Balanitis, Phimosis, and Paraphimosis



  • Balanitis:
    • Balanitis is an inflammation of the glans penis.
    • Posthitis is an inflammation of the foreskin or prepuce.
    • Balanoposthitis is inflammation of both the glans penis and the foreskin.
    • Balanitis xerotica obliterans (BXO) is lichen sclerosus of the glans penis (uncommon).
  • Phimosis and paraphimosis:
    • Phimosis: when the foreskin is too tight to retract back to expose glans penis; can be physiologic (normal) or pathologic
    • Paraphimosis: a urological emergency where the foreskin is retracted over the glans penis and cannot return to normal position which can lead to strangulation, vascular compromise, and even necrosis
  • System(s) affected: renal/urologic; reproductive; skin/exocrine
  • Recurrent infections and irritations (for example condom catheter) can lead to pathologic phimosis.
  • Inappropriate forced reduction of a physiologic foreskin can lead to chronic scarring and pathologic phimosis.
  • Paraphimosis is a pediatric emergency; if left untreated, can lead to necrosis and autoamputation


  • 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

Balanitis: will affect 3–11% of males

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

Etiology and Pathophysiology

  • Balanitis:
    • Allergic reaction (condom latex, contraceptive jelly, soaps)
    • 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. Most phimosis referrals seen in pediatric urology clinics are normal physiologically phimotic foreskins (1). Inappropriate care of physiologic phimosis can lead to acquired phimosis by repeated forced reduction of the foreskin. Uncircumcised penises require no special care and with normal hygiene, most foreskins will become retractile over time.

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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