcised males – but can be seen in boys with redundant foreskin

Balanoposthitis is inflammation of the glans and foreskin

Since isolated posthitis is actually rare you’ll often find that coliqually we referent to both balanitis and balanoposthitis as “Balanitis.”

On history patient parents/patients report pain, redness, swelling, itching, irritation, or discharge of the penis. Little ones might be crying inconsolably, especially after they void or during diaper changes and care. You’ll want to explore hygiene (how they wipe and with what, bathing habits etc,.), possible allergens, and for older males sexual practices and history of sexually transmitted infections. On exam you’ll see swelling and redness of the glans, meatus, and sometimes the penile shaft. Balanoposthitis will also display inflammation of the foreskin and difficult retraction of the prepuce. There can be discharge form the urethra – it is either clear or exudative, and may be foul smelling. Smegma is physiologic, and does not have the same foul odor.

Inadequate personal hygiene in uncircumcised males is the most common cause of balanitis. Moisture between the foreskin and the glans leads to skin breakdown and infection. Here is a list of some of the common infectious etiologies.

Candida (following a recent antibiotic course) – you’ll see erythema, fissures and thick white discharge
E.coli (pre-potty training) – erythema, edema, exudate, superficial erosions
Enterococcal spp. (young children) – erythema, edema, exudate, superficial erosions
Group A strep and Staph aureus (older kids) – Fiery red skin with exudate
Gonorrhea, chlamydia, trichomonas, gardnerella, syphilis (teens)
Tinea cruris – annular itchy lesions

If you’re not sure of the etiology, and especially in sexually active teens, obtaining fungal and bacterial swabs can be very helpful – even if they won’t result in the ED.

Management

Not all cases are infectious, but many are and treatment centers around suspected etiology. The management of balanitis depends on the etiology and includes general hygiene and treatment of infections. All patients should be taught proper hygiene – gentle retraction of the foreskin and cleaning with warm water, avoiding harsh soaps. Mild cases are good candidates for topical antibiotics like Bacitracin, Polysporin, and Mupirocin. Neosporin has been implicated in an irritant dermatitis like reaction in some boys and isn’t the best choice. Unless you are 100% certain that the cause is NOT infectious, avoid topical corticosteroids.

If you think it’s candida then use topical or oral antifungal medications (nystatin). If you diagnose anaerobic bacteria then topical or oral Metronidazole, topical clindamycin, or oral amoxicillin-clavulanate are good options. Group A strep and Staph respond to cephalexin. Treat sexually transmitted causes according to local resistance patterns – like you’d treat urethritis – ceftriaxone 250mg IM x1 + Azithromycin 1g PO x1 – follows by 100mg of doxycycline bid x7 days +/- metronidazole 500mg PO bid x7d.

Immediate Urological consultation is warranted for urinary obstruction, paraphimosis (foreskin is so swollen that it can’t be retracted), and necrotizing fasciitis (fortunately rare). Complications include urethritis, inguinal lymphadenitis, necrotizing fasciitis (Fournier’s gangrene), phimosis, and paraphimosis.