Balanitis is an inflammation of the glans penis due to infection or other causes. Symptoms include local flushing, plaque on the head, swelling, pain, cracks and erosions, and difficulty urinating. With inadequate therapy, a number of complications can join. Diagnostic methods imply the identification of diseases and factors affecting the development of the condition, identification of the pathogen, if balanitis is caused by an infectious agent. Treatment is individual and depends on the cause; may include hygiene procedures, topical application of ointments, antibacterial and antifungal therapy, if indicated, circumcision.
Balanitis affects 3-11% of men of any age, but more often the pathology is diagnosed in older patients. In the summer, the incidence is higher, the prevalence of balanitis correlates with the standard of living, hygienic culture, religious and ethnic traditions. It has been proven that inflammation of the head of the penis practically does not occur in men with circumcised foreskin. In uncircumcised men, smegma accumulates in the preputial sac, which creates conditions for the reproduction of microflora. In almost 100% of cases, balanitis occurs in combination with inflammation of the inner layer of the foreskin – postitis (balanoposthitis). The relevance of the problem in uroandrology is associated with the frequent recurrent course of the disease and the occurrence of a number of complications that reduce the quality of life (including intimate).
The etiology of inflammation of the head of the penis is multifactorial. The disease can be of infectious origin or occur against the background of local and systemic pathological processes. Infectious balanitis is caused by fungal (candida), viral (HPV), bacterial agents (treponema pallidum, hemolytic streptococcus, Neisser’s gonococcus), protozoa (Trichomonas), etc. genitourinary tract and urological operations. The predisposing factors for the development of the inflammatory process in the head area are:
- Improper hygiene. Unsatisfactory or excessive hygiene of the genitals reduces the factors of local protection. Infection easily penetrates into the formed microcracks against the background of dry mucosa. The presence of a short bridle and phimosis contributes to the accumulation of smegma, which causes mechanical and chemical irritation of the head. In addition, in such conditions, the growth of pathogenic microflora begins, causing an inflammatory reaction.
- Local irritating factors. Local contraception, antiseptics, chlorinated water, and some medications are considered as provoking factors for balanitis. Aggressive substances not only corrode the skin, but also contribute to allergy. Rare replacement of diapers in children and bedridden adult patients, wearing uroconservative is often complicated by inflammation of the genitals.
- Immunosuppressive conditions. Patients with reduced immune reactivity (after organ transplantation, chemoradiation therapy, while taking hormones, antibiotics, with some diseases) are more likely to suffer from balanitis. In these cases, a fungal pathogen, Candida albicans, is usually isolated.
- Diseases of the urogenital tract. Recurrent UTIs, phimosis, short frenulum, nephrourolithiasis, urological surgery, and medical manipulation are common causes of balanitis. A combination of mechanical trauma, weakening of the immune system, and activation of a secondary infection is characteristic of patients after surgery. Urine containing salt provokes inflammation in the urethra and the head of the penis.
Pathogenesis is represented by a dynamic complex of cytological and chemical processes occurring in tissues in response to injury or exposure to a physical, chemical or biological agent, including local reactions and resulting morphological changes. Aseptic inflammation, its transition to infectious and thickening of smegma enhance the general reaction. In children under 5 years of age, when the foreskin is forced to move, the synechial membranes are damaged, pathogenic bacteria penetrate through the wound surface, as a result of which balanitis develops. In elderly patients, urine changes its physicochemical properties, often its density is higher, salts and sometimes sugar are present. Concomitant phimosis and urine accumulation leads to mechanical and then chemical irritation of the skin. The secondary attachment of microbial flora aggravates inflammation.
By the nature of the course, an acute and chronic inflammatory process is distinguished. Pathology can be primary or accompany any disease. By the type of pathogen, viral, fungal, bacterial balanitis are distinguished; according to the mechanism of occurrence – post-traumatic, allergic, drug (chemical), etc. For an acute infectious process, given the severity of inflammation and features of the course, the following forms are characteristic:
- Simple (catarrhal). Most often, balanitis is found in the form of catarrhal inflammation. Hyperemia and swelling are moderately expressed, the general state of health suffers slightly. Mild itching and burning are present. With timely and correctly selected treatment, recovery occurs quickly and without the formation of scar tissue.
- Erosive (ulcerative). The inflammatory process progresses, and erosive defects are formed on the skin, with clear boundaries and weeping. Gradually, erosion covers an increasing area, almost always the inner layer of the foreskin is involved. It is impossible to completely bare the head because of the pain syndrome and the formed phimosis. Inguinal lymph nodes may be enlarged.
- Gangrenous. Further development of inflammation, deepening and fusion of erosions covered with purulent plaque leads to tissue necrosis. The patient’s state of health is severe, which is caused by intoxication, pain syndrome and an increase in the temperature reaction. Inguinal lymphadenitis and phimosis are recorded in almost all men with gangrenous balanitis.
Symptoms of balanitis depend on the severity of the inflammation and the stage of the disease: in the acute process, the clinical manifestations are brighter. The disease is characterized by redness and swelling of the head, plaque with an unpleasant odor, ulceration (often with bleeding) and plaques, difficulty urinating, narrowing of the external opening of the urethra, itching and pain, impaired erectile function. Acute urinary retention with balanitis is less common.
If phimosis has joined, during the act of urination, urine accumulates under the foreskin and swells it. In some patients, a reaction of regional lymph nodes is recorded – inguinal lymphadenitis or lymphadenopathy. In the chronic course of the disease, the symptoms are moderately expressed, relapses are typical against the background of a weakened immunity of any genesis: taking antibiotics, hypothermia, errors in nutrition, changing the climatic zone, etc.
Further progression of infectious inflammation can lead to urethritis, cellulitis (a bacterial infection of the deeper layers of the skin) and gangrene of the penis. The outcome of a recurrent inflammatory process can be phimosis (including cicatricial) and paraphimosis, meatostenosis and urethral strictures. Possible urinary retention, vesicoureteral reflux, erectile dysfunction. With a timely appeal to a urologist or dermatovenerologist, many undesirable consequences can be avoided. Men with balanitis and phimosis have an increased risk of developing penile cancer: due to the inability to open the head, diagnosis is difficult, and the existing tumor in the initial stages has no painful manifestations.
The presumptive diagnosis is established after examination by an urologist-andrologist. To clarify the reason, you may need to consult a dermatovenerologist, endocrinologist, rheumatologist, oncologist. Diagnostic measures include testing for diabetes mellitus, culture of biomaterial from the affected areas for flora and drug sensitivity, serological tests for syphilis, tests for HIV and STIs, potassium hydroxide test for suspected genital candidiasis. In severe balanitis, an ultrasound of the bladder with control of residual urine is justified, which makes it possible to establish obstructive disorders.
If the cause of balanitis remains unclear, the disease has a recurrent course, or there is no effect from the therapy, a biopsy of suspicious areas is performed, followed by morphological examination. Differential diagnosis is carried out with psoriasis, soft and hard chancre, herpesvirus infection, malignant neoplasm.
With a confirmed venereal disease, drugs are prescribed taking into account the pathogen. Additionally, the scheme includes immunomodulators, multivitamins, treatment of the head with antiseptic solutions. Both partners receive treatment. Patients with nonspecific balanitis without phimosis are recommended:
- Thorough care of the genitals. Daily retraction of the foreskin and elimination of smegma is the basic rule of hygienic care. The naked head of the penis is washed with warm water without the use of irritating detergents. Trays with decoctions of herbs that have anti-inflammatory effects (chamomile, calendula, sage), irrigation with baking soda solution, lotions with antiseptics (dioxidine, chlorhexidine, etc.) relieve pain and reduce inflammation.
- The use of corticosteroids. In patients (regardless of age) with mild symptoms of non-infectious balanitis, local administration of hormones is possible. In boys over 3 years old, the foreskin is carefully pulled back. Treatment success with no relapse is 65-95%. Hormonal drugs should not be applied for more than 14 days, as this can lead to thinning of the skin. For patients with xerotic balanitis, circumcision is more justified, since they are more likely to develop cicatricial phimosis.
- Dermatotropic drugs with immunosuppressive action. With frequent relapses, instead of corticosteroids, it is preferable to prescribe drugs based on the macrolactam ascomycin, which has an immunosuppressive, anti-inflammatory, dermatotropic effect. The effect of therapy is 64%. In the absence of positive dynamics, they resort to surgical intervention.
- Antibacterial therapy. If a secondary bacterial infection has joined, local and systemic use of antibiotics is justified. With severe clinical manifestations and complications (for example, penile cellulitis), oral administration of broad-spectrum antibacterial drugs is indicated initially empirically. After receiving the results of bacterial culture, correction of the therapy regimen is performed, if necessary.
- Antifungal drugs. Balanitis of candidal etiology involves the use of antifungal drugs of local and systemic action, a diet with the rejection of sweet, yeast-containing foods and alcohol. Repeated attacks of a fungal infection may indicate a serious impairment in the functioning of the immune system. With underlying diabetes mellitus, it is important to achieve your glucose target.
Phimosis with frequent relapses of balanitis is the main indication for circumcision, which greatly eases the condition and allows you to lead a full sex life. With erectile dysfunction, the patient is advised to consult a sexologist.
Prevention and prognosis
In most cases, if you follow all the doctor’s recommendations, unpleasant symptoms decrease in 3-5 days. The prognosis for life is favorable. Preventive measures include using hypoallergenic condoms for casual sex, avoiding local contraception, wearing appropriate sized cotton underwear, and having regular sex life. When wearing a uroconservative or diaper, timely replacement of products and special care products with moisturizing and antiseptic properties are recommended.
Particular attention is paid to the hygiene of the genitals: the penis must be washed with warm water and soap or gel with a neutral medium without irritating effect. The foreskin must be shifted. Detergents should not be used more often than 1 time a day, since lysozyme, an antibacterial enzyme that protects against infectious microorganisms, and secretions of the sebaceous glands, which moisturize, lubricate and protect the urethral mucosa and skin from infection, are destroyed. For all symptoms of trouble, you need to see a doctor.