Balanitis: Symptoms

The main symptom of balanitis is a more or less painful reddened and inflamed glans. As a rule, however, only the upper skin layers are inflamed and not the deep corpus cavernosum of the glans. Those affected often report rashes and unclear changes in the glans. An itchy glans is also a frequently mentioned symptom.

Usually affected men also suffer from discharge from the penis. This effluent can be of different colours and malodorous. The consistency is often purulent. The retraction of the foreskin is usually difficult and also painful. This may also be due to swelling of the glans (edema). This can make urination difficult and painful. In severe cases, the control of the urine stream can also be disturbed. Sometimes balanitis is even associated with impotence, even if only temporarily.

The inflammation of the glans remains limited to the penis in most cases. Systemic signs of inflammation such as fever, malaise or vomiting are not typical of balanitis. However, in some pre-existing conditions, balanitis can also cause severe systemic reactions. This is especially true in the case of additionally existing diseases that affect the immune system. Deep damage to the skin of the glans, even with bleeding, occurs only in advanced, severe disease.

Indications of the cause of balanitis

In addition, there are a number of balanitis signs that already provide clues to a possible trigger. Some are listed here as examples:

• When infected with the herpes virus, a large number of grouped blisters are formed. The infection is usually accompanied by fever and swelling of the inguinal lymph nodes.
• Human papillomavirus (HPV) infection triggers condylomas – cauliflower-like growths often located at the base of the glans.
• The syphilis infection leads to a painful ulcer with a hard edge.
• Raised redness or whitish discoloration with itching are indications of a fungal infection.
• Balanitis in the context of a Reiter´s syndrome is characterized by redness, which is delimited by a white border, and skin damage to the glans.
• Balanitis plasmacellularis zoon is a chronic inflammation of the glans of unknown cause. It is characterized by smooth, lacquer-like and reddish-brown spots.

Balanitis: causes and risk factors

There are a variety of causes that can be responsible for balanitis. There is often a combination of several causes. Thus, mechanical irritation can promote infection. In one third of all patients no clear cause of the inflammation of the glans can be found.

The causes of balanitis can be roughly divided into non-infectious and infectious causes. In addition, acornitis can occur in the context of other diseases.

Non-infectious causes of balanitis

A frequent cause of inflammation of the glans is insufficient or excessive cleaning (“cleanliness balanitis”). If hygiene is inadequate, residual smegma accumulates – a yellowish-white mass of sebaceous gland secretions, skin cells and bacteria). This can lead to balanitis.

Also high mechanical and chemical stress – for example through disinfectants and excessive washing – can provoke balanitis.

In some cases, balanitis is also the result of an irritation or allergic reaction to medication, perfumes or (latex) condoms.

Infectious causes of balanitis

The two most common causes of balanitis are probably fungal and bacterial infections.

Bacterial causes of balanitis include infections with staphylococci, enterococci, streptococci and also with Mycobacterium tubercolosis, the pathogen causing tuberculosis. In addition, the bacterium Gardnerella vaginalis can also lead to balanitis. This germ is a frequent trigger of bacterial vaginosis in women (vaginitis). Men can become infected with the bacterium in sick women and develop balanitis.

Balanitis caused by fungi is also called balanitis candidomycetika. Like bacterial infections, fungal infections can either be local or systemic (i.e. they can also affect the rest of the body).

Candida albicans, a yeast fungus, is the most common pathogen causing balanitis candidomycetika. Although the yeast fungus Candida albicans can be detected on the glans in about 15 percent of men, only a small proportion of them develop balanitis. Non-circumcised men more often get balanitis from fungi than circumcised men. In most cases the fungus is transmitted through sexual contact.

Another fungal infection, namely with Malassezia furfur, is pityriasis versicolor (bran fungus lichen). This form of skin fungus is very rare in Europe, but common in tropical areas. It especially affects the back, shoulders, neck and chest, sometimes also other parts of the body like the penis. Characteristic of this fungal infection are sharply defined, brownish and scaly lesions.

Other fungal infections affect the penis even less frequently. Especially mushrooms, which settle in the groin, can spread continuously to the penis.

The inflammation of the glans penis also occurs in the context of sexually transmitted diseases. Particularly noteworthy are infections with herpes viruses and human papilloma viruses (HPV) – especially type 6 and 11. HPV in particular leads to protracted balanitis, which is not easy to defeat.

Other possible triggers are trichomonads, gonococci, Treponema pallidum (pathogen of syphilis) and Haemophilus ducreyi.

Balanitis in the context of other diseases

Various skin diseases can facilitate but also trigger balanitis. These include pemphigus vulgaris, seborrheic dermatitis and psoriasis.

Lichen sclerosus et atrophicancs should also be mentioned here. The chronic skin disease of unclear cause causes typical white plaques on the foreskin and the glans. This form of inflammation of the glans is called Balanitis xerotica obliterans. In the course of the disease scars form and the foreskin becomes thin. The scars lead to a narrowing of the foreskin. The disease can spread to the urethra.

Within the scope of Reiter’s disease, a non-infectious inflammation, about one quarter of those affected develop balanitis. This disease is characterized by the three symptoms joint inflammation, urethritis and conjunctivitis. It usually occurs one to four weeks after a urinary tract or gastrointestinal infection.

Balanitis plasmacellularis zoon occurs in older men between 50 and 80 years of age. The cause of this form of acorn infection is unclear. There is small bleeding and deposits of hemosiderin, an iron storage protein. In addition, immune cells infiltrate the tissue of the glans.

In rare cases, an inflammation of connective tissue strands can lead to the death of tissue and thus trigger a dangerous balanitis gangraenosa. She needs emergency treatment.

Balanitis in the context of cancer treatment

In rare cases, the so-called BCG instillation can lead to granulomatous balanitis as part of the treatment of bladder carcinoma. BCG is the abbreviation for a species of bacteria. To prevent recurrence of bladder cancer, the bladder can be flushed with weakened BCG bacteria. The bacteria trigger a local inflammation that activates the immune system. This should inhibit the further development of cancer cells.

Risk factors for balanitis

The main risk factor for balanitis is poor intimate hygiene. It is important to wash the penis, and especially the glans, daily with warm water to remove smegma. Failure to clean – but also too aggressive cleaning – can promote the development of balanitis.

Also a badly retractable, narrowed foreskin (phimosis) favours a balanitis. It is easier for pathogens to attach themselves to the glans and spread. For this reason, circumcision seems to significantly reduce the risk of balanitis.

People with certain diseases are statistically more likely to have balanitis than otherwise healthy people. This is particularly true in the case of diabetes mellitus. Probably the sugar in the urine of diabetics promotes the development of balanitis. Very often diabetics have a fungal infection as the cause of balanitis.

Severe overweight and the chronic inflammatory bowel diseases Crohn’s disease and ulcerative colitis are also considered risk factors for acorn infection.

Balanitis: examinations and diagnosis

Men should see a urologist if they suspect acorn infection. At the beginning of the balanitis diagnosis, a detailed conversation with the patient is held to establish the patient’s medical history (anamnesis). The doctor asks, for example:

• How intensively do you practice intimate care?
• Have you noticed any changes in the glans or penis?
• Do you suffer from pain or itching?
• Do you have problems with urination or sexual intercourse?
• Do you have any known skin diseases or other illnesses?

During the physical examination, the lymph nodes, especially in the groin, and the glans must be examined. Already when looking at the glans penis the doctor usually notices a redness and swelling. In addition, discolorations of different colours are often observed. The foreskin should be examined closely. Often she is also affected by the inflammation. The doctor will also pay attention to any narrowing of the foreskin.

As already described in the symptoms, many causes of balanitis can be identified by typical, visible changes in the glans, such as grouped blisters in a herpes infection.

If infectious balanitis is suspected, a smear should nevertheless be taken from the glans penis and the urethra entrance to determine the pathogen. This smear can be examined under the microscope – possibly with the aid of special staining. Thus fungi can be identified particularly well with a potassium hydroxide stain. In addition to a smear test, it may be considered to prepare a culture in order to cultivate existing pathogens and thus better identify them.

In very rare cases, the blood of balanitis patients can also be tested for the pathogen or antibodies against the pathogen. This can be useful for certain types of fungi. However, the blood test is usually reserved for unclear and serious cases.

A small tissue biopsy is considered in case of unclear and complicated balanitis. However, in infectious balanitis, the findings of a biopsy are usually unspecific. In uncertain cases, however, a biopsy can be used above all to investigate the suspicion of a tumour or skin disease. There are in fact a number of diseases that are similar to balanitis or are a complicated form of balanitis. These include a certain precancerous stage (erythroplasia queyrat), penis carcinoma, the autoimmune vascular disease Behcet’s disease and infection- or drug-induced rash (Steven-Johnson syndrome).

If there are problems urinating, the doctor will examine the urethral outlet for signs of inflammation. He asks the patient whether the foreskin “inflates” when urinating. If there are indications of urinary tract involvement, the doctor will also do an ultrasound examination of the bladder. This can exclude or confirm an obstruction of the urine flow.

It is also possible that a balanitis has been triggered by several causes at the same time. This always also means that even after a supposed cause has been identified, further research may still be necessary. Thus, a wart caused by the human papilloma virus can be followed by another infection.

Are warning signs of a complicated course of balanitis:

• Signs of blood poisoning (sepsis)
• a poorly controlled diabetes
• Inability to retract the foreskin
• Blockages in urination

Balanitis: Treatment

The treatment of acorn inflammation depends on various factors: the cause of the inflammation, the findings of the glans and the patient’s general condition. The basis of any balanitis therapy is good and appropriate intimate hygiene. This includes daily washing of the genital area with warm water and also good drying. Camomile sitz baths can be taken to support the therapy. For almost all infections, the partner should be treated as well, even if he or she has not shown any symptoms so far.

Local balanitis treatment usually sufficient

In the case of infectious inflammation of the glans, local (external) balanitis therapy is usually sufficient. An ointment containing the antibiotic metronidazole is usually prescribed against bacteria. It has a very wide spectrum of activity. Cotrimazol is mostly used against fungi, which is effective against a large number of fungi. This is usually enough to defeat the infection. If after four weeks of anti-fungal therapy no success can be seen, the diagnosis should be reconsidered.

In the case of balanitis of a non-infectious nature, local cortisone therapy with an ointment is usually tried first. Cortisone dampens the inflammation and thus usually significantly improves the symptoms. However, it should be noted that the symptoms of cancer (precursors) can also improve under cortisone, but recur after discontinuation of the ointment.

If cortisone does not help, an ointment with Pimecrolimus, a stronger drug to calm the immune system, can also be used.

Systemic balanitis therapy with tablets

In certain situations, however, the medication must be taken in tablet form. This is the case with diabetes mellitus (diabetes), severe alcoholism, chemotherapy, AIDS and also prolonged use of cortisone. In addition, an increased risk of recurrence of the infection must be expected in these cases.

Operation

With repeated balanitis as well as with a narrowed foreskin a circumcision can be considered. The foreskin of the penis is removed surgically. Circumcised men are usually less susceptible to infections. Especially in the case of lichen sclerosus, surgery is often performed to prevent urethral narrowing.

Balanitis therapy for children

There are special therapy recommendations for children which must be observed. The parents or the child itself should consistently perform daily intimate hygiene with retracted foreskin and, if necessary, apply a cortisone ointment twice a day.

If the foreskin is constricted, it should only be pushed back, if at all, in consultation with the attending doctor. This can be very painful and unpleasant. For this reason, the use of local anaesthesia with an ointment or the administration of painkillers (possibly locally) may be considered.

Balanitis: course of disease and prognosis

In the vast majority of cases, the balanitis treatment is permanently successful. If the therapy does not work, the choice of medication can be adjusted in order to better fight the acorn inflammation.

An untreated balanitis can ascend along the urinary tract. Possible consequences are a urinary tract infection, a bladder or prostate inflammation. Urinary tract infections are rare in men and must be treated more consistently than in women.

If the balanitis – despite proper therapy – does not improve, this may be an indication of a malignant process. In this case a biopsy should be performed. In most cases this is then an erythroplasia queyrat.

In rare cases, precancerous lesions are caused by chronic inflammation of the glans.

In patients with a weakened immune system, infectious balanitis should be particularly observed. On the one hand, it is easily possible for the infection to spread and affect other parts of the body. On the other hand, balanitis can also be the first sign of an existing infection in the body. In addition, infections with a weakened immune system can also take a much more severe course than in healthy individuals and lead to severe skin damage with bleeding. For example, persistent fungal balanitis can lead to painful inflammation of blood-carrying vessels.

In rare cases, a narrowing of the foreskin (phimosis) can result from balanitis.