Balanitis in adults

INTRODUCTION AND TERMINOLOGY — Balanitis is defined as inflammation of the glans penis [1]. The word is derived from the Greek "balanos," which means "acorn."

When the prepuce (foreskin) also becomes involved, the condition is known as balanoposthitis. In common usage, "balanitis" and "balanoposthitis" are interchangeable, although balanoposthitis occurs only in uncircumcised males. For the remainder of this discussion, we will refer to both conditions using the term "balanitis."

The diagnosis and treatment of balanitis in adults will be reviewed here. Balanitis in children is discussed separately. (See "Balanitis and balanoposthitis in children and adolescents: Clinical manifestations, evaluation, and diagnosis" and "Balanitis and balanoposthitis in children and adolescents: Management".)

EPIDEMIOLOGY — In the United States, balanitis accounts for approximately 11 percent of males seen in urology clinics. Approximately 3 percent of uncircumcised patients are affected globally [2].

ETIOLOGY — Most cases of balanitis are due to infection. However, in clinical practice, cases of balanitis can also be "nonspecific," meaning that no associated condition or etiology is identified following diagnostic evaluation (table 1). (See 'Diagnostic evaluation' below.)

●Infections – Most cases of balanitis are related to inadequate hygiene in uncircumcised patients. In the uncircumcised male, the area between the glans and inner foreskin is a moist environment. Physiologic secretions from the meatus, prostate, and bladder collect in the preputial space. These secretions provide a protective barrier for the urethral meatus and glans penis. In addition, lysozymes in these secretions provide some defense against infection [3]. When the foreskin is not routinely retracted and the glans is not cleansed appropriately, smegma (a collection of desquamated squamous epithelial cells, squalene, beta-cholestanol, and long-chain fatty acids) can develop, disrupting the protective barrier. This compromise of host defense may permit secondary infection and inflammation, leading to balanitis.

The causative organism can arise from overgrowth of organisms normally residing in the groin region, spread of adjacent cutaneous infection, or pathogens introduced by sexual contact (table 1).

In addition to inadequate hygiene, balanitis occurs more frequently in patients with the following risk factors:

•Diabetes mellitus

•Obesity

•History of sexually transmitted infections

•Trauma (eg, zipper injury or inappropriate foreskin manipulation)

•Edematous conditions such as congestive heart failure, cirrhosis, and nephrotic syndrome

●Noninfectious etiologies – While infectious etiologies are most common, dermatologic conditions and premalignant conditions can also cause balanitis [4-20]. The range of conditions known to cause balanitis are summarized in the table (table 1) [21].

CLINICAL MANIFESTATIONS

Initial presentation — Balanitis presents as pain, tenderness, or pruritus of the glans and/or foreskin, which generally develops over three to seven days.

Physical examination shows erythema of the glans, which may be associated with a curd-like or purulent exudate.

While a specific underlying etiology is not always identified, recognition of key features can assist in more efficient and specific treatment. Additional features by etiology are described below and in the table (table 1). (See 'Additional features by etiology' below.)

Complications — Localized edema may develop if balanitis is allowed to progress without treatment, which can result in tightening and scarring. Paraphimosis, which refers to trapping of the foreskin behind the glans penis, requires urgent reduction.

The diagnosis of phimosis and paraphimosis may be overlooked in the hospital setting, especially in patients with abnormal mental status. Accurate diagnosis of phimosis and paraphimosis requires careful physical examination, including evaluation of foreskin mobility in all patients presenting with balanitis.

●Phimosis – Phimosis is an abnormal constriction of the opening in the foreskin that precludes retraction over the glans penis. It results from chronic inflammation and edema of the foreskin due to balanitis [2,22]. Development of a phimosis often complicates sexual function, voiding, and hygiene.

If a phimosis is present, examination should be approached with caution, as a forcible retraction can result in paraphimosis (trapping of the foreskin). (See 'Phimosis and paraphimosis' below.)

●Paraphimosis – Paraphimosis refers to the trapping of the foreskin behind the glans penis and is a urologic emergency (picture 1).

When paraphimosis develops, the constricting foreskin becomes trapped proximal to the glans penis. Under these circumstances, the constricting band will limit the venous and lymphatic outflow while allowing continued arterial inflow. Over the course of minutes to hours the glans will increase in size and become exquisitely painful. (See 'Phimosis and paraphimosis' below and "Paraphimosis: Clinical manifestations, diagnosis, and treatment".)

●Chronic balanitis – Chronic, untreated balanitis can lead to ulcerative lesions of the glans and foreskin and meatal or urethral stricture. Chronic balanitis may also predispose to premalignant and malignant lesions; however, there is contradictory evidence on this topic [23,24]. (See 'Penile intraepithelial neoplasia' below and "Carcinoma of the penis: Epidemiology, risk factors, and pathology".)

Additional features by etiology — Balanitis from any etiology presents with pain and erythema of the glans. Additional symptoms and signs vary according to etiology. Etiologies and presenting features are compared in the table (table 1).

Cases lacking features suggestive of etiology are termed "nonspecific balanitis" (algorithm 1). (See 'Assessing for etiology' below and 'Empiric treatment' below.)

Candida balanitis — Of cases with identifiable causes, candidal infection is the most common. Candida colonization of the penis occurs in 15 to 20 percent of males and is more common in diabetic persons and in individuals who are uncircumcised or who have partners with recurrent vaginal candidiasis [25,26]. Candida albicans is the dominant species.

Symptomatic candidal infection typically presents with a painful or pruritic erythematous rash; a white, curd-like exudate or white patches on the penis are sometimes present. Pruritus and burning is present and can be most notable after sexual intercourse. The infection can also spread to thighs, gluteal folds, buttocks, and scrotum. Physical examination may reveal the presence of small papules with blotchy erythema and an eroded, dry, or glazed appearance (picture 2) [21,27].

Balanitis or phimosis in an otherwise healthy patient can be the first presenting symptom of diabetes mellitus [28]. Poorly controlled blood glucose is associated with proliferation of candidal species beneath the foreskin, which leads to balanitis.

Other infectious etiologies

●Gram-positive cocci – Group A streptococcus and Staphylococcus aureus are common skin pathogens that can cause balanitis, especially in the setting of inadequate hygiene or trauma.

●Anaerobes – Anaerobic bacteria have been reported as a cause of balanitis (with mixed species, which may include Gardnerella vaginalis), especially in uncircumcised males [5]. Subpreputial anaerobic infection can result in a foul-smelling discharge, inflammation and edema of the glans/foreskin, erosive lesions, and inguinal lymphadenopathy (picture 3).

●Sexually transmitted infections – Sexually transmitted pathogens, including Trichomonas vaginalis, herpes simplex virus, human papillomavirus (HPV), syphilis, scabies (picture 4), Neisseria gonorrhea, Chlamydia trachomatis, and Mycoplasma genitalium, may also cause this condition.

Clinical manifestations associated with these organisms are discussed briefly in the table (table 1) and in more detail separately.

●(See "Trichomoniasis: Clinical manifestations and diagnosis", section on 'Male'.)

●(See "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection", section on 'Clinical features'.)

●(See "Syphilis: Epidemiology, pathophysiology, and clinical manifestations in patients without HIV", section on 'Clinical manifestations'.)

●(See "Mycoplasma genitalium infection", section on 'Associated clinical syndromes'.)

Dermatologic etiologies — Dermatologic conditions that may result in balanitis include psoriasis, eczema, lichen planus, lichen sclerosus, plasma cell (Zoon's) balanitis, contact dermatitis, and fixed drug eruption (table 1) [29].

In most cases, additional skin manifestations noted on total body skin examination assist with completing the clinical picture; however, for plasma cell balanitis, contact dermatitis, and fixed drug eruption, balanitis is the only manifestation of the skin condition.

●Psoriasis – Psoriasis presents as erythematous scaly plaques on the glans and may also affect intertriginous areas. It may also manifest as "inverse psoriasis," which is characterized by no visible scaling. (See "Psoriasis: Epidemiology, clinical manifestations, and diagnosis", section on 'Inverse (intertriginous) psoriasis'.)

●Atopic dermatitis – Atopic dermatitis may involve the penis with symptoms of dryness and pruritus and physical findings of erythema and edema of the glans. There is often a prior history of atopic dermatitis or recurrent nonspecific skin rashes. (See "Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis", section on 'Clinical manifestations'.)

●Lichen planus – Lichen planus is an inflammatory disorder with skin, genital, and oral mucous membrane manifestations. Pruritic, violaceous plaques are the characteristic finding on physical examination. Erosive mucosal lesions can also occur. (See "Lichen planus", section on 'Other forms of lichen planus'.)

●Lichen sclerosus – This chronic inflammatory dermatosis frequently involves the genitalia. Penile involvement is known as balanitis xerotica obliterans (BXO), which is analogous to vulvar lichen sclerosus. (See "Vulvar lichen sclerosus: Clinical manifestations and diagnosis".)

BXO often presents with white or hypopigmented penile lesions, pruritus, painful erections and voiding, and bleeding or ulceration with intercourse (picture 5). There can be bullae, ulceration, or hemorrhagic vesicles. The foreskin can become thickened and phimotic, and urethral strictures can develop.

Although penile lichen sclerosus is a benign condition, it can also be associated with penile squamous cell carcinoma. (See "Carcinoma of the penis: Clinical presentation, diagnosis, and staging", section on 'Premalignant lesions'.)

●Plasma cell (Zoon's) balanitis – Plasma cell (Zoon's) balanitis is a disease of older males who are uncircumcised. It presents as symmetrical, well-marginated erythema of the glans and foreskin and may be confused with carcinoma in situ [21]. It is generally diagnosed by biopsy and treated by circumcision.

●Contact dermatitis – The appearance of an irritative or allergic reaction can range from slight erythema to severe penile edema. A careful clinical history to identify exposure to potential irritants (eg, cleansers or other products) or allergens is an important component of diagnosis of contact dermatitis. Patch testing can be helpful for identifying allergic contact dermatitis. (See "Irritant contact dermatitis in adults", section on 'Clinical manifestations' and "Clinical features and diagnosis of allergic contact dermatitis" and "Patch testing".)

●Fixed drug eruption – Balanitis can represent a reaction to a specific medication as described in several case reports. The pathophysiology of balanitis as a manifestation of a drug eruption is not well understood.

A fixed drug eruption is characterized by the recurrent appearance of skin lesions over the course of 30 minutes to 8 hours following exposure to the drug. Typical lesions are round or oval plaques with erythema, edema, and sharply defined borders that occur at the same site each time the offending agent is administered. The most commonly offending agents are tetracyclines, salicylates, phenacetin, phenolphthalein, and some hypnotics [21,30-32]. (See "Fixed drug eruption".)

Penile intraepithelial neoplasia — Penile intraepithelial neoplasia, or PeIN, includes both HPV- and non-HPV-related neoplasia that can eventually progress to invasive penile squamous cell carcinoma [21,33,34]. Bowenoid papulosis (picture 6) is a premalignant focal epidermal dysplasia. Bowen's disease (picture 7) describes cutaneous squamous cell carcinoma (cSCC) in situ, while Erythroplasia of Queyrat (picture 8) describes cSCC in situ involving the penis. Further details are discussed separately. (See "Carcinoma of the penis: Epidemiology, risk factors, and pathology", section on 'Penile intraepithelial neoplasia' and "Carcinoma of the penis: Clinical presentation, diagnosis, and staging", section on 'Premalignant lesions'.)

Reactive arthritis — Reactive arthritis (formerly Reiter syndrome) is a less common cause of balanitis [21]. Associated symptoms include painful joints, a more generalized dermatitis, mouth sores, swollen or painful glands, and malaise or fatigue.

Twenty to 40 percent of males with reactive arthritis develop circinate balanitis, which is characterized by small, shallow, painless ulcerative lesions on the glans penis (picture 9 and picture 10 and picture 11 and picture 12) [35]. There may also be a serpiginous annular dermatitis that often has a grayish-white granular appearance with a "geographical" white margin [21]. (See "Neutrophilic dermatoses", section on 'Reactive arthritis'.)

Circinate balanitis, when occurring as a component of reactive arthritis, is often a self-limited condition but can persist for several months. Patients with circinate balanitis associated with reactive arthritis may also have other genital symptoms, including dysuria, penile discharge, and prostatitis. Additional clinical manifestations of reactive arthritis are discussed elsewhere. (See "Reactive arthritis", section on 'Clinical manifestations'.)

DIAGNOSTIC EVALUATION

Making the diagnosis — Balanitis should be suspected in patients who complain of penile pain and/or redness. The diagnosis is confirmed by the presence of an inflamed and erythematous glans on physical examination.

Ruling out complications — For males who are uncircumcised, mobility of the foreskin should be assessed to exclude phimosis and paraphimosis (trapping of the foreskin behind the glans) (picture 1), which are complications of balanitis.

Paraphimosis requires urgent urologic consultation. (See 'Complications' above and 'Phimosis and paraphimosis' below and "Paraphimosis: Clinical manifestations, diagnosis, and treatment".)

Assessing for etiology — Once a diagnosis of balanitis is made, further evaluation for etiology is pursued. Most commonly, balanitis in uncircumcised patients is due to inadequate hygiene with superimposed Candida infection, though other etiologies are possible. While a specific etiology is not always identified, recognition of key features can assist in more efficient and specific treatment:

●A history of diabetes mellitus or human immunodeficiency virus infection conditions suggests Candida balanitis. A potassium hydroxide (KOH) stain for budding yeast and/or pseudohyphae (picture 13) can assist with evaluation for Candida, or an empiric trial of treatment for Candida can be prescribed (algorithm 1). (See 'Candidal infection' below.)

Candidal infection can be a presenting finding of diabetes mellitus in a patient that was previously undiagnosed.

●A total body skin examination should be performed. The presence (or history) of eczema, psoriasis, or other generalized skin conditions should prompt a referral to dermatology for diagnosis of a generalized skin condition with associated balanitis. (See 'Dermatologic etiologies' above.)

●The urethral meatus should be assessed carefully for concomitant urethritis and discharge, alongside a detailed sexual history. Presence of symptoms or risk factors should prompt testing for sexually transmitted infections, including Neisseria gonorrhea, Chlamydia trachomatis, M. genitalium, T. vaginalis, herpes simplex virus (HSV), human papillomavirus, and syphilis. Identification of vesicles or ulcers make a diagnosis of HSV or syphilis much more likely. (See "Urethritis in adults and adolescents" and "Screening for sexually transmitted infections".)

●Other factors that may suggest bacterial infection include a history of local trauma (eg, zipper injury or foreskin manipulation), inguinal lymphadenopathy, or purulent discharge. Gram stain and culture of a urethral swab can assist with identifying the causative agent. (See 'Bacterial and other infections' below.)

●Inflammatory arthritis on musculoskeletal examination suggests reactive arthritis. Testing for antecedent or concomitant infection can be pursued, though confirmatory testing for pathogens has a low diagnostic yield, as the infection has resolved by the time mucocutaneous symptoms develop. (See "Reactive arthritis", section on 'Antecedent or concomitant infection'.)

●A history of recent new medications should prompt an evaluation for drug-induced balanitis and a stepwise approach to identifying and discontinuing the potential culprit medication.

Cases in which a specific etiology is not identified are termed "nonspecific balanitis." In such cases, response to empiric treatment is a key component of the diagnostic process (algorithm 1). (See 'Empiric treatment' below.)

In patients with skin manifestations suggestive of a dermatologic etiology, a referral to dermatology is warranted to confirm the diagnosis through clinical examination or biopsy or perform additional evaluation for premalignant disease. (See 'Dermatologic etiologies' above and 'Penile intraepithelial neoplasia' above.)

MANAGEMENT

Phimosis and paraphimosis — Phimosis and paraphimosis must be recognized and triaged urgently. (See 'Complications' above.)

Phimosis can be treated in the emergent setting by dilation using a surgical clamp and pain medication. In the event this is not successful, a dorsal slit circumcision can be performed by a urologist to temporize the problem. Definitive treatment, under elective circumstances, is complete circumcision.

When paraphimosis develops, the constricting foreskin traps venous and lymphatic outflow while arterial inflow continues. The subsequent swelling causes exquisite pain and potential compartment syndrome. This condition requires urgent reduction. (See "Paraphimosis: Clinical manifestations, diagnosis, and treatment", section on 'Treatment'.)

Hygiene measures for all patients — Attention to genital hygiene is the most important intervention for all patients with balanitis. Retraction of the foreskin with thorough genital cleansing can be both preventive and therapeutic. Twice-daily bathing of the affected area with saline solution should be encouraged [21,27].

A balance must be established between overly aggressive and inadequate hygiene measures. Overuse of detergents, soaps, perfumes, condoms, and other chemicals (spermicidal agents, petroleum jelly), similar to poor hygiene, can also result in inflammation to the skin of the glans/foreskin [36].

In addition, dermatitis can result from irritation secondary to the shearing effects of clothing. Patients should be advised to wear looser-fitting clothing to reduce irritation from shearing.

Empiric treatment — Patients with nonspecific balanitis for whom an underlying etiology is not identified should be treated empirically with local hygiene and topical antifungal and steroid therapies, using the following stepwise approach (algorithm 1):

●Uncircumcised patients – In uncircumcised patients, nonspecific balanitis may respond to saline solution bathing alone. If symptoms improve, twice-daily saline solution bathing should continue for at least 14 days or until symptoms resolve. Patients who have a low baseline level of hygiene may benefit from extended saline solution bathing indefinitely, as a prophylactic measure.

●Circumcised patients and uncircumcised patients who do not respond to saline bathing – We suggest empiric treatment for candidal infection with clotrimazole 1% cream or miconazole 2% cream twice daily for 7 to 14 days. (See 'Candidal infection' below.)

●Persistent symptoms – For those who have no improvement with saline bathing and antifungal therapy, we suggest a trial of hydrocortisone 1% cream or ointment twice daily for seven days for nonspecific dermatitis.

Directed treatment for identifiable causes — Most cases of balanitis are nonspecific and are treated empirically (see 'Empiric treatment' above). Specific features from the patient's history and examination, when noted, can guide directed treatment. (See 'Assessing for etiology' above.)

Candidal infection — For most patients, treatment includes the use of topical antifungal agents, usually for one to three weeks. First-line therapy includes a topical imidazole, either clotrimazole 1% or miconazole 2%, applied twice daily [21]. Nystatin cream (100,000 units/g) can be used in patients allergic to imidazoles. For patients who have severe symptoms, options are a single dose of oral fluconazole 150 mg [37] or the combination of a topical imidazole and hydrocortisone 1% cream twice daily.

Dietary supplementation with lactobacillus-containing yogurt has been proposed as an attempt to decrease candidal colonization in these patients. Although there are no studies of lactobacillus in the treatment or prevention of candidal balanitis, given that it decreases candidal colonization of the rectum and vagina among females, there is a theoretical basis for its utility [38,39]. We do not suggest alternative therapies with phytogenic agents, including garlic, calendula, and goldenseal, since there are no reliable data showing their effectiveness.

Female sexual partners of patients with balanitis should be offered testing for Candida or empiric treatment to reduce the likelihood of reinfection [21]. (See "Candida vulvovaginitis in adults: Treatment of acute infection", section on 'Male partners with postcoital hypersensitivity reaction'.)

Bacterial and other infections — Specific pathogens are not usually identified, and therefore, treatment choices are empiric.

●Suspected anaerobic infection – We suggest topical metronidazole 0.75% applied twice daily for seven days; oral metronidazole (500 mg twice daily for seven days) may be necessary for more severe cases [21]. Oral amoxicillin-clavulanate or clindamycin topical cream are alternative regimens.

●Suspected streptococcal or staphylococcal infection – We suggest mupirocin cream applied three times daily for 7 to 14 days. Oral dicloxacillin (500 mg four times daily for seven days) or cephalexin (500 mg four times daily for seven days) may be necessary for more severe cases.

For patients with recurrent infectious balanitis, circumcision or dorsal slit surgery should be strongly considered after the infection has been treated.

Less common etiologies — Directed therapy is warranted if specific features noted on history and examination suggest a specific cause.

●Sexually transmitted infections – Management of trichomonas, herpes simplex virus infection, human papillomavirus infection, syphilis, scabies, and M. genitalium infection is discussed separately. (See "Treatment of genital herpes simplex virus infection" and "Syphilis: Treatment and monitoring", section on 'Treatment of early syphilis' and "Mycoplasma genitalium infection", section on 'Treatment' and "Scabies: Management".)

●Dermatologic and premalignant conditions – Dermatologic conditions known to cause balanitis include psoriasis, eczema, lichen planus, lichen sclerosus, plasma cell (Zoon's) balanitis, and contact dermatitis. Confirmation of diagnosis, treatment of these conditions, and periodic surveillance for premalignant conditions is managed by dermatology. Details on treatment for dermatologic conditions associated with balanitis are discussed separately:

•(See "Treatment of psoriasis in adults".)

•(See "Treatment of atopic dermatitis (eczema)".)

•(See "Lichen planus", section on 'Treatment'.)

•(See "Irritant contact dermatitis in adults", section on 'Management'.)

•(See "Fixed drug eruption", section on 'Management'.)

•(See "Carcinoma of the penis: Surgical and medical treatment".)

•(See "Male adult circumcision", section on 'Zoon balanitis'.)

●Reactive arthritis – The suggested treatment of circinate balanitis is hydrocortisone 1% cream applied twice daily for relief of symptoms. In addition, any concurrent infection should be treated. Occasionally, systemic corticosteroid treatment is required, either for refractory circinate balanitis or due to the severity of systemic and extragenital symptoms. These patients are usually managed by rheumatology. (See "Reactive arthritis", section on 'Treatment of other clinical features'.)

Recurrent or refractory cases — Circumcision should be considered when balanitis recurs in spite of consistent hygiene measures and directed treatment or if daily steroid cream is required to maintain response [21].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Balanoposthitis" and "Society guideline links: Lichen sclerosus".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Lichen sclerosus (The Basics)" and "Patient education: Balanitis in adults (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Definition – Balanitis is defined as inflammation of the glans penis. Balanoposthitis includes concomitant inflammation of the foreskin. This topic uses "balanitis" to refer to both conditions. (See 'Introduction and terminology' above.)

●Etiology – Most cases of balanitis are related to inadequate personal hygiene and subsequent infection and inflammation in uncircumcised patients. When the foreskin is not routinely retracted and the glans is not cleansed appropriately, smegma can develop, disrupting the protective barrier. This compromise of host defense may permit secondary infection and inflammation, leading to balanitis.

In clinical practice, balanitis may be "nonspecific," meaning that an underlying etiology is not identified. Of cases with identifiable causes, candidal infection is the most common. Various other infectious agents, dermatologic conditions, and premalignant conditions have been associated with balanitis (table 1). (See 'Etiology' above.)

●Clinical manifestations – Balanitis presents as pain, tenderness, or pruritus of the glans and/or foreskin, commonly associated with erythematous lesions, urethritis, or a curd-like or purulent exudate.

While a specific underlying etiology is not always identified, recognition of key features can assist in more efficient and specific treatment (table 1). (See 'Clinical manifestations' above and 'Additional features by etiology' above.)

●Diagnostic evaluation – Physical examination should include inspection of the glans, foreskin, and the urethral meatus for inflammation/discharge.

Careful inspection for phimosis and paraphimosis (trapping of the foreskin behind the glans penis (picture 1)) should be performed, as paraphimosis is a urologic emergency. (See 'Ruling out complications' above and 'Complications' above.)

History and physical examination, including a comprehensive extragenital examination, sometimes point to specific etiologies that have management implications (table 1 and algorithm 1). (See 'Diagnostic evaluation' above and 'Assessing for etiology' above.)

In patients with skin manifestations suggestive of a dermatologic etiology, a referral to dermatology is warranted to confirm the diagnosis through clinical examination or biopsy or perform additional evaluation for premalignant disease. (See 'Dermatologic etiologies' above.)

Cases in which a specific etiology is not identified are termed "nonspecific balanitis." In such cases, response to empiric treatment is a key component of the diagnostic process.

●Management – Management of uncomplicated balanitis without an identifiable cause is initially focused on local hygiene measures and evaluating for complications, followed by empiric treatment for candidal infection and/or noninfectious dermatitis if symptoms are persistent (algorithm 1). (See 'Management' above.)

•Hygiene measures – Attention to genital hygiene is the most important intervention for all patients with balanitis. In uncircumcised patients, retraction of the foreskin with thorough genital cleansing can be both preventive and therapeutic.

We suggest twice-daily bathing of the affected area with saline solution (Grade 2C). (See 'Hygiene measures for all patients' above and 'Empiric treatment' above.)

•Additional empiric treatment – In circumcised males and in uncircumcised males who do not respond to saline solution bathing, we suggest empiric treatment for candidal infection with clotrimazole 1% twice daily or miconazole 2% twice daily (Grade 2C).

For those who have no improvement on antifungal therapy, we suggest a trial of hydrocortisone 1% cream twice daily for nonspecific dermatitis (Grade 2C). (See 'Empiric treatment' above.)

•Specific treatment for other etiologies – If other specific etiologies are identified, directed therapy is warranted. Management generally consists of topical antibiotics for bacterial infections, topical steroid creams for dermatologic conditions, and potential ablation or excision of premalignant lesions. (See 'Less common etiologies' above.)