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Referral and warning signs
When to refer
Refer to specialist (Urology/Dermatology) if: Recurrent balanitis. Severe symptoms. Phimosis or paraphimosis present. Suspicion of malignancy. Failure to respond to standard treatment.
Red flags
- Inability to retract foreskin (phimosis)
- Foreskin retracted and unable to return to normal position (paraphimosis - URGENT)
- Suspicious lesion for malignancy
- Failure to resolve with treatment
Signs and symptoms
- Redness (erythema) of the glans penis
- Soreness or irritation
- Discharge (may be cheesy white with Candida, or purulent)
- Erosions or small ulcers on the glans
- Itching
- Pain
- Tight foreskin (phimosis) may be associated or a predisposing factor
Risk factors
- Poor hygiene, especially in uncircumcised men
- Diabetes mellitus (increased risk of Candida)
- Use of irritating soaps or chemicals
- Sexual transmission (Candida, Trichomonas)
- Phimosis
- Immunosuppression
Diagnosis
Clinical assessment
Based on clinical appearance of inflammation of the glans. Assess for discharge, erosions. Retract prepuce if possible. Check for associated urethral discharge or genital ulcers.
Investigations
- Swab from under prepuce or glans: Microscopy (KOH prep for Candida hyphae, wet mount for Trichomonas), Gram stain, Culture & Sensitivity.
- Blood glucose testing (if recurrent or suspect diabetes).
- STI screening (RPR/VDRL, HIV testing).
Diagnostic criteria
Clinical signs of inflammation confined primarily to the glans penis.
Management
Non-pharmacological management
- Advise on proper hygiene: Gentle washing with warm water, thorough drying.
- Avoid irritant soaps.
- Advise retraction of foreskin for cleaning (if possible).
- Consider circumcision if phimosis is present and balanitis is recurrent.
- Partner examination/treatment if STI suspected (Trichomonas) or Candida is recurrent.
Pharmacological treatment
- Likely Candida/Mixed:
- - Fluconazole 150-200 mg PO single dose.
- - PLUS Metronidazole 400 mg PO BID for 7 days (covers Trichomonas and anaerobic bacteria).
- - Consider topical antifungal cream (e.g., Clotrimazole 1%) applied BID.
- If symptoms persist after initial treatment:
- - Ensure partner has been evaluated/treated if appropriate.
- - Re-evaluate diagnosis, consider referral.
Monitoring
Assess for resolution of symptoms.
Complications
- Phimosis (scarring leading to inability to retract foreskin)
- Paraphimosis (foreskin trapped behind glans - emergency)
- Ulceration
- Meatal stenosis (narrowing of urethral opening)
- Recurrent balanitis
Prevention
- Good personal hygiene
- Control of diabetes mellitus
- Circumcision can reduce risk
- Avoid irritants
Patient education
- Explain the condition and likely causes.
- Instruct on hygiene measures.
- Explain medication use.
- Advise on diabetes screening if relevant.
- Discuss circumcision if applicable/recurrent.
- Advise on seeking care if symptoms persist or worsen, or if unable to retract/replace foreskin.
Uganda-specific notes
Candida is a common cause. Consider co-existing STIs. Ensure diabetes is considered in recurrent cases.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 3, Section 3.2.8.1