Chronic balanoposthitis: course

Chronic balanoposthitis is a long-term or frequently recurring inflammation of the glans penis and foreskin. Unlike an acute episode, which often resolves after a short course of treatment, chronic balanoposthitis is usually caused by underlying conditions such as persistent irritation, phimosis, diabetes, skin disease, or recurring infections.

It's important to understand that the term "balanoposthitis" describes the site of inflammation, not a single specific cause. European guidelines emphasize that this term covers a variety of conditions, sometimes unrelated, including infections, dermatoses, and precancerous changes. [1]

In chronic cases, the goal of management is broader than simply "relieving redness." It is necessary to reduce discomfort and urinary disturbances, decrease the risk of scarring and phimosis, rule out sexually transmitted infections, and detect precancerous changes in the skin of the penis, which may appear as "persistent inflammation." [2]

Since candidiasis and bacterial findings are secondary in some patients, determining the underlying cause of the inflammation becomes clinically important. This is especially important if symptoms persist for weeks, recur after treatment, or respond poorly to standard topical treatments. [3]

Code according to ICD 10 and ICD 11

In the International Classification of Diseases, 10th revision, balanoposthitis is coded as N48.1. The list indicates that balanitis also falls under this code, and if the cause is infectious, additional coding of the pathogen is permitted. [4]

The International Classification of Diseases, 11th revision, uses the GB06.0 block "balanitis or balanoposthitis" with further subcategories, including irritant variant and infectious variant. In practice documentation, the code corresponding to the underlying mechanism, if identified, is most often selected. [5]

Table 1. Code according to ICD 10 and ICD 11

System	Formulation	Code
International Classification of Diseases, 10th revision	Balanoposthitis	N48.1
International Classification of Diseases, 11th revision	Balanitis or balanoposthitis	GB06.0
International Classification of Diseases, 11th revision	Irritable balanoposthitis	GB06.01
International Classification of Diseases, 11th revision	Balanoposthitis due to infection	GB06.02
International Classification of Diseases, 11th revision	Other specified forms	GB06.0Y
International Classification of Diseases, 11th revision	Unspecified version	GB06.0Z

[6]

Epidemiology

Balanitis is a common condition, with reviews indicating a lifetime incidence of approximately 3%-11% of men. When the inflammation also affects the foreskin, it is called balanoposthitis, with a reported prevalence of approximately 6% among uncircumcised men. [7]

In broader reviews of balanoposthitis, prevalence rates range from 12% to 20% in men of various ages. These figures depend on the forms included by the authors, how the diagnosis was determined, and the population groups examined. [8]

In adults, one of the most significant risk factors is the combination of uncircumcised status and diabetes. StatPearls estimates a prevalence of approximately 35% in this group, which explains why doctors often recommend carbohydrate metabolism testing during relapses. [9]

The protective effect of circumcision is supported by meta-analyses: StatPearls estimates a reduction in the prevalence of inflammatory conditions of the glans penis of approximately 68%. This does not mean that circumcision “treats every cause,” but shows the influence of anatomical conditions and the microenvironment under the foreskin. [10]

Table 2. Prevalence benchmarks

Indicator	Grade	Comment
Balanitis throughout life	3%-11%	Evaluation from clinical reviews
Balanoposthitis in uncircumcised men	about 6%	An oft-cited benchmark
Balanoposthitis in men of all ages	12%-20%	Depends on criteria and sample
Balanoposthitis in uncircumcised men with diabetes mellitus	about 35%	High-risk group
Reduction in prevalence after circumcision	about 68%	Evaluation from meta-analyses

[11]

Reasons

Chronic conditions most often develop according to the principle of "constant irritant plus microorganisms." Moisture and secretions are retained under the foreskin, which facilitates the growth of Candida fungi and mixed bacterial flora, especially with incomplete retraction of the foreskin or phimosis. [12]

Infectious causes include candidal balanoposthitis, anaerobic infection, aerobic infection, and certain pathogens that may be sexually transmitted. European guidelines specifically list, among others, Trichomonas vaginalis, herpes simplex virus, syphilis, and human papillomavirus as possible causes or associated findings in lesions in this area. [13]

Non-infectious causes are no less important. These include dermatoses, which may present differently on the glans penis than on the rest of the body: lichen sclerosus, lichen planus, psoriasis, seborrheic dermatitis, and irritant and allergic contact dermatitis. These conditions often result in "persistent inflammation," and the presence of Candida may be secondary, as noted by the authors of the European guidelines. [14]

A separate section covers drug reactions, primarily fixed drug erythema, as well as precancerous changes, collectively known as penile intraepithelial neoplasia. This is why, in cases of persistent lesions, ulcers, bleeding, and lack of response to treatment, a biopsy is often required. [15]

Table 3. Causes of chronic balanoposthitis by groups

Group	Examples	Typical hint
Fungal	Candida albicans and other Candida species	itching, whitish coating, oozing
Anaerobic bacterial	mixed anaerobic flora	unpleasant odor, discharge, maceration
Aerobic bacterial	staphylococci, streptococci and others	redness, soreness, purulent discharge
Dermatoses	lichen sclerosus, psoriasis, eczema, lichen planus	long-term course, relapses, poor response to antimicrobial agents
Sexually transmitted infections	herpes simplex virus, syphilis, Trichomonas vaginalis	ulcers, erosions, vesicles, systemic signs, risky contact
Drug reactions	fixed drug erythema	repetition in one place after a certain medicine
Precancerous changes	penile intraepithelial neoplasia	"velvety" persistent red plaques, erosions, bleeding

[16]

Risk factors

The most common risk factor is uncircumcision combined with conditions that impair ventilation and cleansing of the prepuce. Guidelines emphasize the role of incomplete foreskin retraction, excess moisture, and smegma accumulation, while both "poor hygiene" and excessive washing with soap can exacerbate inflammation by irritating the skin. [17]

Diabetes mellitus increases the risk due to glucosuria, changes in the local microenvironment, and decreased immune defense. StatPearls cites a high prevalence of balanoposthitis in uncircumcised men with diabetes, and Russian expert reports emphasize that a significant proportion of patients first discover diabetes when they seek treatment for recurrent candidal infections. [18]

Immunodeficiency conditions and immunosuppressive therapy increase the likelihood of persistent infections and atypical clinical presentations. European guidelines recommend testing for human immunodeficiency virus (HIV) and other causes of immunodeficiency if inflammation is severe or persistent. [19]

Sexual practices and contact with irritants also influence risk: friction, microtrauma, intimate hygiene products, lubricants, spermicides, and contact allergens. In chronic cases, it is important to assess not only infections but also household factors that contribute to daily irritation. [20]

Table 4. Risk factors and what they change

Risk factor	Mechanism	Practical conclusion
Uncircumcised condition, phimosis	stagnation of moisture and secretions, difficulties in cleansing	hygiene correction, assessment of the need for surgical treatment
Frequent use of soaps and gels	irritation and disruption of the skin barrier	switching to gentle cleansing, eliminating irritants
Diabetes mellitus	growth of Candida and bacteria, decreased immune defense	blood glucose testing, diabetes correction
Immunosuppression	persistent infections, atypical manifestations	advanced diagnostics, careful choice of therapy
Risky sexual behavior	probability of sexually transmitted infections	screening for infections as indicated
Obesity and constant humidity	maceration and chronic irritation	reducing humidity, controlling body weight

[21]

Pathogenesis

The skin and mucous membranes of the glans penis are thin and sensitive to changes in humidity and chemical irritants. Prolonged contact with a moist environment under the foreskin leads to maceration, microcracks, and a weakened barrier function, facilitating the penetration of microorganisms and increasing the inflammatory response. [22]

Microbiologically, a mixed picture is often observed. Russian experts emphasize the role of anaerobic microflora in balanoposthitis, while European guidelines recommend culture or subforeskin examination in situations of diagnostic uncertainty to distinguish "primary infection" from secondary colonization. [23]

In dermatoses, the pathogenesis is different: inflammation is maintained by the skin's immune mechanisms, and infection can be secondary. For example, in lichen sclerosus, chronic inflammation leads to tissue compaction, scarring, and the formation of phimosis, which further impairs ventilation and intensifies the vicious circle of inflammation. [24]

If the process continues for months, structural consequences appear: thickening and fissures of the foreskin, narrowing of the external urethral opening, painful intercourse, and urinary difficulties. It is at this stage that "cream alone" often provides only temporary relief unless the underlying factors are addressed.

Symptoms

Chronic balanoposthitis is characterized by redness and swelling of the glans penis, itching, burning, and discomfort that wax and wane. An unpleasant odor and discharge under the foreskin are often present, especially if the inflammation is accompanied by bacterial growth.

Pain during urination and tenderness to the touch occur with severe inflammation, fissures, and erosions. With candidal infections, whitish plaque and oozing often appear, while with irritant dermatitis, a burning sensation and a "scraped skin" sensation predominate after contact with soap or other products. [25]

Chronic inflammation often manifests itself with signs of atrophy or thickening of the foreskin, scarring, and gradual narrowing, making complete retraction difficult. At this stage, inflammation is often maintained mechanically: microtrauma occurs when attempting retraction, and a moist environment persists when complete cleansing is impossible.

Systemic symptoms, such as high fever, are usually uncommon in uncomplicated forms. Their occurrence may indicate a significant bacterial infection, complications, or another cause, so prompt evaluation is recommended for fever and severe pain. [26]

Classification, forms and stages

In practice, the most useful classification is the etiologic one: infectious forms, non-infectious dermatoses, drug reactions, and precancerous conditions. European guidelines list key "clinically significant" variants, including candidal processes, anaerobic and aerobic infections, lichen sclerosus, lichen planus, psoriasis and circinate balanitis, eczema, and penile intraepithelial neoplasia. [27]

Based on the course of the disease, there are acute episodes, recurrent episodes, and chronic persistent inflammation. Recurrent episodes typically involve repeated flare-ups after treatment, while chronic persistent episodes involve constant symptoms and signs of inflammation without clear intervals.

Severity is generally classified as mild, with redness and itching without erosions or urinary disturbances; moderate, with cracks and pain; and severe, with significant swelling, erosions, ulcers, bleeding, or suspected precancerous lesions. This gradation helps determine the scope of examinations and the need for a biopsy. [28]

Staging in chronic cases can be conveniently described as "inflammation without scarring," "inflammation with scarring and phimosis," and "inflammation with complications." Importantly, the transition to scarring increases the likelihood of relapse, and the effectiveness of local therapy alone is lower if the anatomical obstruction remains. [29]

Table 5. Forms of chronic balanoposthitis and leading signs

Form	The leading cause	Typical signs	What is often required additionally?
Candidal	Candida	itching, whitish deposits, maceration	glucose assessment, exclusion of dermatosis
Anaerobic	anaerobic mixed flora	odor, discharge, maceration	systemic therapy according to indications
Aerobic	aerobic bacteria	pain, purulent discharge	culture, antibiotic correction
Dermatoses	lichen sclerosus, psoriasis, eczema	persistent plaques, cracks, relapses	dermatological evaluation, biopsy if in doubt
Medicinal	fixed drug erythema	repetition in one place	drug withdrawal, confirmation by anamnesis
Precancerous	penile intraepithelial neoplasia	persistent "velvety" erythema, erosions	mandatory biopsy and treatment by specialists

[30]

Complications and consequences

One of the common complications of chronic inflammation is scarring of the foreskin, leading to the development of phimosis. This not only impairs hygiene and promotes inflammation, but can also lead to painful intercourse and urinary problems.

With severe swelling and attempts to forcefully retract the foreskin, another complication is possible: paraphimosis, when the foreskin becomes wedged behind the glans penis, impairing blood circulation. This condition is considered an emergency, as delayed treatment increases the risk of ischemic tissue damage. [31]

Chronic dermatoses, primarily lichen sclerosus, can be complicated by narrowing of the external urethral orifice and urethral lesions. European guidelines discuss surgical options for persistent phimosis and stenosis, including dissection of the external urethral orifice and reconstructive interventions for urethral lesions. [32]

Another fundamentally important consequence is the risk of missing precancerous changes. Penile intraepithelial neoplasia can mimic "persistent balanoposthitis," and therefore, in the case of persistent lesions and a poor response to treatment, the issue of biopsy becomes a matter of oncological safety. [33]

When to see a doctor

Consulting a doctor is necessary if symptoms persist for more than 7-14 days despite careful hygiene and avoidance of irritants. This is especially important in relapses, when inflammation returns soon after treatment and an underlying cause must be identified. [34]

Urgent consultation is necessary for ulcers, blisters, bleeding, severe pain, enlarged inguinal lymph nodes, or suspected sexually transmitted infections. Guidelines emphasize the role of testing for herpes simplex virus and syphilis in the presence of ulcerative lesions. [35]

Emergency care is required if signs of paraphimosis, a sharp increase in swelling, inability to urinate, or a high temperature occur alongside severe pain. These signs may indicate a complicated condition or a condition that requires immediate intervention. [36]

Routine examination is especially advisable in patients with diabetes mellitus, immunosuppressive therapy, and severe phimosis. In these situations, the risk of persistent disease is higher, and standard treatment regimens without correcting underlying factors often produce short-term results. [37]

Diagnostics

The first step is a detailed medical history, focusing on the duration of symptoms, frequency of recurrences, hygiene habits, use of soaps and gels, the presence of phimosis, as well as medications and possible allergens. European guidelines emphasize that appearance can be a "clue" but is not absolutely specific to a specific cause. [38]

The second step is an examination. The degree of redness and swelling, the presence of cracks, erosions, plaque, odor, and discharge are assessed, as well as the ability to fully retract the foreskin. If a precancerous process is suspected, clear plaque boundaries, a "velvety" surface, bleeding, and persistence of the lesion are important. [39]

The third step is laboratory diagnostics as indicated. A preputial swab is recommended to detect Candida and perform bacterial culture, as well as testing for sexually transmitted infections, if indicated by the patient's history or clinical findings. For ulcers, a nucleic acid test for the herpes simplex virus is recommended, and for ulcerative lesions, a syphilis diagnosis is also considered. [40]

The fourth step is an assessment of metabolic and immune factors. The recommendations suggest a urine glucose test if candidiasis is suspected, and in severe or persistent cases, consideration should be given to testing for human immunodeficiency virus (HIV) and other causes of immunodeficiency. This helps identify underlying conditions that make treatment "unsustainable." [41]

The fifth step is a biopsy and specialist consultation. A biopsy is considered in cases of diagnostic uncertainty, persistent disease, and suspected precancerous lesions. For dermatoses, a dermatologist's assessment is helpful. This approach reduces the risk of missing penile intraepithelial neoplasia and allows for tailoring therapy based on the type of dermatosis. [42]

Table 6. Step-by-step diagnostic algorithm

Step	Action	What can we find out?
1	History: hygiene, irritants, sexual risks, medications, relapses	probable mechanism and triggers
2	Examination of the glans and foreskin, assessment of phimosis	type of lesion, severity, complications
3	Smear and culture from the preputial sac according to indications	Candida, mixed bacterial flora
4	Tests for sexually transmitted infections as indicated	herpes, syphilis, chlamydia infection and others
5	Glucose assessment, if necessary, expanded testing for immunodeficiency	background causes of relapses
6	Biopsy of persistent and atypical lesions	exclusion of precancer and clarification of dermatosis

[43]

Differential diagnosis

If ulcers, blisters, or severe pain are present, sexually transmitted infections, including herpes simplex virus infection and syphilis, are considered first. European guidelines specifically recommend appropriate testing for ulcerative lesions. [44]

In long-term plaques and relapses, dermatological causes often compete: psoriasis, eczema, lichen sclerosus, and lichen planus. These conditions can cause persistent redness and cracks, with the secondary infection merely "superimposed" on the primary inflammation. [45]

Plasma cell balanitis, known as Zoon's balanitis, is a distinct condition: it is a chronic lesion in uncircumcised men that may appear as a "varnished" red plaque. Guidelines discuss treatment options and the potential for circumcision to be curative. [46]

It is critical to distinguish "persistent inflammation" from penile intraepithelial neoplasia. This is accomplished using clinical signs, dermatoscopic clues in specialized practice, and, if in doubt, biopsy. It is precisely this differential diagnosis with precancerous lesions that determines why chronic balanoposthitis should not be treated indefinitely without determining the cause. [47]

Table 7. Differential diagnosis: quick reference points

State	What is similar	What helps to distinguish
Candidal balanoposthitis	itching, redness, plaque	Candida smear, connection with diabetes
Irritant contact dermatitis	burning, redness	association with soaps, gels, lubricants; improvement after removal of the irritant
Psoriasis	persistent erythema, cracks	lesions on other areas of the skin, family history
Sclerotic lichen	cracks, scarring, phimosis	whitish areas, narrowing, need for long-term observation
Balanitis Zuna	persistent red plaque	chronic lesion in uncircumcised individuals, biopsy possible for confirmation
Penile intraepithelial neoplasia	"inflammation", erosion	persistence, bleeding, biopsy as a key test
Herpes infection	pain, erosions	blisters and ulcers, herpes simplex virus nucleic acid test

[48]

Treatment

The basis of treatment for chronic balanoposthitis is eliminating contributing factors: reducing moisture under the foreskin, avoiding irritating cleansers, and establishing gentle daily cleansing with warm water. European guidelines emphasize that both poor hygiene and excessive washing with soap can contribute to inflammation, so the goal is a gentle regimen and the elimination of irritants. [49]

In cases of severe phimosis or frequent recurrences, correction of the anatomical factor is important. Recommendations indicate that circumcision may be necessary in recurrent cases or in the presence of phimosis, as it eliminates the conditions for chronic maceration and microbial growth. The decision is made individually, taking into account the cause and the patient's plans. [50]

If the clinical picture and smear suggest candidal infection, topical therapy with 1% clotrimazole twice daily for 7-14 days is recommended. For severe symptoms, a single oral dose of 150 mg fluconazole is acceptable, and for severe inflammation, a combination of a topical imidazole and 1% hydrocortisone is possible. [51]

For anaerobic infections, European guidelines recommend a regimen of metronidazole 400-500 milligrams twice daily for 1 week, and as an alternative, amoxicillin with clavulanic acid 375 milligrams three times daily for 1 week. In practice, it is important to confirm the indications with clinical and, if possible, microbiological evidence, because chronic infections often have a mixed course. [52]

For aerobic bacterial infections, recommendations include topical application of 2% mupirocin 2-3 times daily for 7-10 days, as well as topical steroids with added antibacterial components for a similar period. In severe cases, systemic antibiotic therapy may be required until culture results are available. [53]

If the inflammation is supported by a dermatosis, the logic changes: anti-inflammatory dermatological therapy becomes the priority. For example, for genital psoriasis, recommendations include topical medium-potency steroids 1-2 times daily until relief, sometimes combined with antifungal or antibacterial agents if signs of secondary infection appear. If there is no response, a reassessment of the diagnosis is necessary. [54]

For lichen planus and a number of other inflammatory dermatoses, topical steroids of moderate to very high potency are recommended depending on severity. Guidelines also indicate that topical calcineurin inhibitors, such as tacrolimus or pimecrolimus twice daily, may be effective, although burning and discomfort may occur initially.[55]

Lichen sclerosus requires a particularly careful approach due to the risk of scarring and damage to the external urethral meatus. Guidelines indicate that circumcision is indicated when topical treatment fails or when daily topical therapy is persistently required, while complications may require orifice surgery or reconstructive procedures. Further monitoring depends on the severity and associated risks. [56]

Zoon's plasma cell balanitis often requires removal of the "dysfunctional" foreskin and control of chronic irritation. Guidelines note that circumcision can be curative, and conservative options include topical steroids and calcineurin inhibitors; the literature also describes laser treatments in selected cases. The choice depends on the center's availability and experience. [57]

If penile intraepithelial neoplasia is suspected or lesions do not respond to therapy, treatment should focus on confirming the diagnosis and specialized management. The guidelines list topical treatments, including imiquimod 5% and fluorouracil 5%, as well as organ-preserving surgical and ablative approaches: excision, Mohs micrographic surgery, cryotherapy, photodynamic therapy, and laser. Risk reduction measures, including human papillomavirus vaccination and smoking cessation, are also mentioned. [58]

Table 8. Treatment by cause: what is usually chosen

Cause	Basic therapy	Options for relapses or severe cases
Candidiasis	clotrimazole 1% 2 times a day for 7-14 days	Fluconazole 150 milligrams once for severe symptoms
Anaerobic infection	metronidazole 400-500 milligrams 2 times a day for 1 week	Amoxicillin with clavulanic acid 375 milligrams 3 times a day for 1 week
Aerobic infection	mupirocin 2% 2-3 times a day for 7-10 days	systemic antibiotics based on culture results
Irritant dermatitis	elimination of irritants, gentle cleansing	hydrocortisone 1% 1-2 times a day until relief
Psoriasis and other dermatoses	topical steroids of appropriate potency	calcineurin inhibitors, dermatologist consultation
Sclerotic lichen	local strong steroids, control of complications	circumcision in case of ineffectiveness or persistent need for therapy
Precancerous changes	treatment in a specialized center	imiquimod 5%, fluorouracil 5%, organ-preserving interventions

[59]

Prevention

Recurrence prevention begins with proper hygiene: daily gentle cleansing with warm water, thoroughly drying the glans after washing, and avoiding scented gels and soaps in the inflamed area. European recommendations specifically emphasize the role of avoiding irritants and maintaining dryness, while also avoiding trauma when retracting the foreskin. [60]

Blood sugar control and diabetes management reduce the risk of candidal recurrences and secondary bacterial complications. For recurring episodes, blood glucose testing and discussion of diabetes treatment targets with a physician are helpful, as without this, topical therapy often provides only temporary relief. [61]

Sexual prevention includes assessing the risk of sexually transmitted infections and using barrier methods during casual contact. If balanoposthitis is associated with a specific infection, testing and treating partners as clinically indicated is important to break the cycle of reinfection. [62]

In persistent phimosis that maintains inflammation, relapse prevention involves eliminating the anatomical factor. Recommendations explicitly state that circumcision may be necessary in recurrent cases or in cases of phimosis, and that once the obstruction is removed, the risk of recurrence of inflammation usually decreases. [63]

Forecast

The prognosis for chronic balanoposthitis is largely determined by the underlying cause. Infectious variants are usually well controlled with appropriate therapy and elimination of triggers, although relapses are possible with persistent phimosis, a moist environment, and uncontrolled diabetes. [64]

With dermatoses, the prognosis is often "control rather than cure." Lichen sclerosus and psoriasis may require long-term maintenance therapy and observation, as the goal is to prevent scarring and complications, not just to relieve redness. [65]

After circumcision, the risk of recurrence is significantly reduced in some patients, as the factor of chronic maceration and secretion accumulation is eliminated. Recommendations note that the likelihood of recurrence is lower after circumcision, although inflammation cannot be completely ruled out if dermatosis or contact allergy persists. [66]

An unfavorable prognosis is primarily associated with late diagnosis of precancerous lesions. If a persistent lesion is treated for a long time as "inflammation" without determining the cause, the risk of missing penile intraepithelial neoplasia increases. Therefore, in the case of persistent lesions, the prognosis directly depends on the timeliness of biopsy and specialized treatment. [67]

FAQ

Can chronic balanoposthitis be non-infectious?
Yes. Skin conditions such as psoriasis, eczema, or lichen sclerosus often cause long-term inflammation, and candidiasis and bacteria can be secondary. In such cases, antimicrobials alone provide a temporary effect until anti-inflammatory therapy for the dermatosis is initiated. [68]

Is testing for diabetes necessary during relapses?
With frequent relapses, this is a reasonable step, especially if candidal manifestations occur. Reviews indicate a high prevalence of balanoposthitis in uncircumcised men with diabetes, and Russian experts note cases where diabetes is first diagnosed during a visit for recurrent candidal infections. [69]

When is a biopsy necessary?
A biopsy is considered in cases of diagnostic uncertainty, persistent lesions, and suspected precancerous changes. Warning signs include persistent red plaques, erosions, bleeding, ulcers, and lack of response to adequate treatment. [70]

Is it possible to treat the condition with antiseptics alone?
In chronic cases, this is rarely sufficient. Antiseptics can temporarily reduce odor and the number of microbes, but they do not eliminate dermatosis, phimosis, or allergic contact dermatitis. The strategy must be causal: identify and treat the underlying mechanism. [71]

Does circumcision help?
Circumcision reduces the risk of inflammatory conditions of the glans penis and may be curative for recurrent cases and phimosis. European guidelines indicate that circumcision may be necessary for recurrent cases or phimosis, and reviews describe a reduced prevalence of inflammatory conditions after circumcision. [72]

Should sexual partners be tested?
It depends on the cause. If a sexually transmitted infection is detected, testing and treatment of partners becomes part of the prevention of reinfection. If the cause is non-infectious, partners often only require information and avoidance of irritants. [73]

Expert comments on the article

Andrey Viktorovich Ignatovsky, andrologist, urologist, venereologist, dermatologist, associate professor of the Department of Dermatovenereology of the First Saint Petersburg State Medical University named after Academician I.P. Pavlov, candidate of medical sciences: “Today there is no unified classification, diagnosis, or approach to the treatment of patients with balanoposthitis.” [74]

Andrey Viktorovich Ignatovsky: "The development of balanoposthitis is facilitated by poor hygiene and irritation from smegma." This formulation clearly emphasizes that relapse prevention begins with proper hygiene and reducing moisture under the foreskin. [75]

Andrey Viktorovich Ignatovsky: "Detergents can also be an irritant." This is critical for chronic conditions, as "therapeutic washing" with harsh detergents can promote contact dermatitis and interfere with the restoration of the skin barrier. [76]

Sergei Aleksandrovich Reva, urologist-oncologist, head of the andrology and oncourology department at the I. P. Pavlov First Saint Petersburg State Medical University, and candidate of medical sciences, said: "Risk factors for penile cancer include balanitis and phimosis." This commentary underscores why it is important not to delay diagnosis of persistent lesions in chronic inflammation. [77]