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Review article
ISSN (o):2321–7251

Balanitis and Balanoposthitis - Review article


S. Arunkumar1, 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: arunssshc@gmail.com

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
Arunkumar et al–
the STD Balanitis
clinic, whichand
is Balanoposthitis
around 11% [2]. Candidal www.ijrhs.com
The preputial sac provides lubrication 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

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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) 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
nd
B. Bacterial (2 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

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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). Increased carriage
iii) Staph. aureus
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 Biopsy ( 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 tacrolimus, middle aged and
Irritation, plaques on glans effacement of Pimecrolimus. elderly
pain, and prepuce with rete ridges. uncircumcised
pinpoint purpuric Topical fusidic
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.
CO2 laser.
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 Squamous Cell
Topical imiquimod.
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 injury,
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
men with acquired phimosis and it is found that 26% to glandular secretions [37]. It contains squalene, beta
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.
The pathogenesis for fissuring in candidal Smegma stones are seen in uncircumcised men. Such
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 /
commonly affects preschool children (2-5 years) and it balanoposthitis (European guidelines) [39]
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 / Paraphimosis
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


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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

Treat as genital ulcer Refer to Surgery


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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