Disorders of the glans penis and foreskin

The most common disorders of the glans penis and foreskin are balanitis, balanoposthitis, phimosis, and paraphimosis.

Balanitis refers to inflammation of the glans penis. Balanoposthitis refers to inflammation of both the glans penis and the foreskin. Local treatment with topical agents usually suffices to manage both conditions.

Phimosis refers to a tight foreskin that cannot be retracted completely. It is often normal in young children but may be pathological if it develops secondary to scarring. Pathological phimosis most commonly occurs as a complication of balanitis or balanoposthitis. Conservative treatment consists of topical corticosteroids and stretching exercises. Circumcision may be required.

Paraphimosis refers to a condition in which the foreskin has retracted and cannot be returned to its original position. Paraphimosis may occur due to phimosis, sexual activity, or trauma. Pain control and manual reduction may be sufficient, although in some cases surgical intervention is required in order to prevent penile necrosis.

• Definition
  • Balanitis: inflammation of the glans penis (may occur in both circumcised and uncircumcised males)
  • Balanoposthitis: inflammation of both the glans penis and the foreskin
• Etiology
  • Poor genital hygiene
  • Contact allergies and topical irritants
  • Drug reaction
  • Bacterial infection (e.g., especially sexually transmitted infections such as gonorrhea)
  • Yeast infection (e.g., Candida diaper dermatitis)
  • Trauma
  • Rarely
    • Reactive arthritis with erosive plaques on the glans penis
    • Pemphigus
    • Pemphigoid
    • Lichen sclerosus (Balanitis xerotica obliterans)
    • Erythroplasia of Queyrat
• Clinical features
  • Pruritus, pain, and edema of the glans penis
  • Erythema and ulcerated lesions of the glans or foreskin
  • Thick penile discharge or discharge from ulcerated lesions
  • Systemic symptoms may occur (i.e., fever, arthralgias, malaise).
• Diagnostics
  • Usually a clinical diagnosis
  • KOH test to confirm suspected fungal infection
  • Gram stain and culture to confirm suspected bacterial infection
• Treatment
  • Conservative
    • Daily retraction of the foreskin and bathing with warm saline solution
    • Avoid known irritants (e.g., soap, perfumes)
    • Topical antifungal (e.g., clotrimazole) for yeast infection
    • Topical bacitracin if bacterial infection is suspected (consider empiric treatment with a cephalosporin for complicated cases)
    • Topical corticosteroid cream and aqueous cream for irritant contact or drug reaction
    • Treat underlying chronic condition (e.g., psoriasis, reactive arthritis, diabetes)
  • Surgical: circumcision in recurrent cases or clinically significant phimosis
• Complications
  • Postinflammatory phimosis
  • Urinary tract obstruction → requires bladder catheterization
  • Recurrent urinary tract infections
  • Penile cancer

References:^[1][2]

• Definition: tight foreskin that cannot be completely retracted over the glans penis
• Epidemiology: Physiologic phimosis occurs in up to 10% of males at 3 years of age, but is less prevalent by 16 years of age (occurring in 1–5% of males).
• Etiology
  • Post-infectious complication following balanoposthitis
  • Congenital
  • Scarring after trauma or circumcision
• Clinical features
  • Difficulty in retracting the foreskin (relative phimosis)
  • Inability to retract the foreskin (full phimosis)
  • Painful erection and/or dyspareunia
• Diagnostics: clinical diagnosis
• Treatment
  • Conservative: : reassurance (high likelihood of spontaneous resolution), topical corticosteroid cream , stretching exercises
  • Surgical: : vertical incision (incision of the constricting bands) or circumcision if conservative management fails
• Complications
  • Foreskin tear with possible hemorrhage
  • Paraphimosis

References:^[3][4]

• Definition: retracted foreskin in an uncircumcised male that cannot be returned to its original position
• Etiology
  • Complication of phimosis (physiological or pathological)
  • Iatrogenic (i.e., following genitourinary procedures such as bladder catheterization)
  • Trauma (vigorous sexual intercourse, forceful retraction of foreskin while urinating, piercing)
• Clinical features
  • Noticeable band of constricting tissue (at the coronal sulcus)
  • Foreskin cannot be returned to its original position ^[5]
  • Edema and pain of the glans penis
  • Features of penile ischemia (blue penile skin and firm glans penis)
• Diagnostics: clinical diagnosis
• Treatment
  • Conservative: manual reduction with adequate pain control (topical anaesthesia, local infiltration, or regional blocks)
  • Surgical
    • Dorsal slit reduction surgery (incision of the constricting band) if manual reduction fails or penile ischemia occurs
    • Circumcision is the last resort
• Complication: penile necrosis

Paraphimosis is a urological emergency.