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How should I assess an adult with balanitis?
- Look for ulceration, inguinal lymphadenopathy, urethritis (dysuria and urethral discharge), and features suggestive of specific balanitides or neoplasia (as referral is indicated).
Basis for recommendation
How should I manage an adult with balanitis?
- Advise daily cleaning under the foreskin with luke warm water, followed by gentle drying.
- Soap or other irritants should not be used on the genitalia.
- Consider prescribing an emollient (such as emulsifying ointment) as a soap substitute.
- For suspected non-specific dermatitis, with or without candidal colonization:
- Prescribe topical hydrocortisone 1% combined with an imidazole cream (clotrimazole 1%, miconazole 2%, or econazole 1%) once or twice a day until symptoms settle, or for up to 14 days.
- If symptoms are not improving by 7 days:
- Advise people to stop treatment with topical hydrocortisone.
- Take a sub-preputial swab to exclude or confirm a fungal or bacterial infection, and treat accordingly.
- For suspected irritant or allergic contact dermatitis:
- Discontinue any suspected triggers (such as latex condoms, creams, or soaps).
- Prescribe a mild topical hydrocortisone 1% cream or ointment once a day until symptoms settle, or for up to 14 days.
- If symptoms are not improving by 7 days:
- Advise people to stop treatment with topical hydrocortisone.
- Take a sub-preputial swab to exclude or confirm a fungal or bacterial infection, and treat accordingly.
- For suspected candidal balanitis:
- Prescribe an imidazole cream (clotrimazole 1%, econazole 1%, ketoconazole 2%, or miconazole 2%) twice a day until symptoms settle, or oral fluconazole 150 mg as a single dose (licensed for people 16 years of age and older).
- If inflammation is causing discomfort, consider prescribing hydrocortisone 1% cream or ointment for up to 14 days in addition to antifungal treatment.
- If symptoms are not improving by 7 days:
- Advise people to stop treatment with topical hydrocortisone.
- Take a sub-preputial swab to exclude or confirm a fungal or bacterial infection, and treat accordingly.
- For suspected or confirmed Gardnerella-associated balanitis:
- Prescribe oral metronidazole (400 mg twice a day) for 7 days.
- If inflammation is causing discomfort, consider prescribing hydrocortisone 1% cream or ointment for up to 14 days in addition to metronidazole.
- If symptoms are not improving by 7 days:
- Advise people to stop treatment with topical hydrocortisone.
- Take a sub-preputial swab to exclude or confirm a fungal or bacterial infection, and treat accordingly.
- For suspected or confirmed streptococcal balanitis:
- Prescribe oral amoxicillin (500 mg four times a day) for 7 days.
- Oral erythromycin (500 mg four times a day) or clarithromycin (250 mg twice a day) for 7 days are alternatives for men who are allergic to penicillin.
- If inflammation is causing discomfort, consider prescribing hydrocortisone 0.5–1% cream or ointment for up to 14 days in addition to antibiotic treatment. If symptoms are not improving by 7 days:
- Advise people to stop treatment with topical hydrocortisone.
- Take a sub-preputial swab to exclude or confirm a fungal or bacterial infection, and treat accordingly.
- If symptoms are worsening or have not settled with treatment, review the diagnosis, take a sub-preputial swab (if this has not been done already) and adjust treatment (if indicated), or seek specialist advice.
Basis for recommendation
These recommendations are based on expert advice from review articles [Edwards, 1996; English et al, 1997] and the UK national guideline on the management of balanoposthitis from the British Association for Sexual Health and HIV [BASHH, 2008].
Non-specific dermatitis, with or without candidal colonization
Contact dermatitis or marked inflammation
Candidal balanitis
- Topical imidazoles and oral fluconazole are widely recommended by experts based on their proven effectiveness in the treatment of candidiasis of the skin, toenails, and perineum in infants [Hay and Moore, 2004].
- CKS recommends continuing treatment until symptoms settle based on advice given in the UK national guideline on the management of balanoposthitis from the British Association for Sexual Health and HIV. Although the licences for most antifungal drugs recommend continuing treatment for a short period of time after clinical cure, CKS found no evidence to support this approach in balanitis.
- CKS found no evidence that one antifungal is more effective than any other in the treatment of balanitis. However, in one study oral fluconazole was preferred to topical treatment by approximately 80% of men requiring treatment for candidal balanitis [Stary et al, 1996].
- CKS found no evidence for the use of topical terbinafine for candidal infection of the skin and it is not recommended for use in children [ABPI Medicines Compendium, 2006]. Systemic treatment with terbinafine is not appropriate for refractory candidiasis and it is not licensed for this purpose [BNF 56, 2008].
Gardnerella-associated or streptococcal balanitis
- An appropriate antibiotic should result in rapid resolution of symptoms and eradication of the offending organism. CKS found no specific trial evidence for the use of antibiotics for balanitis, but antibiotics are routinely used by experts when balanitis is thought to be caused by a bacterial infection.
How should I manage recurrent balanitis?
- Treat as for an acute episode of balanitis.
- Reinforce advice on personal hygiene.
- In addition:
- Consider prescribing an emollient (such as emulsifying ointment) as a soap substitute.
- For irritant or allergic contact dermatitis, advise avoiding potential triggers such as lubricant gels, latex condoms, and topical medications.
- For candidal, streptococcal or Gardnerella-associated balanitis, advise the man that his partner should be tested for infection and treated if appropriate (see the CKS topics on Bacterial vaginosis and Candida - female genital).
Basis for recommendation
These recommendations are based on expert advice from review articles [Edwards, 1996; English et al, 1997] and the UK national guideline on the management of balanoposthitis from the British Association for Sexual Health and HIV [BASHH, 2008].
- Hygiene advice:
- Testing partners for candidal, streptococcal, and Gardnerella infection:
- Testing and treating partners who have a proven candidal or Gardnerella infection will prevent reinfection and recurrent balanitis.
- Studies have shown that in men with candidal balanitis, their partner is more likely to have a candidal infection [Davidson, 1977; Mayser, 1999].
- Studies have shown that in women with Gardnerella vaginalis, their male partners have high rates of Gardnerella in their urine or urethra [Edwards, 1996].
- The primary reservoir for group B beta-haemolytic streptococci is the female genital tract, and sexual transmission is the most likely cause of streptococcal balanitis [English et al, 1997].
When should I refer an adult with balanitis?
- If penile cancer is suspected, refer urgently to dermatology or urology. See the section on Penile cancer in the CKS topic on Urological cancer - suspected.
- If ulceration, urethritis, or inguinal lymphadenopathy are present — refer to genitourinary medicine (GUM).
- If balanitis is recurrent and associated with inability to retract the foreskin (phimosis) — refer to urology.
- If balanitis is recurrent and no underlying cause can be identified, or balanitis persists despite treatment — refer to dermatology, urology, or GUM depending on the most likely underlying cause.
Basis for recommendation
These recommendations are based on expert opinion from review articles [Edwards, 1996; English et al, 1997] and the UK national guideline on the management of balanoposthitis from the British Association for Sexual Health and HIV [BASHH, 2008].
Specific balanitides or neoplasia
- A dermatologist or urologist may carry out a biopsy to help confirm or exclude a diagnosis of penile cancer or specific balanitides.
- A dermatologist may identify allergic contact dermatitis by patch testing.
Ulceration, urethritis, or inguinal lymphadenopathy
Persistent or recurrent balanitis
- Specialist advice should be sought to exclude underlying balanitides and provide advice on further management.
Prescriptions
For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).
Topical imidazoles
Age from 16 years onwards
Clotrimazole 1% cream
Apply to the affected area 2 to 3 times a day until symptoms have settled.
Supply 20 grams.
Econazole 1% cream
Apply to the affected area twice a day, until symptoms have settled.
Supply 30 grams.
Ketoconazole 2% cream
Apply to the affected area twice a day, until symptoms have settled.
Supply 30 grams.
Miconazole 2% cream
Apply to the affected area twice a day, until symptoms have settled.
Supply 30 grams.
Topical corticosteroids
Age from 16 years onwards
Hydrocortisone 1% cream
Apply thinly to the affected area once or twice a day. If there is no improvement after 7 days return to your doctor; if there is an improvement, continue using this cream for up to 14 days.
Supply 15 grams.
Hydrocortisone 1% ointment
Hydrocortisone 1% ointment
Apply thinly to the affected area once or twice a day. If there is no improvement after 7 days return to your doctor; if there is an improvement, continue using this cream for up to 14 days.
Supply 15 grams.
Anticandidal + hydrocortisone preparations
Age from 16 years onwards
Clotrimazole 1% + hydrocortisone 1% cream
Clotrimazole 1% / Hydrocortisone 1% cream
Apply thinly to the affected area once or twice a day. If there is no improvement after 7 days return to your doctor; if there is an improvement, continue using this cream for up to 14 days.
Supply 30 grams.
Miconazole 2% + hydrocortisone 1% cream
Miconazole 2% / Hydrocortisone 1% cream
Apply thinly to the affected area once or twice a day. If there is no improvement after 7 days return to your doctor; if there is an improvement, continue using this cream for up to 14 days.
Supply 30 grams.
Nystaform HC cream (contains nystatin and hydrocortisone 0.5%)
Nystaform HC cream
Apply thinly to the affected area once or twice a day. If there is no improvement after 7 days return to your doctor; if there is an improvement, continue using this cream for up to 14 days.
Supply 30 grams.
Timodine cream (contains nystatin + hydrocortisone 0.5%)
Timodine cream
Apply thinly to the affected area once or twice a day. If there is no improvement after 7 days return to your doctor; if there is an improvement, continue using this cream for up to 14 days.
Supply 30 grams.
Fluconazole: single dose
Age from 16 years onwards
Fluconazole capsule: 150mg as a single dose
Fluconazole 150mg capsules
Take the capsule as a single dose.
Supply 1 capsule.
Antibiotics for 7 days
Age from 16 years onwards
Amoxicillin capsules: 500mg three times a day
Amoxicillin 500mg capsules
Take one capsule three times a day for 7 days.
Supply 21 capsules.
Metronidazole tablets: 400mg twice a day
Metronidazole 400mg tablets
Take one tablet twice a day for 7 days.
Supply 14 tablets.
Erythromycin e/c tablets: 500mg four times a day
Erythromycin 250mg gastro-resistant tablets
Take two tablets four times a day for 7 days.
Supply 56 tablets.
Clarithromycin tablets: 250mg twice a day
Clarithromycin 250mg tablets
Take one tablet twice a day for 7 days.
Supply 14 tablets.
Emollients
Age from 16 years onwards
Emulsifying ointment
Use as a soap substitute.
Supply 500 grams.
Epaderm emulsifying ointment
Use as a soap substitute.
Supply 500 grams.
E45 cream
Use as a soap substitute.
Supply 500 grams.