Preputial discharge

Specialty: Nephrology and urology.

• subpreputial exudate
• discharge under the foreskin
• pathological smegma

Why it occurs

• Candidal balanitis (fungal infection by Candida albicans in the balanopreputial space that produces a whitish, thick, lumpy cottage cheese-like discharge and punctate erythema of the glans)
• Bacterial balanoposthitis (opportunistic bacterial infection by mixed aerobic or anaerobic flora, common in uncircumcised patients with poor hygiene or mild phimosis, causing a purulent exudate with an unpleasant odor)
• Excessive accumulation of smegma (normal physiological scaly sebaceous secretion that accumulates due to inadequate genital hygiene or difficulty in retracting the foreskin)
• Balanitis xerotica obliterans or lichen sclerosus (chronic inflammatory skin lesion that generates preputial sclerosis, whitish plaques, mucosal erosion with serous secretion and stenosis of the meatus)
• Zoon plasma cell balanitis (benign chronic inflammatory lesion with shiny erythematous "lacquer" plaques exuding serohematic fluid)

Initial workup

Detailed physical examination with gentle retraction of the foreskin to evaluate the glans and balanopreputial groove (ruling out ulcers or suspicious lesions); smear of the secretion for direct microscopic examination and microbiological culture (search for yeast, aerobic and anaerobic bacteria); biopsy of the foreskin or glans in chronic erosive lesions that do not respond to empirical treatment.

Standard management

• Clotrimazole cream 1% or Miconazole 2% — apply to the glans and balanopreputial groove every 12 hours for 7-10 days for candidal balanitis; keep the foreskin retracted during application if possible
• Metronidazole 0.75-1% cream or ointment — apply locally twice a day if infection by anaerobic bacteria is suspected, or metronidazole 500 mg PO every 12 hours for 7 days in severe cases
• Hydrocortisone cream 1% — topical application for short periods of 5-7 days to reduce the non-infectious inflammatory component, always associated with antimicrobial treatment if infection coexists
• Washed with warm water and thoroughly dried without rubbing.