“The end of my penis is red, sore and itchy under the foreskin, and it’s getting hard to pull back”

BALANITIS is inflammation of the glans (balanoposthitis if the foreskin is also involved), presenting as a red, sore, itchy glans with discharge; recurrent episodes and progressive difficulty retracting the foreskin suggest developing PHIMOSIS (non-retractile foreskin) — examine without forcibly retracting. Irritant or contact dermatitis and dermatoses are common causes and Candida is a minority cause (BASHH balanoposthitis guideline 2025). Importantly, recurrent CANDIDAL balanitis is strongly associated with DIABETES and can be a presenting feature, so CHECK glucose/HbA1c in recurrent balanitis. Screen the causes: candidal/infective (red glans, itch, white curd-like material — commoner with diabetes, antibiotics, immunosuppression), irritant/contact dermatitis and hygiene (too little or too much), bacterial infection, STI (GUM screen if at risk), psoriasis/lichen planus, and crucially LICHEN SCLEROSUS (balanitis xerotica obliterans, BXO) — a white, atrophic, scarring change causing pathological phimosis and meatal stenosis that needs dermatology/urology involvement (potent topical steroids, sometimes circumcision) and carries a small increased penile SCC risk. Manage per cause: hygiene advice (gentle washing, drying, avoiding irritant soaps), topical antifungal ± mild steroid for candidal disease, appropriate treatment of bacterial/STI causes, and optimisation of diabetes. Refer for pathological phimosis, suspected lichen sclerosus/BXO, recurrent/refractory balanitis, or any suspicious/non-healing lesion (urology; NICE NG12: suspected cancer pathway referral for a penile mass or ulcerated lesion once an STI is excluded, a persistent lesion after STI treatment, or unexplained or persistent foreskin or glans symptoms), and consider circumcision in pathological phimosis/recurrent disease — never forcibly retracting a phimotic foreskin, examining with a chaperone offered, and treating paraphimosis as a same-day emergency. Handle an embarrassing problem sensitively, check glucose, screen for BXO, treat by cause, and safety-net. NICE NG12 applies to a persistent or suspicious penile lesion or unexplained persistent foreskin/glans symptoms.