Balanitis: Etiologies, suggestive features, and additional diagnostic studies

Etiology	Suggestive features on penile examination	Additional suggestive history and physical examination findings	Diagnostic studies
Infectious
Candida albicans	White, curd-like exudate	Concomitant painful, pruritic, erythematous rash (cutaneous candidiasis); history of diabetes mellitus, HIV, or other immunocompromised condition; partner with recurrent vaginal candidiasis	KOH stain confirms diagnosis
Bacterial infection	Purulent or foul-smelling exudate	Inguinal lymphadenopathy	Bacterial culture
HSV, syphilis	Vesicular or ulcerative lesions		HSV and syphilis testing
Additional STIs^*		Behavioral risk(s) for STIs, concomitant urethritis	STI^* testing; consider Mycoplasma genitalium in the presence of urethritis
Dermatologic
Psoriasis	Erythematous, scaly plaques	Similar plaques on TBSE, including intertriginous areas	Clinical appearance; biopsy assists in cases of diagnostic uncertainty
Eczema	Erythema, edema, dryness, and pruritus	History of eczema or recurrent generalized dermatitis	Clinical appearance
Lichen planus	Intensely pruritic, flat-topped, purplish plaques	Erosive mucosal lesions, dysphagia/odynophagia, similar plaques on TBSE, Koebner reaction	Biopsy of affected area
Plasma cell (Zoon's) balanitis	Symmetrical, well-marginated erythema in older, uncircumcised males		Biopsy of affected area
Allergic reaction/contact dermatitis	Broad range from slight erythema to severe penile edema	History of frequent genital cleansing	Patch testing can determine presence of allergy
Fixed drug eruption	Round plaques with erythema, edema, and sharply defined borders, within hours of drug exposure	Recent history of tetracyclines, salicylates, or hypnotics
Premalignant
Lichen sclerosis	White penile lesions with pruritus, blisters, ulceration, or hemorrhagic vesicles	Painful erections and voiding, urethral strictures	Most are diagnosed based on clinical appearance; biopsy assists in cases of diagnostic uncertainty
Bowenoid papulosis	Discrete papules or plaques in groups, may be pigmented	Appearance is similar to genital warts	Biopsy of affected area
Carcinoma in situ (erythroplasia of Queyrat)	Well-circumscribed, solitary, red, velvety lesion, typically painless	History of human papillomavirus infection, affects older, uncircumcised men	Biopsy of affected area
Cutaneous squamous cell carcinoma in situ (Bowen's disease)	Erythematous, well-demarcated, scaly patch or plaque on the penile shaft		Biopsy of affected area
Other etiologies
Reactive arthritis	Shallow, painless ulcers on the glans (circinate balanitis)	Dysuria, penile discharge, and prostatitis; ocular inflammation; serpiginous annular dermatitis; inflammatory arthritis; or enthesitis	Evaluation for typical causative pathogens through urine and genital swab testing and stool cultures, plain radiographs of affected joints

Balanitis has a wide range of causes. Presenting signs and symptoms vary according to etiology. Of cases with an identifiable cause, candidal infection is the most common.

HIV: human immunodeficiency virus; HSV: herpes simplex virus; STI: sexually transmitted infection; TBSE: total body skin examination

* Trichomonas, HSV, human papillomavirus, scabies, Mycoplasma genitalium, gonorrhea, chlamydia.

Graphic 113319 Version 4.0

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Balanitis: Etiologies, suggestive features, and additional diagnostic studies