Balanitis, Phimosis, and Paraphimosis

Balanitis, Phimosis, and Paraphimosis is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Balanitis:
    • An inflammation of the glans penis
    • Posthitis is an inflammation of the foreskin.
    • Balanitis xerotica obliterans (BXO) is lichen sclerosus of the glans penis (uncommon).
  • Phimosis and paraphimosis:
    • Phimosis: tightness of the distal penile foreskin that prevents it from being drawn back from over the glans
    • Paraphimosis: constriction by foreskin of an uncircumcised penis, preventing the foreskin from returning to its position over the glans; occurs after the retracted foreskin becomes swollen and engorged; a urologic emergency
  • System(s) affected: renal/urologic; reproductive; skin/exocrine
ALERT
  • Recurrent infection and irritations (condom catheters) can lead to phimosis.
  • Recurrent balanitis, either chemical or infectious, can lead to an acquired phimosis.
  • Inappropriate forced reduction of a physiologic foreskin can lead to chronic scarring and acquired phimosis; unfortunately, many times done due to instructions from health care providers
  • Paraphimosis is a pediatric emergency; if left untreated, can lead to necrosis and autoamputation

Epidemiology

  • Balanitis: predominant age: adult; predominant gender: male only
  • Phimosis/paraphimosis: predominant age: infancy and adolescence; unusual in adults; risk returns in geriatrics; predominant sex: male only

Incidence
Balanitis: will affect 3–11% of males

Prevalence
Phimosis: in the United States: 8% of boys age 6 years and 1% of men >16 years of age (1)

Etiology and Pathophysiology

  • Balanitis:
    • Allergic reaction (condom latex, contraceptive jelly)
    • Infections (Candida albicans, Borrelia vincentii, streptococci, Trichomonas, HPV)
    • Fixed-drug eruption (sulfa, tetracycline)
    • Plasma cell infiltration (Zoon balanitis)
    • Autodigestion by activated pancreatic transplant exocrine enzymes
  • Phimosis:
    • Physiologic: present at birth; resolves spontaneously during the first 2 to 3 years of life through nocturnal erections, which slowly dilate the phimotic ring
    • Acquired: recurrent inflammation, trauma, or infections of the foreskin
  • Paraphimosis:
    • Often iatrogenically or inadvertently induced by the foreskin not being pulled back over the glans after voiding, cleaning, cystoscopy, or catheter insertion

Geriatric Considerations
Condom catheters can predispose to balanitis.

Pediatric Considerations
Oral antibiotics predispose male infants to Candida balanitis. Inappropriate care of physiologic phimosis can lead to acquired phimosis by repeated forced reduction of the foreskin.

Risk Factors

  • Balanitis:
    • Presence of foreskin
    • Morbid obesity
    • Poor hygiene
    • Diabetes; probably most common
    • Nursing home environment
    • Condom catheters
    • Chemical irritants
    • Edematous conditions: CHF, nephrosis
  • Phimosis:
    • Poor hygiene
    • Diabetes by repeated balanitis
    • Frequent diaper rash in infants
    • Recurrent posthitis
  • Paraphimosis:
    • Presence of foreskin
    • Inexperienced health care provider (leaving foreskin retracted after catheter placement)
    • Poor education about care of the foreskin

General Prevention

  • Balanitis:
    • Proper hygiene and avoidance of allergens
    • Circumcision
  • Phimosis/paraphimosis:
    • If the patient is uncircumcised, appropriate hygiene and care of the foreskin are necessary to prevent phimosis and paraphimosis.

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