Disorders of the glans penis and foreskin

Balanitis and balanoposthitis

• Overview & Risk Factors
  • Balanitis: Inflammation of the glans penis; Balanoposthitis: Inflammation of glans + foreskin.
  • Uncircumcised males with poor hygiene (smegma accumulation).
  • Diabetes Mellitus (DM): Glucosuria promotes fungal growth; frequently the first sign of occult DM.
  • SGLT2 inhibitors (e.g., empagliflozin): Increased urinary glucose.
  • Etiology: Most common is Candida albicans; others include anaerobes, GAS, STIs, contact dermatitis, and Lichen sclerosus.
• Clinical Presentation
  • Penile erythema, burning, pruritus, soreness, and dysuria.
  • Candida: Satellite pustules/papules, superficial erosions, and white curd-like exudate.
  • Anaerobic/Bacterial: Severe edema, superficial ulcerations, and foul-smelling purulent discharge.
• Diagnostic Evaluation
  • Clinical diagnosis: Based on characteristic exam.
  • HbA1c / Fasting blood glucose: High-yield screening step for new/recurrent candidal balanitis.
  • KOH preparation: Shows pseudohyphae and budding yeast.
  • STI testing / Gram stain & culture: Indicated for purulent discharge or ulcerations.
  • Punch Biopsy: Indicated for refractory, persistent, or indurated lesions to rule out Penile SCC / Erythroplasia of Queyrat.
• High-Yield Differentials
  • Lichen Sclerosus (Balanitis Xerotica Obliterans - BXO): Ivory-white atrophic/sclerotic plaques, meatal stenosis, phimosis; Tx: High-potency topical steroids.
  • Circinate Balanitis: Painless shallow serpiginous erosions on glans; associated with Reactive arthritis (HLA-B27, uveitis, urethritis, oligoarthritis).
  • Lichen Planus: Pruritic, purple/violaceous, polygonal flat papules; oral involvement.
  • Penile SCC: Non-healing indurated ulcer or velvety red plaque; requires biopsy.
• Management
  • General: Hygiene with warm water only; dry thoroughly; optimize glycemic control.
  • Candidal (1st-line): Topical Clotrimazole 1% or Miconazole 2% BID $\times$ 1–3 weeks (Oral Fluconazole 150 mg single dose for severe cases).
  • Anaerobic/Bacterial: Oral Metronidazole or Amoxicillin-clavulanate; topical Mupirocin.
  • Definitive / Recurrent: Circumcision (curative for refractory cases or pathologic phimosis).
• Complications
  • Pathologic Phimosis: Inability to retract foreskin due to chronic scarring/fibrosis.
  • Paraphimosis: Foreskin trapped behind the corona $\to$ venous congestion, ischemia, and necrosis (urologic emergency; manual reduction or dorsal slit required).
  • Fournier Gangrene: Rapidly progressive necrotizing fasciitis in uncontrolled DM / immunocompromised patients.