Fungal balanitis:

Clotrimazole 1% cream applied topically twice daily until symptoms settle (topically applied creams damage latex condoms and diaphragms).

Or

Fluconazole oral 150mg single dose

Streptococcal balanitis:

Amoxicillin oral 500mg 8 hourly

Or

Clarithromycin oral 250mg 12 hourly

N.B. Clarithromycin should not be prescribed concurrently with ciclosporin, sirolimus or tacrolimus.

• For further information refer to the West of Scotland Sexual Health Managed Clinical Network guidelines.
• NICE provides a useful clinical knowledge summary on balanitis.
• Fungal balanitis may produce a thick, curdy discharge. Infection with beta-haemolytic streptococci is often severe and may warrant empirical treatment. Suspect bacterial or fungal balanitis if symptoms do not resolve with good hygiene.
• If ulceration, urethritis or inguinal lymphadenopathy are present refer to Sexual Health services. If penile cancer is suspected, refer urgently to genitourinary medicine or urology. Patients with recurrent balanitis and non-retractable foreskin should be referred to urology. If balanitis is recurrent and no underlying cause can be identified, or balanitis persists despite treatment, exclude underlying diabetes mellitus and refer to GUM or urology, depending on the most likely underlying cause.
• Take a sub-preputial swab if symptoms are severe or do not resolve with hygiene measures. Review any culture results and ensure that an appropriate antibiotic has been prescribed. Screening should be offered to partners where a sexually transmissible agent is found. In patients with recurrent candidal balanitis, testing and treatment of sexual partners may prevent further recurrence.
• General advice: Advise daily cleaning under the foreskin with lukewarm water, followed by gentle drying. Soap or other irritants should not be used on the genitalia. Consider prescribing an emollient as a soap substitute.