How can I differentiate between infectious and non-infectious causes of balanitis in my patients?

Differentiating between infectious and non-infectious causes of balanitis in patients primarily involves clinical assessment, targeted investigations, and considering the patient's history and response to initial management ¹.

• Sub-preputial Swabs: To confirm or exclude fungal or bacterial infections, a sub-preputial swab can be taken ¹. However, it is important to note that Group B streptococcus is often a commensal and may not require treatment, and Candida can be a superadded infection, meaning its presence does not rule out an underlying skin condition ¹.
• Clinical Presentation and History:
  • If non-specific dermatitis is suspected, initial management involves advising on good daily hygiene, including washing with lukewarm water and avoiding irritants like soap ¹.
  • For suspected irritant or allergic contact dermatitis, advising the patient to avoid suspected triggers (e.g., soap, latex condoms) is key ¹.
  • Consider specific infectious causes like candidal, bacterial, or anaerobic (Gardnerella) balanitis based on clinical signs and symptoms, guiding the choice of topical or oral antimicrobial treatment ¹.
  • Suspected sexually transmitted infections (STIs) warrant referral to a local sexual health clinic or management in primary care based on clinical judgement ¹.
• Persistent, Recurrent, or Severe Cases: If balanitis is severe, persistent, or recurrent, especially if Candida infection is present, consider blood testing for HbA1c, HIV, or other causes of immunocompromise ¹. This can help identify underlying systemic conditions that might predispose to infections or be non-infectious causes themselves ¹.
• Referral for Diagnostic Clarity: Specialist referral to a dermatologist, sexual health specialist, or urologist is advised if the diagnosis is uncertain, if balanitis is persistent or recurrent and does not respond to initial primary care management, or if specific non-infectious conditions like Zoon's balanitis or lichen sclerosus are suspected (which may require a penile biopsy) ¹. Suspected allergic contact dermatitis may warrant referral for patch testing ¹.