A 4-year-old US-born Hispanic boy presented with penile discharge and painful urination. His mother reported that he had no fever, trauma, history of masturbation, or recent travel history. She did not suspect any abuse. There had been no similar complaints in the past.
The child had mild purulent discharge at the external urethral meatus; erythema of the glans penis; and minimal swelling of the prepuce, which could not be retracted. There were no other abnormal physical findings. The patient was able to pass urine normally. Results of urinalysis by dipstick were normal.
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The clinical diagnosis was acute balanoposthitis. In one US study, the third most common reason for post-neonatal circumcision was recurrent balanoposthitis (in 23% of cases). The most common reasons were concomitant surgery (in 27% of cases) and parental choice (in 39%).1 An Australian study found phimosis, acute balanoposthitis, and balanitis xerotica obliterans to be the most common medical indications for circumcision at all ages.2
Inadequate hygiene is the most common cause of nonspecific acute balanoposthitis, which usually occurs in boys aged 2 to 5 years.3 Irritation from soaps, bubble baths, laundry detergent, and antistatic sheets have also been implicated. Other causes include trauma from masturbation and zip-fastener injuries.3,4
Infection is a relatively uncommon cause of acute balanoposthitis in children. Candida albicans is the most frequently identified pathogen, although it is an innocent saprophyte in most cases. Streptococcus pyogenes, Staphylococcus aureus, Neisseria gonorrhoeae, Chlamydia trachomatis, and anaerobes are the usual bacterial pathogens in children in this country.3,5,6 Viral and protozoal infections are reported causes in third world countries.7 Acute balanoposthitis may occur from S pyogenes infection because of the increased incidence of perineal carriage in patients with streptococcal pharyngitis.8
Balanitis xerotica obliterans is a rare cause of acute balanoposthitis in children.4 This condition manifests as whitish plaques on the surface of glans and prepuce, usually around the corona and up to the external meatus; the foreskin is thickened, fibrous, and nonretractable.
Clinical features of nonspecific acute balanoposthitis include pain, erythema, and swelling of the glans penis and prepuce.9 In most cases, there is little or no discharge. Acute balanoposthitis caused by S pyogenes presents with pain, intense redness, and a moist exudate under the prepuce and on the glans.3 True urethral discharge, suggestive of sexually transmitted disease, is seen after milking the length of the urethra starting from the base of the penis.3
In most prepubertal patients with acute balanoposthitis, diagnostic testing is unnecessary. In patients with discharge, a rapid group A b-hemolytic Streptococcus test may be warranted.
Treatment of nonspecific acute balanoposthitis includes a sitz bath, gentle cleaning of the preputial sulcus, and application of a low-potency corticosteroid cream.3 Children with recalcitrant, recurrent (more than 2 episodes), or an initial acute balanoposthitis that causes pathological phimosis may require circumcision.3,4
Educating parents on foreskin care can help prevent recurrence. Prognosis is good for patients with nonspecific or streptococcal acute balanoposthitis. In some patients, recurrence may be related to a persistent underlying cause, such as diabetes or atopy.10 *
1. Wiswell TE, Tencer HL, Welch CA, Chamberlain JL. Circumcision in children beyond the neonatal period. Pediatrics. 1993;92:791-793.
2. Spilsbury K, Semmens JB, Wisniewski ZS, Holman CD. Circumcision for phimosis and other medical indications in western Australian boys. Med J Aust. 2003;178:155-158.
3. Schwartz RH, Rushton HG. Acute balanoposthitis in young boys. Pediatr Infect Dis J. 1996;15:176-177.
4.Vohra S, Badlani G. Balanitis and balanoposthitis. Urol Clin North Am. 1992; 19:143-147.
5. Orden B, Martin R, Franco A, et al. Balanitis caused by group A beta-hemolytic streptococci. Pediatr Infect Dis J. 1996;15:920-921.
6. Kyriazi NC, Costenbader CL. Group A beta-hemolytic streptococcal balanitis: it may be more common than you think. Pediatrics. 1991;88:154-156.
7. Edwards S. Balanitis and balanoposthitis: a review. Genitourin Med. 1996;72: 155-159.
8. Mogielnicki NP, Schwartzman JD, Elliott JA. Perineal group A strepococcal disease in a pediatric practice. Pediatrics. 2000;106(2, pt 1):276-281.
9. Escala JM, Rickwood AM. Balanitis. Br J Urol. 1989;63:196-197.
10. Birley HD, Walker MM, Luzzi GA, et al. Clinical features and management of recurrent balanitis; association with atopy and genital washing. Genitourin Med. 1993;69:400-403.