Symptomatic BCG balanitis occurring after induction of intravesical BCG immunotherapy. What is the optimal treatment duration and regimen?

Intravesical Bacillus Calmette Guerin (BCG) immunotherapy is the standard initial therapy for patients with high-grade urothelial bladder cancer without muscle invasion. While minor complications due to intravesical BCG immunotherapy are common, cutaneous infections of the glans penis are quite rare. Granulomatous balanitis can be devastating if not identified and treated early. A well-established treatment regimen and duration of therapy is lacking. We review the English literature to define an optimal treatment strategy. To date there have been 12 reports of BCG balanitis occurrences after intravesical instillation of BCG for non-muscle invasive bladder cancer. In general, there appears to exist both under-diagnosis and failure of early diagnosis of the disease. Additionally, there are still many unanswered questions such as: What is the optimal regimen and duration of the treatment? Is repeated intravesical BCG administration safe, in patients with prior balanitis, for managing tumor recurrence or maintenance of BCG protocols? What are the clinical signs and symptoms of BCG balanitis? Isoniazid therapy of at least three months with adjuvant Rifampicin therapy for a minimum of two weeks is an optimal regimen. Repeated and maintained administration of intravesical BCG after prior balanitis is affordable. Early diagnosis and treatment of BCG balanitis usually leads to complete resolution and minimal morbidity.