When should I consider referring a patient with balanitis to a specialist for further evaluation?

You should consider referring a patient with balanitis to a specialist for further evaluation in several circumstances, particularly if there is suspicion of malignancy or if the condition is persistent or complex ¹.

• Suspected Malignancy: Arrange an urgent referral using a two-week pathway if there is a penile mass or a persistent penile lesion, especially if a sexually transmitted infection (STI) has been excluded or treated, to rule out penile intraepithelial neoplasia or malignancy ¹. This also applies to unexplained or persistent penile symptoms affecting the foreskin or glans ³. Men with genital lichen sclerosus or lichen planus also require specialist referral to exclude malignant change ¹.
• Persistent or Recurrent Balanitis: Refer if balanitis is persistent or recurrent and does not respond to initial management in primary care ¹. For children, this also applies if the balanitis is not responding to management in primary care ¹.
• Uncertain Diagnosis: Referral is appropriate if the diagnosis is uncertain, as a biopsy may be needed ¹.
• Associated Phimosis: If balanitis is recurrent and associated with phimosis, refer to a urologist for consideration of circumcision ¹. For children, suspected lichen sclerosus and/or persistent phimosis warrants referral to a paediatric urologist or surgeon for consideration of circumcision ¹.
• Specific Conditions:
  • Suspected Allergic Contact Dermatitis: Refer to a dermatologist for consideration of patch testing ¹.
  • Suspected Zoon's Balanitis: A penile biopsy may be needed to exclude penile intraepithelial neoplasia, which can present similarly ¹.
  • Suspected Lichen Sclerosus: A penile biopsy may be needed to exclude penile intraepithelial neoplasia or malignancy ¹. For children, if phimosis due to lichen sclerosus has not responded to topical corticosteroid treatment, paediatric urology referral is recommended to consider circumcision ¹.