Penile Erythematous Lesions

Dec 1, 2014 0 Comments in General Medical Posts by
Penile Erythematous Lesions

Penile Erythematous Lesions

Penile erythematous lesions are often embarrassing and discomforting for the patient due to ongoing pain, inflammation and itching. In addition, most of the lesions may also interfere with the quality of sex life due to painful intercourse or erectile dysfunction. It is therefore necessary to identify and manage the pathophysiology of these lesions to restore the quality of life.

Primary Causes of Penile Lesions

male sexual organ imageThere are a number of pathophysiological conditions that may present with moderate to severe rash of penis; such as:

  1. Pre-malignant lesions like Bowen disease of glans penis
  2. Zoon’s balanitis or other forms of balanitis
  3. Sexually transmitted diseases
  4. Infectious or hypersensitivity conditions of the skin such as, herpes simplex infection, psoriasis, eczema, lichen sclerosus, scabies and candidiasis.

Based on latest estimates, most chronic and apparently harmless cases of penile erythematous lesions are seen in the setting of zoon balanitis. Although the exact cause is not known but researchers believe that the origin is usually multi-factorial. Most statistically significant factors include:

  1. Improper genital hygiene
  2. Genetic or acquired hypersensitivity issues like IgE hypersensitivity
  3. Persistent exposure to excessive heat, rub, friction or pressure in the penile region due to lifestyle or occupational choices

Sign and Symptoms

Erythema or redness of penis can be localized or generalized. In most cases, the symptoms of Zoon Balanitis are slow to develop and includes (1):

  1. Tenderness of penis
  2. Pain in the pubic region that may be localized or spread to involve pelvic region also
  3. Circumferential, non-scaly shiny rash like lesions that are often described as ‘cayenne pepper spots’
  4. Sensation of itching and irritation along the penis (more pronounced over the lesions)
  5. Blood-stained undergarments

Data indicates that 11% of all the males who visit urology clinics are diagnosed with zoon balanitis (2)

Risk Factors

It has been observed that most of these lesions are reported in:

  1. Middle aged to elderly males
  2. Men with poor genital hygiene
  3. Uncircumcised males
  4. Chronic or poorly managed infection with Mycobacterium smegmatis

Differentiate Zoon Balanitis With Other Causes of Penile Rash

Stress & ED

Symptomatology and severity of lesions are usually helpful in establishing a preliminary diagnosis in most cases; for example:

  1. Presence of symptoms like fever, malaise, penile discharge, burning urination and arthralgia suggests a sexually transmitted infection. These symptoms are largely absent in Zoon balanitis patients. Clinically it is fairly difficult to differentiate balanitis ulcer from syphilitic ulcers.
  2. Bowen disease is often characterized by appearance of multiple non-healing ulcer like lesions on the glans penis. It is quite challenging to differentiate Bowen disease and balanitis based on the physical appearance alone. However, early identification and prompt management is necessary because 5 to 30% of all cases of Bowen disease (also known as Erythroplasia of Queyrat or squamous intraepithelial neoplasia of penis) transform into malignant lesions.
  3. Penile rash due to skin inflammatory or hypersensitivity diseases is differentiated based on; presence of extra-penile lesions, hypo or hyperpigmentation, cosmetic changes in the appearance of penis, episodes of superficial bleeding, atrophic changes, painful urination and other symptoms of urinary tract infection (3)

Diagnosis of Penile Erythematous Lesions

Clinically, all suspected erythematous penile lesions are identified by biopsy and histo-pathological studies to differentiate between pre-malignant lesions like Bowen disease and non-malignant Zoon balanitis. Treatment options revolve around topical ointments like triamcinolone cream (mixed with zinc oxide) and nystatin (2).

Prevention of zoon balanitis and other inflammatory conditions of penis involves:

  1. Maintenance of optimal genital hygiene
  2. Circumcised males are less prone to develop penile erythematous lesions


  1. Noss, M. R., & Cha, J. (2012). Erythematous penile lesion. The Journal of family practice, 61(12), 753-755.
  2. Barrisford GW. Balanitis and balanoposthitis in adults. UpToDate. December 19, 2011. Available at: Accessed October 26, 2012.
  3. Teichman, J. M., Sea, J., Thompson, I. M., & Elston, D. M. (2010). Noninfectious penile lesions. Am Fam Physician, 81(2), 167-74.
  4. Aggarwal, N., Parwani, A. V., Ho, J., Cook, J. R., & Swerdlow, S. H. (2014). Plasma Cell (Zoon) Balanitis: Another Inflammatory Disorder That Can be Rich in IgG4+ Plasma Cells. The American journal of surgical pathology, 38(10), 1437-1443.
  5. Ezra, N., Binder, S. W., & Behroozan, D. (2012). Plasma cell balanitis presenting in a patient with a history of syphilis. American journal of clinical dermatology, 13(2), 129-133.