Balanitis

Template

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Circumcision statusChoose oneFirst line

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Findings presentChoose any

Findings absentChoose any

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HydrocortisoneChoose any

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Counseling

Balanitis usually improves within a few days with gentle care. Recommended supportive care with OTC medications as needed with an emphasis on warm water soaks, rinsing after urinating, and never forcing the foreskin back. Return precautions given including trouble urinating, spreading redness, fever, pus, a foreskin stuck behind the head of the penis, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

CounselingNot in the note with these choices

Discussed the need for emergency evaluation today. Caregiver expressed understanding and agreement with plan. Answered all questions.

Note when inserted as is

Balanitis
• Irritation of the foreskin from soaps, trapped urine, or friction
• No pain with urination, inability to urinate, redness spreading beyond the foreskin, or fever
• Started Bactroban to the foreskin
• Discussed avoiding bubble baths and harsh soaps, rinsing with warm water, and gentle foreskin care without forced retraction
• Follow up if not improving

Balanitis usually improves within a few days with gentle care. Recommended supportive care with OTC medications as needed with an emphasis on warm water soaks, rinsing after urinating, and never forcing the foreskin back. Return precautions given including trouble urinating, spreading redness, fever, pus, a foreskin stuck behind the head of the penis, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

What the sources cover

Cause: irritant, candidal, bacterial
Trouble urinating; spreading cellulitis present or absent
GAS swab
Clotrimazole or Nystatin for candida; Keflex for cellulitis; none
Avoid irritants with retraction care
Urology for recurrent balanitis or voiding trouble

Return precautions in the template

trouble urinatingspreading rednessfeverpusa foreskin stuck behind the head of the penis

Sources

Pediatric Care Online: Phimosis

Few formal guidelines cover this topic, so the template also leans on expert opinion.