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Review article
ISSN (o):2321–7251
Department of STD, Chengalpattu Medical College, Chengalpattu, Tamil Nadu, India.1- Professor & HOD, 2- Assistant Professor,
3&4 – Junior Residents.
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.
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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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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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.
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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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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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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].
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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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Granulomatous balanoposthitis after Intravesical
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Balanitis / Balanoposthitis
Review after 1
week
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Balanitis
Improved Improved
No Improvement
Consider Circumcision
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