• Diagnose balanitis in an adult on the basis of clinical findings:
• Penile soreness, itch, and odour are common symptoms.
• Redness on the glans penis (and often the foreskin) with exudate are usual. Swelling of the glans penis and foreskin may be seen.
• Dysuria and dyspareunia may occur.
• Balanitis is mostly seen in uncircumcised men and an inability to retract the foreskin is common.
• Swabs (for example, a sub-preputial swab) are not necessary for diagnosis, but can be useful for identifying the underlying cause if symptoms are severe, recurrent, or persistent.

These recommendations are based on expert opinion from secondary care review articles which indicate that balanitis usually presents with specific clinical features [Edwards, 1996; English et al, 1997].

• For a list of causes in adults, see Causes in adults.
• Ask about:
• Hygiene practices (for example, how often is the penis cleaned?) — lack of hygiene predisposes to non-specific dermatitis.
• Exposure to irritants — such as soaps or creams.
• Trauma — for example, during sexual intercourse or vigorous cleaning.
• Exposure to infections — has the man's partner had bacterial vaginosis or a vaginal candidal infection?
• A history of diabetes or immunosuppression — which predisposes to infection.
• Look for clinical features of balanitis and for other skin conditions elsewhere (such as seborrhoeic dermatitis), which suggest a specific underlying cause.
• Take a sub-preputial swab if balanitis is:
• Severe.
• Recurrent.
• Mild, but persists despite treatment.
• Only swab for Gardnerella-associated balanitis if this is suspected clinically. State 'gardnerella' on the laboratory form when requesting the test, as most laboratories will not routinely test for the organism.
• Check blood glucose levels or urine for glycosuria if balanitis is severe, persistent, or recurrent (especially if candidal balanitis is present).

• Non-specific dermatitis — redness of the glans penis, which often extends onto the skin of the shaft of the penis.
• Candidal balanitis — redness on the undersurface of the glans penis, with sparing around the urethral meatus. Small, eroded papules may be present with a white cheese-like matter, that can be rubbed off easily. In people with diabetes, candidal balanitis often presents with more severe features (such as intense redness of the glans penis and pain).
• Irritant or allergic contact dermatitis — redness of the glans penis with localized swelling (especially in allergic contact dermatitis).
• Gardnerella-associated balanitis — a fishy odour and a sub-preputial mucoid discharge (see the CKS topic on Bacterial vaginosis).
• Streptococcal infection — may present with a rapid onset of severe penile redness and pain, and is usually accompanied by a purulent exudate. Streptococcal balanitis with exudate can be distinguished clinically from urethritis with urethral discharge by the pattern of redness on the glans penis. In streptococcal infections there is usually no redness of the urethral meatus, unlike urethritis where the urethral meatus is typically red.

These recommendations are based on expert advice from review articles [Alsterholm et al, 2008; Bhalani et al, 2008; Singh and Bunker, 2008].

Predisposing factors

• Poor hygiene, recurrent trauma, or exposure to irritants are common causes of balanitis; therefore, identifying and correcting these predisposing factors will reduce the risk of recurrence [Birley et al, 1993; Fornasa et al, 1994].

Sub-preputial swab

• A swab is useful to confirm, or exclude, an infectious cause of balanitis. Most people with balanitis presenting in primary care have mild non-specific dermatitis (with or without candidal colonization), which usually responds rapidly to empirical treatment. Therefore, it seems sensible to swab when balanitis is severe or recurrent, or not settling despite treatment with a combined topical corticosteroid and antifungal.

Excluding diabetes

• Diabetes predisposes to skin infections, especially candidal infections, and people with diabetes often develop severe infections. A survey of 138 men with candidal balanitis found one in 10 had diabetes that was previously undiagnosed. Therefore, excluding diabetes in men with severe or recurrent balanitis is recommended [Waugh, 1998].