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Balanoposthitis SK Edwards, CB Bunker, Fabian Ziller and Willem I Van Der Meijden Int J STD AIDS Published Online 14 May 2014 DOI: 10.1177/0956462414533099

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Balanoposthitis SK Edwards, CB Bunker, Fabian Ziller and Willem I Van Der Meijden Int J STD AIDS Published Online 14 May 2014 DOI: 10.1177/0956462414533099 International Journal of STD & AIDS http://std.sagepub.com/ 2013 European guideline for the management of balanoposthitis SK Edwards, CB Bunker, Fabian Ziller and Willem I van der Meijden Int J STD AIDS published online 14 May 2014 DOI: 10.1177/0956462414533099 The online version of this article can be found at: http://std.sagepub.com/content/early/2014/05/06/0956462414533099 Published by: http://www.sagepublications.com Additional services and information for International Journal of STD & AIDS can be found at: Email Alerts: http://std.sagepub.com/cgi/alerts Subscriptions: http://std.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav >> OnlineFirst Version of Record - May 14, 2014 What is This? Downloaded from std.sagepub.com by guest on June 17, 2014 XML Template (2014) [2.5.2014–10:58am] [1–12] //blrnas3/cenpro/ApplicationFiles/Journals/SAGE/3B2/STDJ/Vol00000/140084/APPFile/SG-STDJ140084.3d (STD) [PREPRINTER stage] Int J STD AIDS OnlineFirst, published on May 14, 2014 as doi:10.1177/0956462414533099 Guidelines International Journal of STD & AIDS 0(0) 1–12 ! The Author(s) 2014 2013 European guideline for the Reprints and permissions: sagepub.co.uk/journalsPermissions.nav management of balanoposthitis DOI: 10.1177/0956462414533099 std.sagepub.com SK Edwards1, CB Bunker2, Fabian Ziller3 and Willem I van der Meijden4 Abstract Balanoposthitis can be caused by a disparate range of conditions affecting the penile skin. This guideline concentrates on a selected group of conditions and offers recommendations on the diagnostic tests and treatment regimes needed for the effective management of balanoposthitis. Keywords Balanitis, balanoposthitis, lichen sclerosus, Zoon’s, lichen planus, candida, anaerobic, aerobic, psoriasis, circinate, eczema, erythroplasia of Queyrat, Bowen’s disease, Bowenoid papulosis Date received: 29 January 2014; accepted: 16 March 2014 Introduction Premalignant conditions: The main objective of this guideline is to aid recogni- tion of the symptoms and signs and complications of Erythroplasia of Queyrat penile skin conditions that may present to a variety of Bowen’s disease clinical specialists in Europe, including dermatology, Bowenoid papulosis sexual health or urology. This guideline concentrates on a selected group of conditions, which may be man- aged by clinicians practising in these disciplines, either Aetiologies alone or in conjunction with other specialists. It is not intended as a comprehensive review of the treatment of Balanitis describes inflammation of the glans penis, all forms of balanitis. It is aimed primarily at people posthitis inflammation of the prepuce. In practice aged 16 years or older. both areas are often affected and the term balano- This guideline offers recommendations on the diag- posthitis is then used. It is a collection of disparate nostic tests and treatment regimes needed for the effect- conditions with similar clinical presentation and vary- ive management of balanoposthitis and includes the ing aetiologies affecting a particular anatomical site (see following penile conditions: Table 1). Balanitis is uncommon in circumcised men Candidal balanitis 1Department of Genitourinary Medicine, Cambridgeshire Community Services, Bury St Edmunds, UK Anaerobic balanitis 2 Aerobic balanitis Department of Dermatology, University College Hospital, London, UK 3Department of Dermatology, DRK Hospital Chemnitz-Rabenstein, Lichen sclerosus Chemnitz, Germany Lichen planus 4Department of Dermatology, Havenziekenhuis, Rotterdam, Netherlands Zoon’s (plasma cell) balanitis Lead editor for IUSTI: Willem I. van der Meijden Psoriasis and circinate balanitis Corresponding author: Eczema (including irritant, allergic and seborrheic) SK Edwards, Department of Genitourinary Medicine, Cambridgeshire Non-specific balanoposthitis Community Services, Bury St Edmunds, UK. Fixed drug eruptions Email: [email protected] NICE has accredited the process used by BASHH to produce its European guideline on the management of balanoposthitis. Accreditation is valid for 5 years from 2014. More information on accreditation can be viewed at www.nice.org.uk/accreditation Downloaded from std.sagepub.com by guest on June 17, 2014 XML Template (2014) [2.5.2014–10:58am] [1–12] //blrnas3/cenpro/ApplicationFiles/Journals/SAGE/3B2/STDJ/Vol00000/140084/APPFile/SG-STDJ140084.3d (STD) [PREPRINTER stage] 2 International Journal of STD & AIDS 0(0) Table 1. Conditions affecting the glans and prepuce1. Premalignant (penile Infectious Inflammatory dermatoses carcinoma in situ) Candida albicans Lichen sclerosus Bowen’s disease Streptococci Lichen planus Bowenoid papulosis Anaerobes Psoriasis and circinate balanitis Erythroplasia of Queyrat Staphylococci Zoon’s balanitis Trichomonas vaginalis Eczema (including irritant, allergic and seborrheic) Herpes simplex virus Allergic reactions (including fixed drug eruption and Stevens Johnson Syndrome) Human papillomavirus Mycoplasma genitalium and in many cases preputial dysfunction is a causal or amplification test (where available) – if an ulcer contributing factor. is present, or alternatively syphilis serology with Other, rarer dermatoses are not included in this follow-up at 3 months. table. Infections, especially with candida, may be sec- . Culture/wet prep or nucleic acid amplification test ondary to primary inflammatory dermatoses. for Trichomonas vaginalis – particularly if a female partner has an undiagnosed vaginal General management of the patient discharge. with balanitis2 . Full routine screening for other sexually trans- mitted infections (STIs) – particularly screening Clinical features for Chlamydia trachomatis infection/non-specific urethritis if a circinate-type balanitis is present. Symptoms and signs vary according to aetiology and . Dermatology opinion for dermatoses and sus- specific conditions are covered in more detail pected allergy. individually. Biopsy – if the diagnosis is uncertain and the con- . Descriptions of the typical appearances of certain dition persists3,4 balanitides are given separately in the management section. Management Diagnosis The aims of management are to minimise sexual dys- function, to minimise urinary dysfunction, to exclude . Balanitis is a descriptive term covering a variety of penile cancer, to treat pre-malignant disease and to unrelated conditions, the appearances of which may diagnose and treat sexually transmitted disease. be suggestive but should never be thought to be Predisposing factors include both poor hygiene and pathognomonic and biopsy3 is sometimes needed overwashing, over-the-counter (OTC) medications as to exclude pre-malignant disease. well as non-retraction of the foreskin. The following investigations are intended to aid Many cases of balanitis seen in practice are a simple diagnosis in cases of uncertainty: intertrigo; i.e. inflammation between two layers of skin . Sexual history taken, with specific questioning on with bacterial or fungal overgrowth. Rapid resolution sexual risk taking. can be achieved most frequently in practice by advising . Sub-preputial swab for Candida spp and bacterial the patient to keep his foreskin retracted if possible, culture – should be undertaken in most cases to having advised him of the risk of paraphimosis. exclude an infective cause or superinfection of a Saline baths are also useful, and medicated OTC skin lesion or dermatosis. talcum powders are helpful in drying the area. This . Urinalysis for glucose – appropriate in some cases advice is simple, but compliance may be challenging. but especially if candidal infection is suspected. Many patients will present having tried antifungal . HSV nucleic acid amplification test or culture for creams, often obtained OTC. The experience is herpes simplex virus – if ulceration present. of relapse with these agents, and the simple meas- . Dark ground examination for spirochaetes and/ ures have a more durable effect when compliance is or Treponema pallidum (TP) nucleic acid lasting. Downloaded from std.sagepub.com by guest on June 17, 2014 XML Template (2014) [2.5.2014–10:58am] [1–12] //blrnas3/cenpro/ApplicationFiles/Journals/SAGE/3B2/STDJ/Vol00000/140084/APPFile/SG-STDJ140084.3d (STD) [PREPRINTER stage] Edwards et al. 3 General advice Alternative regimens . Avoid soaps while inflammation is present5 . Fluconazole 150 mg stat orally12 (Ib, A) – if symp- . Advise about risks of condom failure if creams are toms severe. being applied . Nystatin cream13 100,000 units/g – if resistance sus- . Patients should be given a detailed explanation of pected, or allergy to imidazoles (IIa, B). their condition with particular emphasis on any . Topical imidazole with 1% hydrocortisone – if implications for their health (and that of their part- marked inflammation is present (IV, C). ner where a sexually transmissible agent is found). Although there has been an increase in reports of drug resistance in serious candidal infection, there is no new Management of specific balanitides evidence pertaining to treatment of candidal balanitis. Infective balanitides A range of infective agents have been isolated more fre- Sexual partners. As there is a high rate of candidal infec- quently in men with balanoposthitis, and may not be tion in sexual partners, they should be offered testing easily differentiated by clinical findings.6 Agents include for candida or empiric anti-candidal treatment to Candida spp, Staphylococcus spp,7 Streptococcus spp8,9 reduce the reservoir of infection in the couple.
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