Inﬂammation of the glans penis is termed balanitis. Inﬂammation of the preputial skin is referred to as balanoposthitis. Clinically, these conditions usually coexist, with the surface of the glans and prepuce both swollen, hyperemic, tender, and itchy. A yellow exudate and superﬁcial ulcers or denudation of the glans surface are characteristic of balanoposthitis. In chronic balanitis, the glans epithelium becomes thickened and assumes a whitish appearance (leukoplakia).
By far the most frequent cause of simple balanitis is congenital or acquired phimosis (see Plate 2-17). In infants, balanoposthitis results from retained smegma, bacteria, and lack of hygiene associated with phimosis and dribbling urine or moist diapers. In adults, urinary incontinence may play an etiologic role. Seborrheic dermatitis, most commonly seen on the scalp, can also be found on the glans penis. Superﬁcial fungal infections from Candida albicans are also common, especially in diabetics. Contact allergy from latex in condoms or ingredients in skin care products must also be considered. Balanitis circinata is a skin manifestation of Reiter syndrome, characterized by arthritis, urethritis, and conjunctivitis. Generalized skin conditions such as lichen planus, psoriasis, erythema multiforme, erythrasma due to Corynebacterium, and erythema ﬁxum are less common conditions that cause simple balanitis. Pemphigus, a group of autoimmune blistering diseases of the skin, and scabies usually produce distinctive lesions on the penile shaft rather than the glans penis. Rarely, phimosis secondary to obstruction of the inguinal lymph nodes from cancer, edema, or elephantiasis may also cause balanitis. Precancerous and cancerous lesions of the glans and prepuce are shown in Plate 2-27.
Balanitis xerotica obliterans, also termed lichen sclerosis, is a progressive form of balanoposthitis that primarily affects the foreskin, leading to whitening and loss of skin color, scarring, and phimosis. Involvement of the urethral meatus can lead to irritation, burning, and stenosis and may require a meatoplasty in cases of stricture. Long-term follow-up is needed to assess for recurrence.
Genital herpes simplex virus 2, caused by a double-stranded RNA virus, is a relatively common, venereally transmitted, painful, itching form of balanitis. Multiple lesions develop as small red areas upon which rounded translucent vesicles appear, containing clear, viral-rich, infectious ﬂuid. After rupture of the vesicles, small round ulcers with a reddish base remain and heal. The infection usually recurs and is currently incurable.
Erosive balanitis may be venereal, such as due to syphilis or chancroid, or nonvenereal in origin, such as that due to histoplasmosis. Although unusual, anaerobic balanoposthitis is a classic form of nonvenereal, erosive balanitis caused by anaerobic gram-negative rods (genus Bacteroides). It is characterized by intense inﬂammation and edema of the prepuce, superﬁcial glans ulcers, foulsmelling discharge, and bilateral inguinal lymphadenopathy. Infection tends to be locally destructive with severe tenderness and can result in tissue necrosis. The presence of phimosis and suboptimal hygiene appear to be prerequisites for this condition. The infection can be transmitted through sexual intercourse, contamination by colonized saliva, or extension from the perirectal area. It generally responds to the timely use of antibiotics and debridement if necessary.
Gangrenous balanitis, in some cases the evolution of erosive balanoposthitis, is generally caused by the same organisms. However, it progresses with such rapidity that an erosive stage may be entirely absent. The ulcers are covered by gangrenous membranes that, when debrided, reveal deep extension of the process into the glans and preputial tissues. The ulcer bases are uneven yet have distinct borders surrounded by inﬂamed tissue. Within a day, the foreskin and even the entire glans and portions of the penile shaft can slough. Abscesses may also develop that involve the scrotum and extend superiorly to the abdominal wall and laterally to the thighs.