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. 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 of the , 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 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; ; ; Diabetes mellitus; ; 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

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Arunkumarthe STD et al clinic,– Balanitis which and is Balanoposthitis around 11% [2]. Candidal The preputial sac provides lubricationwww.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 , prevalence rate of type II diabetes mellitus in India is 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 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 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

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A. Fungal : Most common cause A. Skin Disorders (i) Candida (albicans, krusei ) (i) Circinate balanitis (Reiter’s syndrome) (ii) Dermatophytosis (ii) 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 (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 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

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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 of dermatophyte infection in other sites. Scraping and microscopy. Culture. iii) Pityriasis versicolor Circinate, fine, Scrapping and Topical antifungals. scaly, microscopy. hypopigmented Woods lamp. areas in glans. Culture. Deep Fungal Infections Multiple non ` Surgical iv) Histoplasma tender punched debridement. capsulatum out ulcers with Systemic antifungals

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indurated margins. like Amphotericin B, Ketoconazole. v) Cryptococcus Necrotizing ulcer Same. neoformans over the glans. vi) Penicillium marneffi Ulcers over the Same. glans. vii) Blastomyces Ulcers over the Same. dermatitidis glans. B. Bacterial Infections Nonspecific Penicillins. Caused i) Group B Streptococci erythema without Cephalosporins. asymptomatically ii) Group A Beta discharge, rarely in adult genital haemolytic streptococci penile edema mucosa. (cellulitis). iii) Staph. aureus Increased carriage in heterosexuals. Sexual transmission is unclear. Commonly involves children. Infrequently occurs. Toxic Shock syndrome is a rare complication. iv) Treponema pallidum Primary syphilis: i) Benzathine ( Also known as Multiple circinate Demonstration Penicillin 24 lakh syphilitic balanitis of lesions eroded to of organism by units IM after test Follman) form irregular dark field dose. ulcers at the glans microscope. penis and prepuce. ii) Secondary Demonstration syphilis: Swollen of T. pallidum glans covered by polymerase with partially chain reaction. coalescent white iii) Serology for flat papules, syphilis. plaques over glans iv)Eliminate the penis. presence[12] of other organism like Candida, Group B Streptococci, Anaerobes, HSV etc. (v) Neisseria gonorrhoea Pain, burning Tender ulcers / i) Grams stain: Single dose Hypopigmentation sensation, pustules on Intracellular Ceftriaxone or of glans penis is a urgency and prepuce and shaft. Gram negative Cefixime. rare complication. frequency of Thick creamy, diplococcic. Simultaneous micturition. greenish yellow ii) Culture treatment with Urethral purulent Doxycycline or

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discharge. discharge. Azithromycin for Lymphadenopathy Chlamydial is seen. infection (vi) Haemophilus Painful shallow Systemic Phimosis and ducreyi ulcers with ragged Antibiotics. phagedenic ulcer and undermined Erythromycin or are the edges. Ceftriaxone or complications. Azithromycin or Ciprofloxacin. (vii) Mycoplasma Simple erythema. Tetracyclines. Mycoplasma genitalium Circinate lesions causes urethritis over the glans independent of penis and prepuce. balanitis. Tendency for Increased risk of bleeding. HIV transmission and susceptibility[13]. (viii) Chlamydia Irritant balanitis. Tetracyclines. D-K serotypes cause balanitis. (ix) Gardnerella Mild Diffuse erythema Subpreputial As per guidelines Symptoms occur vaginalis and other symptoms and mild irritation culture and depending on within 7 days of aerobes Pruritus and over glans penis Group A the sensitivity of the sexual contact. irritation over and prepuce. streptocooci, organism. Most common in Glans penis Increased staph aureus and Erythromycin uncircumcised and prepuce offensive , fishy Gardnerella 500mg bd, 2% men. odour in sub vaginalis. fusidic acid cream. Congenital preputial phimosis and discharge acquired phimosis.

(SPD)[14]. Poor hygiene. Normally this organism is present in glans penis and prepuce. Concomitant anaerobic infection is common. Sexually acquired. (x) Non specific Large, Dark field Penicillin and Coexists with spirochaetal infection ( serpiginous, microscopy. Metronidazole[15]. other infections. Borrelia infection) superficial, foul Spirochaetes Aetiology:

smelling tender. demonstrated. Commonly Treponema refringens, Treponema phagedenis, Treponema balanitidis, Borrelia vincenti. (xi) Mycobacterim Ulcers with ( HPE) MDT. Common in

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leprae and (xii) undermined edges shows Anti tuberculous countries with Mycobacterim over glans penis. tuberculoid treatment. increased tuberculosis Involement of granuloma prevalence of glans penis and formation. tuberculosis. Phimosis[16]. Associated with Chronic papular positive Mantoux eruption of glans test. penis which may be ulcerated, and heals with scarring[17] . (xiii) Anaerobes ( Foul smelling Superficial Diagnosed Transmitted by Bacteroides, discharge. erosion of glans clinically and Anogenital nonclostridial Swelling of penis, coronal treated early. contact. anaerobes). Also known glans penis. sulcus. Predisposing as erosive bacterial Preputial edema. factor: Contact by balanitis. Tender mouth or finger, lymphadenitis. poor genital hygiene, phimosis, uncircumcised. Causative agents:[18] Fusobacterium, Bacteroides, Anaerobic cocci etc., Complication: Gangrenous balanitis. C. Viral Prodromal Multiple tender Serology, Acyclovir tablets. Due to HSV1,2. (i) Herpetic balanitis symtoms papulo vesicles culture in chick 5% Idoxuridine [19] Predisposing (HSV) common. over the glans embryo, baby solution in DMSO. factors: Pain in penis penis and or hamster kidney, Uncircumcised and inguinal prepuce. Hep 2 cells. men, region. Multiple necrotic Biopsy. poor genital Dysuria and ulcers over glans Light and hygiene, orogenital urethral Electron contact. discharge microscopy (ii) Human papilloma Redness, Diffuse or patchy 1) 5% Acetic 1) 5 Fluorouracil Screening for other virus (HPV) itching, erythematous acid test- on (5FU) cream STDs is burning macules or application the application once/ recommended. sensation, pain maculo papules on lesions become twice weekly. Screen the partner and fissuring the inner aspect of white- aceto 2) 0.5% and Inform the of glans penis. prepuce. white. podophyllotoxin self partner about the 2) HPE: application. risk of Hyperkeratosis 3) 25% Podophyllin transmission. and once a week (under Advise barrier parakeratosis. super vision). protection. 3) Detection of 4) 5% Imiquimod Advise for follow types. cream twice weekly up. for 16 weeks.

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D. Protozoal Pain, dysuria. Ulcers and Biopsy. Metronidazole Described first by (i) Amoebic balanitis erosions over Culture, smear, Circumcision. Straub in 1924. ( Caused by Entamoeba glans penis, wet mount Seen in histolytica) edema of prepuce. preparation. uncircumcised Phimosis, men with poor discharge. hygiene. Auto inoculation and intercourse with infected partner[20] are the main modes of transmission. (ii) Trichomonas Copious Superficial Wet Mount: Metronidazole. Sexually acquired. vaginalis frothy erosions present from Associated with discharge. over the glans subpreputial other infections. penis. discharge - 15-50% of men Phimosis. demonstration with trichomonas Mucopurulent of the organism. infection are greenish frothy Culture: asymptomatic discharge with HPE: Dense carriers. fishy odour. lymphocytic Long prepuce is an infiltrate in important upper dermis predisposing [21]. factor. (iii) Leishmania Ulcers over glans Demonstation of Systemic/ local donovani penis and prepuce. leishmania pentavalent amastigotes in antimony smear / biopsy. compounds. E. Parasitic Pruritus Raised, slightly 5% permethrin Transmitted by (i) Sarcoptes scabiei var elongated, cream application. close body contact. hominis circumscribed Emphasis on good tracts and nodules local hygiene. over glans penis Treatment of and scrotum, shaft household contacts and penis. and sexual partners of patient is mandatory. (ii) Creeping eruptions ( Itching Erythematous Albendazole 400- Cutaneous larva itchy papules and 800mg daily for 3 migrans) linear serpiginous days. bizarre tracts. II. Non infective Shallow, circinate HPE: Not required usually Common in A. Skin irregular greyish Hyperkeratosis, Some cases : 1% Shigella associated

disorders white lesions with parakeratosis, hydrocortisone disease[22]. (1) Circinate balanitis / raised edges acanthosis, cream twice daily Post infection Balanoposthitis ( coalesce to form elongated rete application. syndrome. Reiter’s disease) geographic ridges, Potent steroids. Overlap with patches with white spongiform Psoriasis, HIV margin[23]. pustule in upper infection. dermis. HLA B 27 plays a Dermal role.

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capillaries – Screening for enlarged, concurrent STIs increased in especially number Chlamydia mononuclear trachomatis. cell infiltrate. Triad includes Extravasation of Conjunctivitis, RBCs. Urethritis and Arthritis. Circinate balanitis and Keratoderma blennorrhagicum seen. 2) Lichen Sclerosis et Usually Recurrent painful HPE: Epidermis Circumcision – Commonly seen in atrophicans (LSA) asymptomatic. vesicles and ulcers : ( Early) Treatment of middle aged men Non over glans penis. Thickened Choice[24] . uncircumcised retractable White plaques on (Late) – Meatotomy for men. foreskin. glans penis and Atrophy, meatal stenosis. Predisposing Pain, prepuce. follicular Topical potent factors: irritation. Thickened non hyperkeratosis. steroids until Idiopathic, trauma, Disturbance of retractable Dermis: remission then autoimmune sexual prepuce. Oedematous intermittently once a disease, genetic function. Hemorrhagic area with loss of week ( for factors, hormonal Urinary vesicles over elastic fibres remission). factors. symptoms. plaques. and alteration in Other treatment : Follow up is Cicatricial collagen. photodynamic mandatory shrinkage, urethral Perivascular therapy, laser, annually. stricture, phimotic band of testosterone prepuce. lymphocytic ointment, infiltrate. calcipotriol ointment, topical Calcineurin inhibitors. 3) Balanitis Xerotica Neonatal Chronic scarring Obliterans ( BXO) circumcision. balanitis. Most commonly caused by LSA, Chronic non- specific balanitis. Associated with phimosis and squamous cell carcinoma. 4) Zoon’s balanitis ( Usually Raised, solitary, Biopsy : HPE: Circumcision ( Described by Zoon Balanitis circumscripta indolent and smooth, well Epidermis : Curative). in 1952. plasma cellularis/ asymptomatic circumcised, red- Atrophy, Topical steroids. Common in

Plasma cell balanitis mild pruritis. orange shiny[25] complete Topical , middle aged and Irritation, plaques on glans effacement of . elderly and prepuce with rete ridges. pain, Topical fusidic uncircumcised pinpoint purpuric SPD, staining Diamond acid[26] cream. men. “ Cayenne shaped or It is an idiopathic of under pepper” surface CO2 laser/ intra

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garments with spotting with lozenge shaped lesional interferon α. chronic, reactive, blood. yellowish hue. keratinocytes in Oral griseofulvin. rare penile Cosmetic basal layer. dermatosis. concern. Watery Etiology: Unclear Anxiety. spongiosis, Predispoing factor: sparse heat, friction, dyskeratotic chronic irritation cells. due to Mycobacterium smegmatis, poor genital hygiene, trauma, hypospadias, HSV infection. 5) Psoriasis Soreness, Crusted, scaly HPE: itching, plaques over glans Hyperkeratosis, change in penis parakeratosis, appearance. (circumcised) red regional glazed patches acanthosis, (uncircumcised). elongated rete ridges, Munro’s micro abscesses, spongiform pustule of Kogoj. 6) Lichen planus (LP) Itching, Well demarcated, LP lesions over Topical steroids, Inflammatory soreness and purple colored, other sites. topical /oral disorder of dyspareunia. plaques over HPE: Cyclosporine, unknown etiology glans, prepuce and Hyperkeratosis, topical Calcineurin with shaft of penis. irregular inhibitors. immunological Erosions on acanthosis, focal Circumcision for basis with lesions mucosal surface wedge shaped persons with LP at in skin, genitals hypergranulosis, glans. and mucous liquefactive membrane. degeneration of basal cell layer. Band like lymphocytic infiltrate in dermo epidermal Junction. 7) Seberrhoeic Itching Erythema Fine scaling at Antifungal cream Due to dermatitis classical sites with mild – Pityriosporum like nasolabial moderate steroids, ovale. fold, scalp and oral steroids. ears. 8) Eczema Dry, red glazed Slightly scaling, itching.

9) Porokeratosis Centrifugally Cryotherapy, CO2 spreading patches laser, topical -5

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surrounded by fluro uracil, ridge like border imiquimod. with central atrophy. 10) Bullous disorders Erosions Topical and oral Pemphigus vulgaris resembling steroids. Bullous pemphigoid balanitis. Immunosuppression. Linear Ig A disease Cicatricial pemphigoid Pemphigus vegetans 11) Dermatitis artefacta Clobetasone butyrate 0.05% ( Moderately potent steroid cream). 12) Crohn’s disease and Ulcerative colitis 13) Behcet’s disease Chronic relapsing disease, unknown etiology, oral ulcers, arthritis, genital ulcers and eye lesions. Premalignant Conditions Well defined red HPE: 5% 5 FU cream, It is a a) Erythroplasia of shiny velvety Confirmatory Cryotherapy, premalignant queyrat plaques, patches and mandatory Laser, condition with sharp SCC in long described by margins and Excision ( Queyrat in term. Recommended) granular surface. 1911[27]. If indurated / Circumcision. Common in keratotic plaques uncircumcised Rule out men. malignancy. Aetiology: exactly unknown, smegma, poor genital hygiene, trauma, friction, heat, maceration. b) Pseudo Phimosis Thick, dry, white, HPE: Massive Topical 5% 5FU Acquired disease epitheliomatous yellow mica like hyperkeratosis, cream for 6 weeks. in elderly. micaceous and keratotic sheets and acanthosis, Local surgical Predisposing balanitis keratotic masses pseudo excision. Factor: Smoking adherent to glans epitheliomatous Others: and tobacco penis and coronal hyperplasia, Cryotherapy, chewing . sulcus. sparse cellular Premalignant. infiltrate. X ray irradiation, Shave biopsy, Locally invasive Electrocautery, low grade malignant lesion. CO laser. 2 Associated with verrucous carcinoma of penis.

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c) Bowen’s disease Well defined, red, Biopsy. Simple excision, Etiology unknown. discrete, scaly, 5% 5FU cream, Carcinoma in situ, erythematous Laser, 20% will go for plaque present Topical imiquimod. Squamous Cell over penile shaft / Carcinoma. prepuce. Follow up is important. d) Bowenoid papulosis Papules and Local excision and Due to HPV plaques over Laser. infection. glans penis. Spontaneous Carcinoma in situ. resolution. Malignant Conditions Ulcer over a) Squamous cell glans penis Carcinoma and

b) Basal Cell carcinoma Prepuce[28]. c) Melanoma d) Metastasis e) Leukemia, CLL B.Miscellaneous Pinpoint Vigorous sexual 1) Trauma abrasions. activity, sharp Erythema over pubic hair piercing glans penis. of frenulum, zip fastening , teeth bites, beads, pin prick, self mutilation. 2) Contact Dermatitis ( Erythema, edema Patch test. Avoidance of Etiology: Balsum irritant and allergic) of penis. precipitating factors. of peru, kathon i) Allergic Washing with soaps. CG, perfume, Emollients. rubber, spermicidal agents, smegma, condoms. ii) Irritant Erythematous, Biopsy: Non Topical steroids like Etiology: Topical Oozing, crusted specific, 1% hydrocortisone antifungals, soaps, lesions ( Early) inflammation. cream once or twice antiseptics, lichenoid plaques daily. podophyllotoxin. ( Late). Systemic steroids. 3) Drug reactions Itching, Edema of Rechallenge Spontaneous fading Etiology: Fixed drug eruptions burning prepuce. with the drug to without treatment. Tetracyclines, (FDE) sensation. Predilection for confirm the Residual NSAIDS, SJS/ TEN glans penis. diagnosis. hyperpigmentation. Sulfonamides, Well demarcated, Hydropic Rarely topical 1% Dapsone, bullous, degeneration of hydrocortisone Warfarin, edematous and basal cell layer. cream bd until Griseofulvin, ulcerated lesions. Spongiosis. resolution. Phenophthalein, Erythromycin, Target lesions. Systemic steroids Phenacetin, Erosions. for severe lesions. Metronidazole, Anti convulsants, Hypnotics.

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Follow up not required. Avoid precipitating agents. 4) Phimosis Common in young boys 5) Granulomatous Multiple painless After intra vesical balanoposthitis firm papules BCG instillation (glans penis), therapy[29] for edema of prepuce. Carcinoma of bladder. Titanium. Low grade fever. 6) Nonspecific Chronic Failure to Circumcision is Etiology : balanoposthitis symptomatic respond to curative. Unknown presentation. conventional associated with topical atopy. treatment. Biopsy : Non specific histology. 7) Balanoposthitis Itching. Redness, swelling. Etiology: Bacterial Simplex Burning infections, sensation mechanical while irritants, urinating. chemicals. 8) Mild balanoposthitis It is balanoposthitis of a localised, inflammatory, nature with few non specific symptoms and a tendency to become chronic or recurrent[30].

Candidal balanoposthitis candidal balanoposthitis may be a cutaneous marker of Accounts for 35% of cases of balanoposthitis. Mostly diabetes mellitus. Various studies have shown that it is acquired sexually. It is commonly seen in patients 55% of known diabetic patients have candidal with diabetes mellitus. Diabetes mellitus interferes balanoposthitis. The presentation of candidal with both cellular and humoral immunity and suppress balanoposthitis varies according to the age group and the host defence against infections. Acquired the sexual activity of the patient. In young, sexually balanoposthitis can be the first sign of diabetes active males, the symptoms include itching, burning mellitus in uncircumcised males. In healthy males, sensation, increased fissuring of the inner part of prepuce and subpreputial discharge. In elderly males,

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who are sexually inactive, itching and moist erythema Physical examination reveals phimosis, erythematous of inner aspect of prepuce and glans penis is more appearance of glans penis, foul smelling subpreputial prominent, whereas fissuring is not that much marked discharge and partially or completely non retractable [31]. Though Indian muslim males are usually prepuce. circumcised, and Hindu males are usually Ammonia dermatitis, foreskin fiddling are the common uncircumcised, there is no scientific data available that differential diagnosis. Though this condition is usually demonstrates the advantage of circumcision in self limiting in nature, penicillins or cephalosporins prevalence of candidal balanoposthitis. Candidal may be useful in some children. In children with posthitis can occur without balanitis. The smegma and recurrent balanitis and causing severe distress the enzymes in prostatic secretion normally control circumcision is advised. Above all, investigation for and eliminate candidal growth. An acute fulminating diabetes mellitus is important, because balanoposthitis oedematous type of balanoposthits may occur with is commonly seen in children with type I diabetes ulceration of penis and a swollen fissured prepuce in mellitus. undiagnosed diabetics. The appearance of prepuce may Smegma and Balanoposthitis be called “volcano like” [32]. Diabetics with balanoposthitis presenting as acquired phimosis was Smegma is the result of desquamated epithelial debris first reported in 1971 [33]. It is seen in one third of collected in the sub preputial space & not formed due to glandular secretions [37]. It contains squalene, beta men with acquired phimosis and it is found that 26% of patients with acquired phimosis had history of type cholesterol, long fatty acids, which produces calcium soaps (Calcium phosphate and Magnesium phosphate). II DM [34]. Clinicians and urologists thus should check the fasting blood sugar of patients with volcano In chronic inflammation this leads to subpreputial like appearance of prepuce. smegma stones formation. Smegma stones are seen in uncircumcised men. Such The pathogenesis for fissuring in candidal balanopostitis is due to the following factors [35]. stones are formed due to poor genital hygiene, lack of retracting and washing the prepuce, accumulation of 1) In uncontrolled diabetics with poor glycemic smegma beneath the foreskin [38]. Patients complain control, there is accumulation of advanced glycation of penile irritation, discharge, pain during and after end products (AGE) in foreskin which results in coitus. Signs include inflammation, partially impaired production of collagen and extra cellular retractable prepuce and purulent SPD. matrix, which further causes decreased hydroxy proline content of collagen and alteration of skin Circumcision and Balanoposthitis : elasticity. Balanitis is uncommon in circumcised men. Balanitis 2) Impairment of sebaceous gland function leads to patients usually have increased risk of carcinoma of loss of skin surface lipids which leads to loss of penis. Circumcision thus helps in preventing elasticity and hydration. carcinoma of penis. Good genital hygiene and safe sex 3) Decreased hydration in stratum corneum. will definitely help to prevent balanoposthitis. The aim 4) During urination and sexual intercourse, the of treating balanoposthitis is to relieve the symptoms, retraction of foreskin produces biomechanical stress to decrease the complications and to restore sexual which causes vertical preputial fissures which leads to function. Treating the associated sexually transmitted fibrosis and subsequent phimosis. diseases and preventing the route of entry of HIV infection is also important. Balanoposthitis in Children: Balanitis in children affects 4% of boys [36]. It Algorithm I is useful for management of balanitis / balanoposthitis (European guidelines) [39] commonly affects preschool children (2-5 years) and it is associated with nonretractable prepuce. It is uncommon in infants and among boys in napkins. Complications: The exact aetiology is not known. It is postulated that Phimosis / it may be due to poor personal hygiene. Organisms like Meatal stenosis / stricture group A haemolytic streptococci (commonest), E.coli, Recurrence, relapse and reinfection Pseudomonas, Klebsiella, Serratia are implicated in Scarring, Depigmentation and hyperpigmentation causing this condition. Autoinoculation from other sites is usually the mode of infection. Preputial adhesion and perforation Symptoms include redness, swelling, ulcer over glans Gangrene penis, itching, pain, subpreputial discharge (SPD), Lymphangitis and lymphedema dysuria, bleeding, low grade fever and weakness. Carcinoma of penis

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Management of non-specific balanitis [40] (Algorithm References

II) 1. P.M. Abdul Gaffoor, P.A. Nabil. Balanitis and Balanoposthitis.. The Gulf Journal of Conclusion Dermatology.Volume 7, No 2, October 2000. Balanoposthitis is thus a treatable condition in 2. Birley HD, Walker MM, Luzzi GA, Bell R, Taylor most of the patients. Persistent recurrent balanposthitis Robinson D, Byrne M, et al. Clinical features and needs extensive search for the cause and circumcision management of recurrent balanitis; association with may be a best option in some of the cases. Since atopy and genital washing. Genitourin Med 1993; 69: prepuce is an immunologically important tissue as well 400-3. as an erogenous tissue it should be removed only when 3. P.N. Arora, S.Arora. Balanoposthitis. A Textbook of mandatory in certain conditions like BXO. Good Indian Association for the study of Sexually genital hygiene and safe sex will definitely help to Transmitted Diseas and AIDS 2nd edition. Pg: 446. prevent balanoposthitis. The aim of treating 4. Lisboa C, Ferreire A, Resenda C, Rodrigues AG balanoposthitis is to relieve the symptoms, to decrease .Infectious balanoposthitis; Management, Clinical and complications and to restore sexual function. Treating laboratory features Int. J Dermatol. 2009 Feb; 48 (2): associated sexually transmitted diseases and 121-4. preventing the entry of HIV infection is also important. 5. English JC III, Laws AR, Keough GC, et al. Prevention and precautions for balanoposthitis : Dermatoses of the glans penis and prepuce. J AM The following instructions and general advice will help Acad Dermatol 1997;37: 1-24. the patients to prevent recurrence of balanoposthitis. 6. Michael Waugh, Sunil dogra. Balanitis and General advice: Balanoposthitis. Textbook of Sexually Transmited nd 1) Avoid frequent washing of genitalia with soaps. Infections. 2 edition p. 696. 2) Maintaining the genital hygiene by using weak 7. C.J. Cold, JR. Taylor. The Prepuce. British Journal salt solution or potassium permanganate soaks of volume 83, Supp. 1: Pages 34-44, January (1:8000) or soap free wash. 1996. 3) Using lukewarm water to clean penis and prepuce. 8. Saunders DN, Dinarella CA, Morhernn VB, 4) Drying the foreskin of the penis after washing and Langerhans cell production of Interleukin. 1. J. Invest. before putting on undergarments. Dermatol 1984; 82: 605-7. 5) During washing and bathing the foreskin should 9. Kupper TS. Interleukin 1 and other human be pulled back to expose the glans fully. keratinocyte cytokines; Molecular and functional characterisation. Adv. Dermotol 1988; 3: 293-306. 6) During urination pulling the foreskin back so that urine does not collect under the prepuce. 10. M.A. Waugh, E.G.V Evans, K.C.Nayyar, R.Fong Clotrimazole (Canesten) in the treatment of candidal 7) After urination dry the penis and prepuce should balanitis in men. British Journal of Venereal Diseases, be replaced. 1978, 54, 184-186. 8) Washing and drying penis after having sex. 11. Engman MF.A Peculiar fungus infection of the Specific advice: skin. Arch Dermatol. Syphilol 1920; 1:730. 1) Safe sex practices. 12. Abennader S, Casin I, Janier M, Zavaro A, 2) Appropriate hygiene. Vendecil MO, Traore F, et al. Balanitis and Infectious 3) Explain the about the condition and its long term agents. A Prospective study of 100 Patients. complications. Ann.Dermatol.Venereol 1995; 122: 580-584. 4) Advice regarding the effect of condoms if creams 13. Horner, Patrick J, Taylor-Robinson, David. The are applied [41]. Association of Mycoplasma genitalium with 5) Frequent changing of diapers in children. Balanoposthitis in men with non- Gonococcal urethritis. Sexually Transmitted Infection 87, 1 (2010) 6) Examination and treatment of sexual partners 38. wherever necessary. 14. GR Kinghorn, BM Jones, FH Chowdhury, I Geary, Balanoposthitis associated with Gardnerella vaginalis infection in men. Br J. Vener Dis 1982; 58:127-9.

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15. Cree GE, Willis AT, Philips KD, Brazier JS. Bacillus-Calmette-Guerin instillation therapy. Int J. Anaerobic Balanoposthitis. Br Med J 1982 ; 284: 859- Urol 2006 Oct ; 13 (10) : 1361-3. 60. 30. C. Veller Fernasa, A. Calabro, A Miglietto M. 16. Chowdhury DS, Chaudhury M. A case report of Tarantello, C. Biasinotto, A. Peserico. Mild gangrenous balanitis in progressive reaction in leprosy. Balanoposthitis. Genito Urin Med 1994; 70: 345-346.. Lepr Rev 1966; 37: 225-6. 31. Shyam B Verma, UWC Wolina, Looking through 17. Sarah Edwards. Balanitis and Balanoposthitis a the cracks of diabetic candidal balanoposthitis!. review. Genitourin. Med 1996; 72: 155-159. International Journal of General medicine. 2011; 4: 18. AN Masferi, GR Kinghorn, BI Duerden. 511-3. Anaerobes in Genitourinary infection in men. Br. J 32. Chih- Chun Ke, Chien Hua Chen, Jen-Jih Chon, vener Dis 1983 Aug 59(4): 255-9. Chung–Cheng Wong, Balanoposthitis with a volcano 19. J.F. Peutherer, Isabel W. Smith, D.H.H Robertson. appearance may the first clinical presentation of Necrotising balanitis due to generalised primary undiagnosed diabetes mellitus. Incont Pelvic Floor infection with Herpes simplex virus type 2. British Dysfunct . 2011; 5 (4) : 120-21. Journal of Venereal Diseases. 1979, 55, 48-51. 33. Skoglund RW ; Diabetes presenting with Phimosis. 20. Cook K.A., Rodrigue RB, Amoebic balanitis, Med. Lancet 1971; 2: 1431. J . Austr. 1964.1: 114-6. 34. Bromage SJ, Cromp A, Pearce I, Phimosis as a 21. Michalowski R. Balanoposthitis in Trichomonas. A presenting feature of Diabetes .BJU Int 2008; 101: Proposed observation. Ann Dermatol Venereol 1981; 338-340. 108: 731-8. 35. Lisboa C, Santos A, Dias C, Azoerdo F, Pina-Vaz 22. Kanerva L, Kousa M, Niemik M, Larsus A, C, Rodrigue A. Candida balanitis: risk factors, J. Eur. Juvalcoski T, Lauharanta J. Ultrahistopathology of Acad Dermatol Venereol 2010. in press. . Br. J. Venereol Dis 1982; 58:188- 36. JM Escala, AMK Rickwood, Balanitis. British 95. Journal of Urology, Volume 63, Page 196-197. 23. Rickwood AM, Hemalatha V. Batrya G, Salz L, 37. Parkash S, Jeyakumar S, Subramanyan Phimosis in boys Br. J. Urol 1980; 52:147-50. K,Chaudhuri S. Human Subpreputial collection: its 24. Jorgeuson ET, Stevenson A. The treatment of nature and formation. J. Urolog 1973; 110: 211-2. phimosis in Boys with potent topical steroid 38. C Sonnex, PE Croucher, WG Dockerty, (Clobetasol propionate 0.05%) cream. Acta Derm Balanoposthitis associated with the presence of Venereol (Stock) 1993; 931: 55-6. subpreputial “ Smegma Stones”. Genito Urin Med. 25. P.V. Krishna Rao, Hari kishan Kumar Yadalla. 1997; 73: 567. Plasma cell balanitis (Zoon’s Balanitis): A 39. S.K. Edwards. European guidelines for the clinicopathological study of 8 cases. Our dermatol management of Balanoposthitis. International Journal online 2012; 3 (2): 109 -111. of STD & AIDS. 2001; 12 (Suppl.3): 68-72. 26. Peter CS, Thomson C, Fusidic acid cream in the 40. Edwards SK Handfield- Jones S, on behalf of treatment of plasma cell balanitis. J. Am. Acad. clinical effectiveness group, British Association for Dermatol. 1992; 27: 633-634. several health and HIV. 2008 UK National Guideline 27. Queyrat M. Erythroplasie du gland. Bull soc Fr on the Management of Balanoposthitis, available from Dermatol Syphiligr 1911; 22: 378-82. http : //www.bashh.org / guidelines. 28. Gatto – Weis C, Topolsky D, Sloane B, Hon JS, 41. Kingston Rajiah, Sajesh K. Veettil, Sureshkumar, Qu H, Fyfe BS, Ulcerative Balanoposthitis of the fore Elizabeth M. Mathew. Study on various types of skin as a manifestation of Chronic lymphocytic infections related to balanitis in circumcised or leukemia. Case report and review of the literature. uncircumcised male and its causes, symptoms and Urology 2000 Oct1; 56 (4) : 669. management. African Journal of Pharmacy and Pharmacology. January 2012; 15 vol. 6(2): 74-83. 29. Yusuke H, Yoshinori H, Kenichi M, Akio H, Granulomatous balanoposthitis after Intravesical

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Management of balanitis/ balanoposthitis (European Guidelines) (Algorithm I )

Balanitis / Balanoposthitis

Take history and examine

Prepuce retractable Prepuce not retractable

Ulceration + Erythema / SPD+, No Ulcer Prepuce scarred Prepuce swollen

Refer to Surgery Treat as genital ulcer No foul smelling Foul smell +

Treat as Genital Ulcer Metronidazole 400mg bd for 1week Antifungal +1% Hydrocortisone cream application bd for 1 week

Review after 1 week

If no improvement, 1) Reassess or 2) Erythromycin 500mg qid for 1 week or 3) Potent Better, Discharge and Follow up steroid cream and follow up

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Management of Non specific Balanitis [40] (Algorithm II )

Balanitis

Culture for pathogens

Pathogens identified, treat No pathogens identified appropriately

Improved No improvement, try empirical Metronidazole Good hygiene, Poor hygiene

emollients / avoid potential irritants Advice to improve genital hygiene

Improved Improved No Improvement

Hydrocortisone 1% cream bd for 1 week

No improvement and significant balanitis. Advice penile biopsy

Treat as per specific diagnosis in biopsy

Shows inflammatory dermatoses

Consider Circumcision

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