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Balanitis and Balanoposthitis - Review Article www.ijrhs.com Review article ISSN (o):2321–7251 Balanitis and Balanoposthitis - Review article S. Arunkumar 1, S. Murugan 2, B. Sowdhamani3, R. Sureshkumar 4 Department of STD, Chengalpattu Medical College, Chengalpattu, Tamil Nadu, India.1- Professor & HOD, 2- Assistant Professor, 3&4 – Junior Residents. Submission Date: 18-11-2013, Acceptance Date: 24-11-2013, Publication Date: 31-01-2014 How to cite this article: Vancouver/ICMJE Style AS, MS, SB, SR. Balanitis and Balanoposthitis - Review article. Int J Res Health Sci [Internet]. 2014 Jan31;2(1):375-92. Available from http://www.ijrhs.com/issues.php?val=Volume2&iss=Issue1 Harvard style A,S., M ,S., S,B., S,R. Balanitis and Balanoposthitis - Review article . Int J Res Health Sci. [Online] 2(1). p. 375-92 Available from: http://www.ijrhs.com/issues.php?val=Volume2&iss=Issue1 Corresponding Author: Dr. S. Arunkumar, Professor & HOD, Department of STD, Chengalpattu Medical College, Chengalpattu, Tamil Nadu, India. Email: [email protected] Abstract Balanitis is defined as inflammation of the glans penis, which often involves the prepuce (Balanoposthitis). In the present scenario, where there is a decline in the tropical Sexually Transmitted Diseases ( STD’s), balanoposthitis is the common condition in uncircumcised male patients attending the STD clinic. Candidal balanoposthitis is a known feature of diabetes mellitus especially in Indian males who are predominantly uncircumcised as the crude prevalence rate of type II diabetes mellitus in India is 9%. In our hospital, 31% of the newly diagnosed diabetic patients were presented only with balanoposthitis. The common etiology for balanoposthitis is candida albicans, but it may be due to a variety of infective and non infective causes. The management of balanoposthitis is given in a simple and step by step approach for specific and non specific causes. Keywords: Balanoposthitis; Candidiasis; Circumcision; Diabetes mellitus; Phimosis; Prepuce; STD’s Introduction Balanitis is defined as inflammation of the there is a decline in the tropical Sexually Transmitted glans penis, which often involves the prepuce Diseases (STD’s) balanoposthitis is the common (Balanoposthitis) [1]. In the present scenario, where condition in uncircumcised male patients attending International Journal of Research in Health Sciences. Jan–Mar 2014 Volume-2, Issue-1 375 Arunkumarthe STD et al clinic,– Balanitis which and is Balanoposthitisaround 11% [2]. Candidal The preputial sac provides lubrication www.ijrhs.com for balanoposthitis is a known feature of diabetes atraumatic vaginal sex. This is aided by the secretion mellitus especially in Indian males who are in preputial sac. predominantly uncircumcised as the crude The secretions contributed by prostate, prevalence rate of type II diabetes mellitus in India is seminal vesicles and urethral glands (Littre’s) 9%. In our hospital, 31% of the newly diagnosed moistens male preputial sac. Aerobic organism like diabetic patients were presented only with group B streptococci, coliforms, corynebacterium, balanoposthitis. Risk factors for balanoposthitis are i) coagulase positive staph. aureus, gonococci, uncircumcised, ii) congenital and acquired phimosis enterococci are seen in subpreputial area normally. [3], iii) poor genital hygiene, iv) lack of safe sex Group B streptococci causes balanitis in practices, v) diabetes mellitus and vi) urinary heterosexuals through sexual transmission is incontinence. Apart from the common etiology unimportant. The preputial sac is also colonised by candida albicans, it is due to a variety of infective Gram negative anaerobes (especially bacteroides and non infective causes [4-6]. Management of melaninogenicus). Mycobacterium smegmatis is a balanoposthitis remains a clinical challenge because benign commensal organism in the genitalia. This the cause is frequently undiagnosed as the clinical organism causes non genital soft tissue infections features are not specific. Hence we decided to do a post surgery/ trauma. review on this topic. The langerhans cells or dentritic cells are Prepuce: important for local mucosal immunity of prepuce. Prepuce or foreskin is an integral part of Langerhans cells [8] and squamous epithelial cells external genitalia that covers the glans penis and [9] of prepuce secrete cytokines that stimulate the T clitoris of male and female genitalia respectively. It helper system. is a specialised mucosal tissue that marks the boundary between mucosa and skin [7]. It gives Etio pathogenesis adequate protection to the genitalia and also The causes of balanoposthitis is both functions as an erogenous tissue. Prepuce is infective and noninfective [4]. Infective composed of squamosal mucous epithelium, lamina balanoposthitis is more common in uncircumcised propria, dartos muscle, dermis, outer glabrous skin. male, as a result of poor genital hygiene, lack of The outer epithelium of prepuce internalises glans aeration, irritation by smegma, diabetes mellitus and penis / clitoris, urethral meatus (male). The inner immune suppression. epithelium decreases external irritation. The mucosal epithelium contains langerhans cells which are an The causes are broadly classified as: important local defense mechanism. Tyson’s glands in lamina propria are often the source of smegma. Langerhans cells are also found in the outer epithelium of prepuce. Infective Non Infective Non infective International Journal of Research in Health Sciences. Jan–Mar 2014 Volume-2, Issue-1 376 Arunkumar et al– Balanitis and Balanoposthitis www.ijrhs.com A. Fungal : Most common cause A. Skin Disorders (i) Candida (albicans, krusei ) (i) Circinate balanitis (Reiter’s syndrome) (ii) Dermatophytosis (ii) Lichen sclerosus et atrophicans (iii) Pityriasis versicolor (iii) Balanitis xerotica obliterans (BXO) (iv) Histoplasma capsulatum (iv) Lichen planus/ Lichen nitidus (v) Blastomyces dermatitidis (v) Zoon’s balanitis (vi) Cryptococcus neoformans (vi) Psoriasis (vii) Penicillium marneffi (vii) Seborrhoeic dermatitis (viii) Pityriasis rosea (ix) Crohn’s disease, Ulcerative colitis (x) Necrobiosis lipoidica B. Bacterial (2nd Most common ) (xi) Hypereosinophilic syndrome (xii) Xanthomatosis ( i) Haemolytic Streptococci(Group B Streptococci) –Most Common (xiii) Histiocytosis X (ii) Staphylococci epidermidis / aureus (xiv) Sarcoidosis (iii) E.coli (xv) Porokeratosis (iv) Pseudomonas (v) Treponema pallidum (xvi) Apthous ulcers (vi) Neisseria gonorrhoea (xvii) Pyoderma gangrenosum vii) Haemophilus ducreyi (xviii) Bullous disorders vii) Mycoplasma genitalium (xix) Behcet’s disease ix) Chlamydia (xx) Premalignant Conditions x) Ureaplasma Erythroplasia of Queyrat, xi) Gardnerella vaginalis Bowen’s disease xii) Non specific spirochaetal infection Bowenoid papulosis xiii) Citrobacter Extra mammary Paget’s disease xiv) Enterobacter (xxi) Malignant conditions xv) Mycobacterium tuberculosis Squamous cell carcinoma, xvi) Anaerobes ( Bacteroides) Basal cell carcinoma, Melanoma, xvii) Haemophilus parainfluenzae infection CLL, Metastasis xviii) Klebsiella pneumonia B. Miscellaneous xix) Leprosy (i) Trauma C. Viral (ii) Poor hygiene i) Herpes simplex virus (HSV) (iii) Irritant & Allergic contact dermatitis ii) Varicella zoster virus (VZV) (iv) Fixed drug eruption iii) Human papilloma virus (HPV) (v) Extra long foreskin D.Protozoal (vi) Phimosis i) Entamoeba histolytica (vii) Incontinence ii) Trichomonas vaginalis (viii) Granulomatous balanoposthitis iii) Leishmania species C. Non specific balanoposthitis E. Parasitic D. Balanoposthitis simplex i) Sarcoptes scabiei var hominis ii) Pediculosis iii) Ankylostoma species iv) Creeping eruptions International Journal of Research in Health Sciences. Jan–Mar 2014 Volume-2, Issue-1 377 Arunkumar et al– Balanitis and Balanoposthitis www.ijrhs.com Among the infective causes, candida albicans is the most common etiology. It is one of the presenting features of diabetes mellitus. Apart from candida albicans, other important agents are staphylococcus, streptococcus, anaerobes and various other organisms may also cause balanoposthitis. Among the non infective causes irritant balanoposthitis, fixed drug eruption, plasma cell balanitis, circinate balanitis are the important ones. Type Symptoms Signs Diagnosis Treatment Remarks I. Infective Pruritus, Dry, raised 1) Subpreputial 1) Topical [10] : First described by A) Fungal burning excoriation discharge swab Clotrimazole cream Engman in Infections sensation, small irregular – Gram stain, or Econazole cream 1920[11]. i) Candida albicans redness of papules and KOH or Sertaconazole Normally carried (Also called as glans and dispersed vesicles preparation and cream or on penis in 14- Balanoposthitis prepuce, with plaques of Culture. Miconazole (2%) 18%. 35% of all Candidomycetica). whitish white cheesy 2) Urine culture. cream or Nystatin cases of infective subpreputial matter. 3) FBS/ PPBS/ Cream for 10-14 balanitis. discharge. Erythema of glans HbA1C. days bd. Predisposing and fissuring of 4) Germ tube 2) Tab. Fluconazole factors: prepuce. test. 150 mg Stat or Uncircumcised Transient T. Itraconazole men urethritis may be 200mg bd for 1day. Antibiotics and seen. steroid abuse. Acute Immunocompromi inflammatory sed edematous Poorly controlled balanoposthitis DM patients. associated with Sexual contact of a diabetes mellitus. partner with vulvovaginal candidiosis. No significant difference between carriage rate in uncircumcised/circ umcised men. ii) Dermatophyte History and Topical antifungals. infection clinical Oral antifungals. evidence
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