Balanitis and balanoposthitis in children and adolescents: Management

INTRODUCTION — This topic will address the management of balanitis and balanoposthitis in children and adolescents. Clinical manifestations, evaluation, and diagnosis of balanitis and balanoposthitis and routine care of the uncircumcised penis are discussed separately. (See "Balanitis and balanoposthitis in children and adolescents: Clinical manifestations, evaluation, and diagnosis" and "Care and complications of the uncircumcised penis in infants and children".)

APPROACH — When managing a patient with balanitis or balanoposthitis, the physician should first identify and treat urinary obstruction. Subsequent management consists of treating the underlying cause. The therapeutic recommendations below are derived from expert consensus and by clinical experience as well as from guidelines developed for older adolescents and adults [1].

Relief of urinary retention — Pain may interfere with urination, but true urinary obstruction from balanoposthitis or balanitis complicated by meatitis is unusual. The patient may be able to void after sitting in a bathtub filled with warm water or, alternatively, after application of topical viscous lidocaine. If these local measures fail, then dorsal penile block (figure 1) and/or procedural sedation, followed by bladder catheterization and prompt pediatric urology consultation, is warranted. If true obstruction occurs or if initial bladder catheterization is unsuccessful, then the patient may undergo dorsal slit procedure or incision of the constricting band of the phimotic foreskin (figure 2) [2]. Circumcision usually follows these emergency procedures once inflammation has subsided.

General measures — Regardless of the etiology, proper treatment of balanitis and balanoposthitis requires institution of local care that will reduce inflammation, help prevent future occurrences, and (in uncircumcised patients) reestablish physiologic function of the foreskin:

●Sitz baths – Soaking of the penis in warm water containing a weak salt solution two to three times per day is advised while inflammation persists.

●Avoidance of irritants – In uncircumcised patients, soap should not be used to clean under the foreskin [3]. In both circumcised and uncircumcised patients, the medical provider should counsel the patient and parents/caregivers to avoid exposure of the affected area to bubble bath oils, talc powder, and other irritants. Adolescents should avoid sexual activity.

●Reinforcement of proper foreskin hygiene (patients with balanoposthitis) – Parents/caregivers should be instructed to clean between the foreskin and glans with a Q-tip and irrigate with clean water regularly until the inflammation resolves [3,4]. For those patients with a tight foreskin or physiologic phimosis, irrigation can be demonstrated by medical personnel with a 5 French or 8 French feeding tube inserted gently into the preputial sulcus [5]. Alternatively, if a feeding tube is not available, the cut tubing of a butterfly needle device may be used, but the clinician should ensure that the cut edge is smooth.

•Once inflammation has resolved, regular bathing of the area in clean water should be sufficient. Parents/caregivers should be advised to avoid soap and not to attempt to clean under the foreskin. They should also be counseled to avoid forceful retraction of the foreskin in young, uncircumcised boys. (See "Care and complications of the uncircumcised penis in infants and children".)

•Older patients with a fully retractile foreskin should thoroughly but gently clean underneath the prepuce with water and dry the glans penis before returning the foreskin to normal position [1].

Treatment by etiology — Proper treatment of balanitis and balanoposthitis relies on correct diagnosis of the underlying cause. (See "Balanitis and balanoposthitis in children and adolescents: Clinical manifestations, evaluation, and diagnosis".)

Nonspecific balanitis and balanoposthitis — In addition to the general measures described above, empirical application of topical antibiotic ointment (eg, Polysporin or Bacitracin) four times daily or mupirocin cream (eg, Bactroban, Bactocin, or Bactoderm) twice daily helps reduce dysuria and may prevent secondary bacterial infection [5]. Ointments that contain neomycin may cause contact dermatitis and should be avoided.

Irritant contact balanitis and balanoposthitis — This condition is marked by excessive cleansing of the penis or foreskin, often in a patient with atopic dermatitis [6]. Occasionally, irritant contact balanoposthitis results from exposure to a specific allergen. (See "Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis", section on 'Clinical manifestations'.)

●Avoidance of precipitants – Any identified precipitants should be avoided, especially soaps. Spermicides and condom lubricants are common culprits in older adolescents.

●Application of emollients – Aqueous creams, such as Keri, Eucerin lotion, or BP (available in the United Kingdom), should be used as a soap substitute after gentle cleansing. The patient or caregiver should avoid creams containing parabens preservatives because of potential sensitization and exacerbation of the condition [7].

The clinician should warn sexually active adolescents who are using creams of the potential for condom failure [1].  

●Topical corticosteroids – Low-potency, topical steroids such as hydrocortisone 1 percent cream may be applied sparingly twice daily for one week. Topical steroids are contraindicated in untreated infections or for continuous prophylaxis.

Fixed drug eruptions — These penile or foreskin lesions resolve once the offending medication (tetracyclines, salicylates, phenacetin, phenolphthalein, or sedative hypnotic agent) is discontinued. Topical steroids, such as hydrocortisone 1 percent cream, applied sparingly twice a day for seven days speeds recovery. Severe cases may be treated with an oral course of prednisone or prednisolone with a tapering dose over 10 to 14 days. Cases associated with Stevens-Johnson syndrome require an intensive approach that addresses the multisystem effects of this disease. (See "Drug eruptions", section on 'Fixed drug eruption' and "Stevens-Johnson syndrome and toxic epidermal necrolysis: Pathogenesis, clinical manifestations, and diagnosis".)

Traumatic balanitis and balanoposthitis — In addition to the general measures described above, empirical application of topical antibiotic ointment (eg, Polysporin or Bacitracin) four times daily or cream (eg, Bactroban, Bactocin, or Bactoderm) twice daily to any breaks in the skin helps reduce dysuria and may prevent secondary bacterial infection [5]. Ointments that contain neomycin may cause contact dermatitis and should be avoided.

Infectious balanitis and balanoposthitis — Proper treatment depends on identifying and treating the source of infection. In young children, the health care provider can start empiric therapy without specific testing based upon history and physical examination in most cases (algorithm 1) [5]. Older children and adolescents should have therapy guided by appropriate laboratory studies (algorithm 2). (See "Balanitis and balanoposthitis in children and adolescents: Clinical manifestations, evaluation, and diagnosis", section on 'Further evaluation'.)

Candidal infection — In infants, candidal infection of the penis or foreskin usually accompanies diaper dermatitis. Treatment consists of topical antifungal agents (eg, clotrimazole or nystatin) and other local measures as discussed in detail separately. (See "Diaper dermatitis".)

In older children and adolescents, topical antifungal agents are also the primary therapy. Sexual partners require evaluation and treatment to prevent recurrence. Evaluation for diabetes mellitus is also warranted for all adolescents in whom sexually acquired infection is excluded and for obese, older children at risk for type 2 diabetes mellitus. (See "Epidemiology, presentation, and diagnosis of type 1 diabetes mellitus in children and adolescents" and "Epidemiology, presentation, and diagnosis of type 2 diabetes mellitus in children and adolescents".)

A single oral dose of fluconazole may be used in patients with candidal infection and either diabetes or severe, recurrent infection [8].

Dermatophytic infection — Treatment for tinea corporis, tinea cruris, or tinea versicolor involving the penis or foreskin is discussed separately. (See "Dermatophyte (tinea) infections", section on 'Tinea corporis' and "Dermatophyte (tinea) infections", section on 'Tinea cruris' and "Tinea versicolor (pityriasis versicolor)", section on 'Management'.)

Bacterial infection — In young children, proper hygiene in conjunction with empirical application of topical antibiotic ointment (eg, Polysporin or Bacitracin) four times daily or mupirocin cream (eg, Bactroban, Bactocin, or Bactoderm) twice daily adequately treats most bacterial balanoposthitis [5]. Ointments that contain neomycin may cause contact dermatitis and should be avoided.

For infections in children with immunocompromise or diabetes mellitus and any child with more extensive infections suggested by fever, lymphadenitis, or degree of swelling and induration that suggests a component of cellulitis, an oral antibiotic such as cephalexin may be added in addition to topical therapy.

Systemic antibiotics are employed to treat group A Streptococcal infection, anaerobic infection, Staphylococcus aureus infection, and sexually transmitted infection as discussed below.

Sexually transmitted diseases in a prepubertal child strongly indicate sexual abuse and warrant reporting to child protective services and further evaluation [9]. (See "Evaluation of sexual abuse in children and adolescents", section on 'Presentation'.)

●Group A streptococcal balanoposthitis – Treatment is the same as for group A streptococcal pharyngitis: oral antibiotics for 10 days. (See "Treatment and prevention of streptococcal pharyngitis in adults and children".)

●Anaerobic balanoposthitis – Common isolates include Gardnerella vaginalis and Bacteroides species. Metronidazole (15 to 35 mg/kg per day in three divided doses) is the most effective treatment for anaerobic infections and should be given in the oral form for one week [10]. Oral clindamycin is an alternative. Amoxicillin-clavulanate (Augmentin) 80 mg/kg per day (maximum dose: 3 g of amoxicillin) in two to three divided doses for one week is an alternative for infections caused by Bacteroides species but not G. vaginalis infections. Clindamycin cream may be used for mild infections to be applied twice daily until resolved. If sexual transmission is suspected, then the patient's sexual partner(s) should also be screened and treated as indicated.

●Staphylococcal balanoposthitis – Children with S. aureus balanoposthitis should receive oral antibiotics that will cover community-acquired methicillin-resistant S. aureus (MRSA) infection. Parenteral therapy is suggested if hospital-acquired MRSA infection is suspected or if the patient is immunocompromised. Therapy should be tailored to pathogen sensitivities once they are available. (See "Skin and soft tissue infections in children >28 days: Evaluation and management".)

●Gonorrheal balanoposthitis – Therapy is the same as for gonococcal urethritis. (See "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents".)

●Chlamydial balanoposthitis – Treatment mirrors that of nongonococcal urethritis. (See "Treatment of Chlamydia trachomatis infection".)

●Syphilitic balanoposthitis – Management is based on the stage of syphilis. (See "Syphilis: Treatment and monitoring".)

Viral balanoposthitis — Genital herpes and genital human papillomavirus (condylomata acuminata) infections may occur through self-inoculation or sexual contact and are difficult to eradicate. Treatment is discussed separately. (See "Treatment of genital herpes simplex virus infection" and "Prevention of genital herpes virus infections" and "Condylomata acuminata (anogenital warts): Management of external condylomata acuminata in adult males".)

Protozoan balanoposthitis — Trichomonas vaginalis and Entamoeba histolytica balanoposthitis are treated with metronidazole [11]. E. histolytica balanoposthitis also requires treatment with a luminal amebicide such as paromomycin [12]. (See "Trichomoniasis: Clinical manifestations and diagnosis".)

Indications for specialty referral — The patients with the following presentations warrant referral to a urologist with pediatric expertise for further management [13]:

●Acute urinary obstruction

●Prolonged or refractory disease course (eg, persistent noninfectious conditions despite several weeks of local care and good hygiene or patients with infectious conditions who have completed a course of targeted antimicrobial treatment without relief of symptoms)

●Recurrent balanoposthitis or development of true phimosis (scarring with inability to retract the foreskin)

In pediatric patients, unresponsive or recurrent balanoposthitis is a potential indication for circumcision. Pathologic evaluation of the prepuce is important to look for balanitis xerotica obliterans [14]. This entity may involve the urethral meatus, may require reconstructive urologic surgery, and is considered precancerous in adults. (See "Carcinoma of the penis: Epidemiology, risk factors, and pathology".)

OUTCOMES — Most patients respond to general care augmented by appropriate topical therapy within seven days. Up to 10 percent of patients have recurrence of balanoposthitis [6].

PREVENTION — Proper hygiene and avoidance of forceful retraction are the most important interventions to prevent balanoposthitis in young uncircumcised boys. (See "Care and complications of the uncircumcised penis in infants and children", section on 'Routine care'.)

Circumcision in the neonatal or postneonatal period as a preventative measure is a controversial topic. Historically, circumcision has been recommended, thinking that it improves genital hygiene, but there are no trial data to support this belief. The presence of a foreskin predisposes to sexually acquired infection (herpes, candidiasis, gonorrhea, syphilis, and human papillomavirus infection), and circumcision reduces the chance of future balanoposthitis [9,15-18]. Circumcision has therefore been used for the treatment as well as the prevention of balanoposthitis [9,16].

A study in Western Australian boys evaluated the most common reasons for circumcision and found that phimosis, balanoposthitis, and lichen sclerosis (balanitis xerotica obliterans) were the medical causes, in that order of frequency [19,20]. The elective use of circumcision in a patient with recurrent infectious balanoposthitis is reported to be curative but should only be performed after the acute infection has resolved [21].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Balanoposthitis".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Balanitis in children (The Basics)" and "Patient education: Care of the uncircumcised penis in babies and children (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Approach – When managing a patient with balanitis or balanoposthitis, the clinician should first identify and treat urinary retention. Subsequent management consists of treating the underlying cause. (See 'Approach' above.)

●Urinary retention – True urinary obstruction from balanoposthitis or balanitis complicated by meatitis is unusual. If pain interferes with urination, then the patient will often be able to void after application of topical viscous lidocaine (emergency department or physician's office) or while sitting in a bathtub filled with warm water. (See 'Relief of urinary retention' above.)

Patients who are still unable to void despite the above measures require dorsal penile block (figure 1) and/or procedural sedation, urgent bladder catheterization, and prompt pediatric urology consultation.

●General measures – Proper treatment of balanitis and balanoposthitis in all patients requires institution of local care that will reduce inflammation, help prevent future occurrences, and (in uncircumcised patients) reestablish physiologic function of the foreskin, including (see 'General measures' above):

•Sitz baths two to three times daily

•Avoidance of irritants such as soap during cleaning, bubble bath oils, and talc powder

•Proper foreskin hygiene as described above

●Treatment by etiology

•Nonspecific or traumatic balanitis and balanoposthitis – In addition to general measures, patients with nonspecific or traumatic balanitis and balanoposthitis warrant empirical application of topical antibiotic ointment (eg, Polysporin or Bacitracin) four times daily or mupirocin cream (eg, Bactroban, Bactocin, or Bactoderm) twice daily to reduce dysuria and prevent secondary bacterial infection. Ointments that contain neomycin may cause contact dermatitis and should be avoided. (See 'Nonspecific balanitis and balanoposthitis' above.)

•Irritant contact balanitis and balanoposthitis – Treatment of irritant contact balanitis and balanoposthitis includes (see 'Irritant contact balanitis and balanoposthitis' above):

-Withdrawal of the precipitating agent (eg, soaps, detergents, spermicides, and condom lubricants).

-Application of aqueous emollient cream.

-Topical, low-potency corticosteroid therapy, such as hydrocortisone 1% cream applied sparingly twice daily for seven days. Topical corticosteroids should only be initiated if the clinician is sure that no concomitant infection exists.

•Fixed drug eruptions – Fixed drug eruptions of the penis or foreskin resolve once the offending medication is discontinued. Topical steroids, such as hydrocortisone 1 percent cream, applied sparingly twice daily for seven days speeds recovery. Severe cases may be treated with an oral course of prednisone or prednisolone with a tapering dose over 10 to 14 days. (See 'Fixed drug eruptions' above.)

•Infectious balanitis and balanoposthitis – Proper treatment of infectious balanitis and balanoposthitis depends on identifying and treating the source of infection. In young children, the health care provider can start empiric therapy without specific testing based upon history and physical examination in most cases (algorithm 1). Older children and adolescents should have therapy guided by appropriate laboratory and microbiology studies (algorithm 2). (See 'Infectious balanitis and balanoposthitis' above.)

●Specialty referral – The patients with the following presentations warrant referral to a urologist with pediatric expertise for further management (see 'Indications for specialty referral' above):

•Acute urinary obstruction

•Prolonged or refractory disease course (eg, persistent noninfectious conditions despite several weeks of local care and good hygiene or patients with infectious conditions who have completed a course of targeted antimicrobial treatment without relief of symptoms)

•Recurrent balanoposthitis or development of true phimosis (scarring with inability to retract the foreskin)