The evidence on the causes of balanitis in children is from small studies carried out in secondary care. CKS found no studies in boys with balanitis presenting in primary care, therefore the causes listed may not accurately represent boys with balanitis in primary care.

• A case series of boys (n = 100) with balanitis attending a urology department in the UK showed that of the 32 who presented acutely to the Accident and Emergency department and had a swab taken [Escala and Rickwood, 1989].
• 47% (n = 15) had no growth of any organisms.
• 22% (n = 7) had a mixed growth of bacteria.
• 31% (n = 10) had a pure growth of one organism (five Staphylococcus aureus, four Proteus vulgaris, one Morganella morgagni).
• The authors concluded that the aetiology of balanitis in children remains unclear. They suggest there is no single causative pathogen, nor is it proven that the suppurative process is necessarily of bacterial origin. A persistence of preputial adhesions seems to predispose to pathogens lodging beneath the foreskin, and poor hygiene also seems to be an obvious factor. However, further studies are needed to evaluate these potential causes.
• In a retrospective survey of uncircumcised (n = 272) and circumcised (n = 273) boys between 4 months and 12 years of age to investigate foreskin problems [Herzog and Alvarez, 1986; Schwartz and Rushton, 1996]:
• Balanitis was diagnosed in 5.9% of uncircumcised boys compared with 2.9% of circumcised boys; the difference was not statistically significant.
• Poor hygiene or fair hygiene was described in 11% of boys who were uncircumcised and 7% of circumcised boys; there was no statistical difference between the groups.