• Diagnose balanitis in a child on the basis of clinical findings:
• Penile soreness, itch, and odour which usually develop over a few days.
• Redness of the glans penis (and often the foreskin) with exudate is usual.
• The glans penis and foreskin may be swollen.
• A sub-preputial swab is not necessary to make a diagnosis, but can be useful for identifying the underlying cause if symptoms are severe or persistent.

This information is based on expert opinion from review articles of secondary care management [Escala and Rickwood, 1989; Orden et al, 1996].

• For a list of causes of balanitis in children, see Causes in children.
• Ask about:
• Hygiene practices (for example, how often is the nappy changed or penis cleaned?) — lack of hygiene predisposes to non-specific dermatitis.
• Exposure to irritants — such as bubble bath, detergents, or creams.
• Trauma — from 'foreskin fiddling'.
• Other skin conditions (such as eczema).
• Look for clinical features and skin conditions which may suggest a specific underlying cause.
• Take a sub-preputial swab if balanitis is:
• Severe (suggesting a secondary infection).
• Mild, but persists despite treatment.

• Non-specific dermatitis — redness of the glans penis which often extends onto the skin of the shaft of the penis.
• Contact balanitis — redness of the glans penis with localized swelling. This is most commonly irritant contact dermatitis; allergic contact dermatitis is unusual in children.
• 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.
• Bacterial infection (for example group A beta-haemolytic streptococci or Staphylococcus aureus) — penile redness and pain, often accompanied by a purulent exudate. Systemic symptoms, such as fever, may also occur.

These recommendations are based on expert advice from review articles [Orden et al, 1996; Schwartz and Rushton, 1996].

Predisposing factors

• Non-specific dermatitis is thought to be the most common cause of balanitis. However, occasionally, specific irritants may be identified that will require avoidance [Schwartz and Rushton, 1996].

Sub-preputial swab

• A swab can be useful to confirm, or exclude, an infectious cause of balanitis. However, most children with balanitis presenting in primary care probably have mild non-specific dermatitis (with or without candidal or bacterial colonization), which usually responds quickly to empirical treatment — making it unnecessary to swab all children.
• A case series investigating boys (n = 32) with balanitis presenting in secondary care suggests that more severe balanitis (increased erythema and exudate) indicates a bacterial infection [Escala and Rickwood, 1989]. Therefore, it seems sensible to swab when balanitis is severe, or not responding to treatment with a combined topical corticosteroid and antifungal.