Balanitis: why the head of the penis gets sore, and what helps

A sore, red head of the penis is an awkward thing to look up, and a more awkward thing to show a doctor. It has a name, balanitis, and it's common. The NHS describes balanitis as the head of the penis being swollen and sore. It isn't usually serious, the NHS says, but it's important to see a GP to find out what's causing it. Several different things cause it, and the treatment depends on which.

What is balanitis?

Balanitis is inflammation of the head of the penis (the glans). When the foreskin is inflamed as well, doctors call it balanoposthitis, and in practice both are often affected together. NICE's guidance for GPs says it can be caused by a range of different conditions affecting the skin of the penis, which may look alike and can happen together.

The British Association for Sexual Health and HIV (BASHH) says balanitis affects up to 20% of uncircumcised men and is uncommon after circumcision. NICE quotes a Portuguese study in which balanitis was diagnosed in 10.7% of the men who attended a sexually transmitted disease clinic between 1995 and 2004. That was one clinic in one country.

Balanitis symptoms: what does it look like?

With balanitis, the head of the penis is usually swollen, itchy and sore, the NHS says. It usually looks red, though this may be less obvious on brown or black skin. Other symptoms can include:

• pain when peeing
• a thick discharge from under the foreskin
• bleeding around the foreskin
• an unpleasant smell
• difficulty pulling back the foreskin

NICE's guidance also lists skin splitting and sexual problems.

What causes balanitis?

Most cases come from inflamed skin on the head of the penis, sometimes with thrush or bacteria growing on top, according to NICE's guidance for GPs. The NHS lists these causes:

• not washing your penis properly
• thrush, a yeast infection caused by a fungus called candida
• soap, shower gels or condoms irritating the skin
• a sexually transmitted infection (STI) such as gonorrhoea or chlamydia
• diabetes, because high levels of sugar in your pee can cause thrush

NICE adds lubricants, fragrances, bubble bath and creams as possible irritants, along with friction during sex, washing too often, other infections such as genital herpes, and skin conditions including psoriasis, lichen sclerosus and Zoon's balanitis. If it started after sex, see our guide to a sore or red penis after sex.

Can washing too much cause balanitis?

Yes. NICE lists over-washing among the causes, and BASHH names both poor hygiene and over-washing as factors that make balanitis more likely. Its guideline also links irritant balanitis to frequent washing of the genitals with soap. A 1993 study at St Mary's Hospital in London looked at 43 men whose balanitis kept coming back or wouldn't clear. In 31 of them (72%) the cause was irritant dermatitis, and those men washed their genitals with soap more often each day than the others. For 28 of the 31, emollient creams and cutting back on soap controlled their symptoms. It was small and at one clinic, but it fits the NHS advice to avoid soap.

Is balanitis an STD, and is it contagious?

Balanitis itself isn't a sexually transmitted infection. BASHH calls it a descriptive term: its causes include infections passed on during sex and ones that aren't. Whether anything can pass to a partner depends on the cause:

• An STI such as gonorrhoea or chlamydia can cause balanitis and can be passed on. If an STI is suspected, the NHS says you may be referred to a sexual health clinic.
• Thrush isn't classed as an STI, but the NHS says it can be triggered by sex or, less often, passed on during sex.
• Zoon's balanitis and lichen sclerosus aren't caused by an infection and can't be passed to a partner, according to the British Association of Dermatologists (BAD).

If you think you might have an STI, the NHS advice is not to have sex, including oral sex, without a condom or dental dam until you've had a check-up or been tested.

How to tell if balanitis is fungal or bacterial

You can't tell for certain at home. NICE's guidance describes typical patterns. Thrush (candidal balanitis) tends to cause blotchy redness on the underside of the head of the penis; a bacterial infection tends to cause painful redness, sometimes with swelling and a pus-like discharge. BASHH warns that appearances aren't proof, partly because a second infection on top of another skin condition is common. A doctor or nurse may take a swab to test for thrush and bacteria.

Kinds of balanitis compared

	What it often looks or feels like.	What a GP may suggest.
Thrush (fungal, also called candidal balanitis)	Blotchy redness, often on the underside of the head of the penis; small itchy or sore spots; or dull red, shiny-looking patches	An antifungal cream, or an antifungal medicine by mouth if symptoms are severe
Bacterial	Painful redness, sometimes with swelling, raw areas and a pus-like discharge	An antibiotic ointment for a mild infection, or antibiotics by mouth for a severe one
Anaerobic bacteria	A foul smell, inflammation under the foreskin, a swollen foreskin and a mucus-like discharge	Antibiotics by mouth
Irritation or allergy	Burning (irritation) or itching (allergy), with a red, scaly rash that lingers or keeps coming back	Avoiding the trigger, a mild steroid cream, and an emollient to wash with
A sexually transmitted infection	Depends on the infection: sores, blisters, a discharge or pain when peeing	Tests and treatment at a sexual health clinic
A skin condition (lichen sclerosus, Zoon's balanitis, psoriasis)	White patches, a foreskin that gets tighter, or sharply edged red patches that last	A specialist for lichen sclerosus or Zoon's balanitis; a steroid cream for psoriasis

The patterns overlap and two causes can happen together, so use this to know what to mention to a GP; it cannot tell you which one you have. Sources: NICE CKS, BASHH, BAD and NHS.

Balanitis treatment: how do you get rid of it?

Treatment for balanitis depends on what's causing it, the NHS says. A GP may prescribe:

• a mild steroid cream or ointment
• an antifungal cream or ointment
• antibiotics

Which cream is used for balanitis?

The right cream depends on the cause. In NICE's guidance, an antifungal treats thrush, antibiotics a bacterial infection, and a mild steroid such as hydrocortisone irritated, inflamed skin; sometimes two are combined. For non-specific dermatitis (inflamed skin with no specific cause), NICE lists either a mild steroid or an antifungal cream. If an STI is the cause, NICE's guidance is referral to a sexual health clinic or treatment by the GP.

Can you get balanitis treatment from a pharmacy?

If thrush is the cause, yes. The NHS says you can buy fluconazole, an antifungal capsule you swallow, from a pharmacy for balanitis, and most people aged 16 or over can take it. Tell the pharmacist first if, for example, you have a heart condition (including heart rhythm problems), kidney or liver problems, or have ever had an allergic reaction to a medicine. Its most common side effects are feeling sick and diarrhoea, and the NHS says symptoms should be better within 7 days; talk to a doctor if they aren't. Clotrimazole cream, another antifungal, is also used on the skin of the penis.

The NHS says you can buy thrush treatment from a pharmacy if you've had thrush diagnosed before and you know the symptoms; the first time, see a GP. Clotrimazole cream can damage the latex in condoms, which may not work as well for at least 5 days after you finish the treatment.

What can you do at home to help balanitis?

The NHS self-care advice for balanitis is gentle washing, careful drying and no soap:

1. Wash your penis every day using just water or an emollient (a moisturising treatment you can also wash with). Don't use soap or shower gel.
2. Gently pull back your foreskin and wash underneath with warm water. NICE's guidance adds: where possible, keep the foreskin pulled back until the head of the penis is dry. The NHS says to always re-cover the penis after cleaning.
3. Dry gently by patting rather than rubbing.
4. Wash your hands before peeing or touching your penis.
5. If you use condoms, choose ones for sensitive skin. Latex-free condoms are available if you have a latex allergy.
6. Skip bubble bath and baby wipes, which NICE lists as irritants.

A pharmacist can help you choose an emollient, and if one stings and doesn't settle after rinsing, the NHS suggests asking them for a different one. Aqueous cream is no longer recommended as an emollient because it can irritate the skin.

How long does balanitis last, and does it go away on its own?

It depends on the cause. NICE's guidance says an episode of balanitis can last a few days, persist for more than a few weeks, or keep coming back. Most improve once the cause has been diagnosed and treated. The NHS says to see a GP if you have symptoms of balanitis, since treatment depends on the cause.

Is balanitis dangerous?

Usually not: the NHS says balanitis is not usually serious. Complications depend on the cause, and NICE lists a foreskin that gets too tight to pull back, problems peeing and sexual problems among them. The BAD says lichen sclerosus is linked with penis cancer in some men, though this is rare, and NICE advises specialist referral when balanitis persists despite treatment, partly to rule this out.

What if balanitis keeps coming back?

A doctor will look for the reason. NICE's guidance suggests blood tests for diabetes, HIV or other causes of a weakened immune system when balanitis is severe, persistent or recurrent, especially when thrush is present. BASHH notes that thrush on the penis can be the first sign that leads to a diagnosis of diabetes, and that irritant balanitis often comes back. If you keep getting balanitis and medicine hasn't helped, the NHS says circumcision (surgery to remove the foreskin) may be considered. NICE advises referral to a urologist when balanitis keeps coming back with a tight foreskin; our guide to a tight foreskin covers that condition.

Lichen sclerosus (balanitis xerotica obliterans)

Lichen sclerosus, also called balanitis xerotica obliterans, is a long-term inflammatory skin condition. In men it's most often seen on the foreskin and tip of the penis, the BAD says. The skin can look red, with little cracks or small blood blisters, and later turn white, and the foreskin often gets tighter. It isn't caused by an infection, can't be passed to a partner and almost never occurs in men circumcised early in life. A dermatologist usually treats it with strong steroid ointments.

Zoon's balanitis

Zoon's balanitis causes glistening, moist, bright red or autumn-brown patches with sharp edges, often on both the head of the penis and the foreskin next to it. The BAD says it usually affects middle-aged to elderly men who haven't been circumcised, usually causes no symptoms and looks worse than it feels. It isn't an infection, can't be passed on, and may be cured by circumcision.

Circinate balanitis

Circinate balanitis causes sharply edged red or grey patches on the head of the penis with an irregular white edge, which can join up into map-like shapes. NICE links it to chlamydia, sometimes with reactive arthritis, and to psoriasis.

When should you see a GP or get urgent help?

See a GP if the head of your penis is swollen, itchy, sore or red, or if you've had treatment for balanitis and it hasn't worked. Adults can also go to a sexual health clinic (also called a GUM clinic). These NHS clinics are free and confidential, you don't usually need a GP referral, and many offer a walk-in service and often get test results quicker than GP surgeries.

Other signs, and where to go:

• If your foreskin is pulled back and won't go back over the head of your penis, call 999 or go to A&E. The NHS calls this (paraphimosis) a medical emergency.
• If the skin is painful, hot and swollen, which can be a sign of a skin infection (cellulitis), ask for an urgent GP appointment or get help from NHS 111.
• If you have a sore, blister, lump or ulcer, a rash or spots, or an unusual discharge, see a GP or go to a sexual health clinic.
• If you have pain when peeing or difficulty peeing, see a GP.

At the appointment, a doctor or nurse will look at your penis and ask a few questions. If your symptoms are severe, they may suggest a blood test to check for conditions that can lead to balanitis, such as diabetes. They may also wipe a cotton bud over the head of your penis to test for infections. Try not to be embarrassed: the NHS points out that doctors and nurses are used to talking about these symptoms. If it's thrush, see our guide to thrush in men.