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Balanoposthitis

Balanoposthitis is defined as an inflammation of the glans penis or the foreskin affecting uncircumcised males, caused by a fungal or bacterial infection.


Presentation

Detailed history including possible irritant agents is required in order to come to the correct diagnosis. Presenting patients may complain of change in color of the penis, itching, and burning sensation when urinating.

Physical examination of the glans penis and the foreskin will reveal a red macular ulcerating lesion. Other signs include erythema and areas of yellow to black discoloration [3].

There are different forms of the inflammation and each form may manifest differently. The first form is blanoposthitis simplex, which manifests as redness, swelling, secretion, and wounds on the glans penis. The second form is balanoposthitis candidomycetica, presenting as glowing redness, appearance of whitish bubbles, itching and burning sensation when urinating; patients with this form are usually diabetic. The third form is Balanoposthitis erosive cicirnata characterized by a chronic course of irregular whitish, red and gray-whitish changes; in some cases it is associated with Reiter's disease.

Balanoposthitis may be associated with an human papillomavirus (HPV) infection, which is suggested by the presence of irregular borders or acetowhite changes with 5% acetic acid treatment.

Immunocompromised patients with systemic fungal infections may show deep ulceration of the glans penis or the foreskin.

Inguinal Lymphadenopathy
  • We report a case of primary syphilis presenting as erosive and crusted balanoposthitis with an underlying chancre, penile edema, and bilateral inguinal lymphadenopathy in a heterosexual man.[ncbi.nlm.nih.gov]
  • [Figure - 1] There was no inguinal lymphadenopathy and tenderness. He was prescribed antifungal cream (clotrimazole 1%), but did not respond. Then he was prescribed co-trimoxazole tablets and acyclovir cream topically.[ijdvl.com]
  • Inguinal lymphadenopathy. 39.1.4 Complications Recurrent bouts of balanitis may cause scarring of the preputial orifice; with a subsequent reduction of preputial elasticity, which may lead to pathologic phimosis (Fig. 39.4 ).[abdominalkey.com]
  • Shallow erosions Foul-smelling subpreputial discharge Edema of the prepuce Inguinal lymphadenopathy Culture Swab for HSV Metronidazole Co-amoxiclav Clindamycin cream Fusobacterium spp.[library.everyonehealthy.com]
Inguinal Lymphadenopathy
  • We report a case of primary syphilis presenting as erosive and crusted balanoposthitis with an underlying chancre, penile edema, and bilateral inguinal lymphadenopathy in a heterosexual man.[ncbi.nlm.nih.gov]
  • [Figure - 1] There was no inguinal lymphadenopathy and tenderness. He was prescribed antifungal cream (clotrimazole 1%), but did not respond. Then he was prescribed co-trimoxazole tablets and acyclovir cream topically.[ijdvl.com]
  • Inguinal lymphadenopathy. 39.1.4 Complications Recurrent bouts of balanitis may cause scarring of the preputial orifice; with a subsequent reduction of preputial elasticity, which may lead to pathologic phimosis (Fig. 39.4 ).[abdominalkey.com]
  • Shallow erosions Foul-smelling subpreputial discharge Edema of the prepuce Inguinal lymphadenopathy Culture Swab for HSV Metronidazole Co-amoxiclav Clindamycin cream Fusobacterium spp.[library.everyonehealthy.com]
Pharyngitis
  • Streptococcus pyogenes is indigenous to the human pharynx and causes acute pharyngitis. Balanoposthitis is an inflammatory disease of the glans and the foreskin.[ncbi.nlm.nih.gov]
  • Streptococcus pyogenes causes a variety of diseases, such as pharyngitis and toxic shock syndrome. In addition, this bacterium is a causative agent of balanoposthitis.[ncbi.nlm.nih.gov]
  • Detection of invasive protein profile of Streptococcus pyogenes M1 isolates from pharyngitis patients. APMIS 2010;118: 167– 178 [CrossRef] [PubMed] [Google Scholar] 13. Zhang Y , Tatsuno I , Okada R , Hata N , Matsumoto M et al.[jmm.microbiologyresearch.org]
  • Gonorrhea: this STI usually presents around 4-7 days after infection as urethritis (with purulent semen-like discharge) or more rarely as pharyngitis or conjunctivitis.[online.epocrates.com]
Neglect
  • If the condition is neglected, erosions may appear in the involved areas. This is referred to as erosive balanoposthitis.[visualdx.com]
  • Also, the disease often occurs in people neglecting personal hygiene. In children very young age balanoposthitis may develop as a result of phimosis and other violations.[domelhor.net]
Suggestibility
  • Forty nine biopsies showed marked koilocytosis suggestive of human papilloma virus (HPV) infection, and of these, only three showed fungal hyphae. This study suggests that HPV may be associated with some cases of patchy balanoposthitis.[ncbi.nlm.nih.gov]
  • These findings are suggestive of a nonspecific polyclonal stimulation of B cells, which might be caused by a persistent infection.[ncbi.nlm.nih.gov]
  • It is not possible to take biopsies from patients with genital warts, but this study suggests that one probably should be more observant for genital dysplasia among those men with warts with a history of balanoposthitis than those with no such history[ncbi.nlm.nih.gov]
  • These results suggest that balanoposthitis is caused by a variety of types of S. pyogenes, with novel clade genotype emm89 isolates playing a role in balanoposthitis infections in Japan.[ncbi.nlm.nih.gov]
  • The results suggest the existence of vaginopathic C. albicans strains with enhanced virulence and tropism for the vagina and the high possibility of sexual transmission of genital C. albicans infection.[ncbi.nlm.nih.gov]
Impulsivity
  • Topical anaesthesia was performed before erbium:YAG laser ablation (focus 1.6-5 mm; frequency 8 Hz; impulse energy mostly 800 mJ; fluence between 11.3 and 20 J cm(-2)). The pulses were partly overlapping.[ncbi.nlm.nih.gov]
Urethral Discharge
  • Each man presented with a similar syndrome of diffuse erythema and pruritus of the glans meatus and coronal sulcus, irritation of the prepuce, and minimal urethral discharge.[ncbi.nlm.nih.gov]
  • Manual stripping of the length of the urethra produced no true urethral discharge.[journals.lww.com]
  • CLINICAL FEATURES • Superficial Erosions with Purulent Urethral Discharge (Neisseria Gonorrhoea) 18.[slideshare.net]
Dysuria
  • Obtain urinalysis to evaluate for suspected urinary tract infection in patients with dysuria. Additional Reading: Lisboa C, Ferreira A, Resende C, et al. Infectious balanoposthitis: management, clinical, and laboratory features.[ebmedicine.net]
  • The individual may complain of pain with urination (dysuria), coital pain (dyspareunia) or impotence. There may be rashes, scaling, fissuring, crusting or discoloration on the affected areas.[library.everyonehealthy.com]
  • There was no dysuria, and the accompanying parent admitted to no knowledge of sexual molestation. Thick yellow material was visible in the preputial sulcus covering the preputial opening.[journals.lww.com]
Burning Micturition
  • CLINICAL FEATURES • Papules / Pustules or Vesicles (even Bullae) with Erosions • Prepucial Edema, Phimosis • Thick, foul smelling subpreputial discharge • Pain / Pruritis / Burning Micturition • Painful LAN • Extensive Ulceration • Phaegedena 14.[slideshare.net]

Workup

Laboratory studies include potassium hydroxide (KOH) slide preparation, which visualizes the hyphae of candida. Cultures are also used to isolate candida species. Serologic tests may be used in rare unclear cases [10]. If malignancy is suspected, such as erythroplasia of Queyrat or Bowen disease, a biopsy is taken from the lesion and examined. Fungal elements characteristic of candidal organisms may be revealed using the periodic acid-Schiff (PAS) stain. Lymphoplasmacytic infiltrates are found in the dermis; however, histologic features are eczematous in nature and nonspecific.

Lymphocytic Infiltrate
  • infiltrates) Wet preparation/culture Metronidazole Entamoeba histolytica Edema of prepuce Discharge Phimosis Spirochete Treponema pallidum (syphilis) Round lesions Erosions develop that lead to ulcers Primary chancre Dark field microscopy TP PCR Other[library.everyonehealthy.com]
  • This overlies an area of oedema with loss of the elastic fibres and alteration in the collagen, which in turn overlies a perivascular band of lymphocytic infiltration.[cirp.org]

Treatment

General measures for the management of the inflammation include paying attention to personal hygiene, avoiding irritants and allergens, wearing cotton underwear, making sure to dry the penis after washing, and using a lubricant during sexual intercourse in order to decrease symptoms of dyspareunia [11].

Emollients, topical corticosteroids, and antihistamines are used in the management of atopic eczema, pruritus, psoriasis, and contact dermatitis. Aluminum acetate soaks may also be beneficial in acute contact dermatitis cases [11].

Seborrheic dermatitis is treated with the general measures in addition to topical antifungals to control erythema and inflammation. Topical corticosteroids or calcineurin inhibitors may be applied as well. Oral fluconazole or itraconazole achieve good results in severe cases or in immunocompromised patients.

Topical vitamin D or calcineurin inhibitors may be used in the management of psoriasis or Reiter's disease. UV light, acitretin, cyclosporine, methotrexate, or biologic agents may be required in severe cases of psoriasis.

Lichen sclerosis is treated with topical corticosteroids. However, surgical intervention is necessary in the case of failure of medical treatment.

Ceftriaxone or cefixime with azithromycin or doxycycline are recommended to be used in the management of gonorrhea. A single dose of azithromycin is advised if the patient is allergic to cephalosporin. Gonorrhea infection is serious and cultures should be taken and examined for antibiotics resistance in patients who do not respond to treatment and have persistent symptoms. Reporting cases to the Centers for Disease Control and Prevention (CDC) is important in patients who do not respond to medical treatment. Evaluation of sex partners during the preceding 60 days is required and treatment should be started in those diagnosed with the infection.

Topical antifungal agents with hydrocortisone are effective in the treatment of candidosis. Oral antifungal agents are recommended in immunocompromised patients or if topical agents prove not to be effective. Underlying diseases, such as HIV or diabetes, should be treated.

The management is difficult in nonspecific cases of balanoposthitis. General measures, topical and oral antifungal agents, corticosteroids, and antibiotics are all ineffective. Surgical intervention with circumcision may be the only option for the treatment of these cases.

The management of zoon balanitis includes topical corticosteroids in addition to an antifungal agent or antibiotics. Cases that do not respond to medical management may require surgical intervention with circumcision [3].

Prognosis

Balanoposthitis has good prognosis; however, in rare cases treatment may fail, which should raise suspicion of malignancy and requires further workup. Two malignancies may resemble balanoposthitis, which are erythroplasia of Queyrat and Bowen disease. Acute promyelocytic leukemia may also present as an ulcerating lesion of the penis mimicking balanoposthitis [9]. A biopsy is taken to rule out both primary and secondary malignancies of the penis. Immunocompromised patients with systemic fungal infections may have worse prognosis leading to deeper ulcerating lesions of the penis.

Etiology

Studies of bacterial or fungal cultures showed higher frequency of positive cultures among patients with balanoposthitis when compared with the control group [1]. Staphylococcus aureus, group B streptococci, Candida albicans, and Malassezia were found in cultures obtained from patients.

Circumcision helps in the prevention of balanoposthitis and other penile infections [3]. Uncircumcised males have higher incidence of developing the inflammation. Preputial smegma stones are usually associated with patients who develop the infection [4]. Cases of balanoposthitis have been reported after Bacillus Calmette-Guerin (BCG) treatment of urothelial cancer [5].

Epidemiology

Balanoposthitis has been reported in different races, and there is no correlation between the development of the inflammation and certain ethnic groups. It affects only males and usually develops in children up to 5 years of age, as well as among sexually active adults. There are no epidemiological studies for balanoposthitis in the United States. However, there are different international studies in other countries. For example, a study of 603 uncircumcised Japanese boys revealed 1.5% cases suffering from inflammation [6]. Another study in Hong Kong revealed that only 1 boy among 2149 elementary schoolchildren had the inflammation [7]. Morbidity and mortality due to balanoposthitis are rare; however mondor phlebitis of the penis has been reported in patients with recurrent candidal infections [8]. Immunocompromised patients with secondary fungal septicemia may have a higher risk of mortality.

Sex distribution
Age distribution

Pathophysiology

The glans penis and the foreskin consist of sensitive tissue, which is usually in contact with irritants, such as moisture, sweat, heat, urine detergents, sexual secretions, and other infectious agents. Inflammation can be caused by any of these irritant factors leading to dysfunction, scarring, and precancerous or cancerous lesions in rare cases.

Prevention

The presence of foreskin in uncircumcised men provides the moist warm predisposing conditions for the development of balanoposthitis [3] [12]. Circumcision is an option for both the prevention and in some cases the management of balanoposthitis.

Good personal hygiene, especially in the genital area, prevents the development of the inflammation. It is advised to avoid irritants and common allergens, fully dry the penis after washing, and use soap substitutes and emollients.

Summary

Balanoposthitis is an infection of the foreskin or the glans penis, which affects mainly uncircumcised men because of the moist warm conditions.

Etiology of the inflammation includes bacterial and fungal infections. The main responsible agents are Candida albicans, Staphylococcus aureus, group B streptococci, and Malassezia [1]. Risk factors include poor hygiene of the genital area, in addition to irritants and allergens.

There is no correlation between the development of the inflammation and certain races as it has been reported in different ethnic groups. It is usually diagnosed in children up to 5 years of age and in sexually active males.

The diagnosis of the inflammation is made based on the history and the physical examination. The clinical picture includes redness, swelling, and ulceration of the glans penis [2]. Whitish bubbles may appear in some cases. If candida infection is suspected, a smear is taken to visualize the hyphae and confirm the diagnosis.

Management of the inflammation includes general measures, such as good personal hygiene and avoidance of the risk factors, irritants, and allergens. Topical or oral corticosteroids, antihistamines, vitamin D, and antibiotics may be used depending on the specific cause of the inflammation. Surgical intervention with circumcision is required in rare cases if medical management fails.

The prognosis of balanoposthitis is good; however, immunocompromised patients may have deeper ulcerating lesions and worse prognosis. If medical management fails, further workup should be done to exclude malignancies.

Avoidance of the risk factors and maintaining a good personal hygiene helps in preventing the inflammation. Circumcision decreases the risk of developing the infection [3].

Patient Information

Balanoposthitis is defined as an inflammation of the glans penis (the tip of the penis). It usually affects uncircumcised men because of the moist warm conditions. The inflammation is usually due to fungal or bacterial infections. Risk factors include poor hygiene and irritation with soap or disinfectants.

The symptoms and clinical features of the inflammation include redness, swelling, secretion, and wounds or ulceration on the tip of the penis. The infection may cause itch sensation in the area and burning when urinating. Other forms of the inflammation may appear as white bubbles or gray-whitish changes on the glans penis.

Thorough history and physical examination of the lesion are required in order to make the diagnosis. Further workup may be needed to confirm the diagnosis including examination of smears from the ulceration and cultures. In rare cases, a biopsy is taken and examined in order to exclude malignancy.

Management of balanoposthitis includes general measures, such as avoiding irritants and allergens, drying the penis after washing, wearing cotton underwear, and using lubricants during sexual intercourse. In addition to these measures, treatment with topical or oral corticosteroids, antihistamines, vitamin D, and antibiotics may be used depending on the specific cause of the inflammation.

The outcome of the inflammation is very good; however, if medical management fails, this raises suspicion of potential malignancy. In these cases further workup is recommended, such as taking a biopsy from the lesion for examination. Immunocompromised patients may have deeper ulcerating lesions with worse outcomes.

Prevention of the inflammation includes good personal hygiene, especially in the genital area. Additionally,  risk factors, such as irritants and allergens, need to be avoided. Circumcision helps in decreasing the risk of getting the infection.

References

Article

  1. Alsterholm M, Flytstrom I, Leifsdottir R, et al. Frequency of bacteria, Candida and malassezia species in balanoposthitis. Acta Derm Venereol. 2008; 88(4): 331-6.
  2. Duerden BI. Black-pigmented gram-negative anaerobes in genito-urinary tract and pelvic infections. FEMS Immunol Med Microbiol. March 1993; 6(2-3): 223-7.
  3. Mallon E, Hawkins D, Dinneen M, et al. Circumcision and genital dermatoses. Arch Dermatol. March 2000; 136(3): 350-4. 
  4. Sonnex C, Croucher PE, Dockerty WG. Balanoposthitis associated with the presence of subpreputial "smegma stones". Genitourin Med. December 1997; 73(6): 567. 
  5. Linden-Castro E, Pelayo-Nieto M, Alias-Melgar A. Penile tuberculosis after intravesical bacille Calmette-Gue´rin immunotherapy. Urology. August 2014; 84(2): e3.
  6. Kayaba H, Tamura H, Kitajima S, et al. Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol. November 1996; 156(5): 1813-5. 
  7. Hsieh TF, Chang CH, Chang SS. Foreskin development before adolescence in 2149 schoolboys. Int J Urol. July 2006; 13(7): 968-70. 
  8. Agrawal SK, Singal A, Pandhi D. Mondor's phlebitis of penis following recurrent candidal balanoposthitis. Int J Dermatol. January 2005; 44(1): 83-4. 
  9. Steinbach F, Essbach U, Florschütz A, et al. Ulcerative balanoposthitis as the initial manifestation of acute promyelocytic leukemia. J Urol. October 1998; 160(4): 1430-1.
  10. Dockerty WG, Sonnex C. Candidal balano-posthitis: a study of diagnostic methods. Genitourin Med. December 1995; 71(6): 407-9.
  11. Pandya I, Shinojia M, Vadukul D, et al. Approach to balanitis/balanoposthitis: Current guidelines. Indian J Sex Transm Dis. July-December 2014; 35(2): 155-7.
  12. Morris BJ. Why circumcision is a biomedical imperative for the 21st century. Bioessays. 2007; 29: 1147-1158. 

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Last updated: 2018-06-22 09:25