Sandbox:Balanitis

Balanitis Microchapters
Patient Information
Overview
Classification Infectious balanitis Non-infectious balanitits Zoon's balanitis Balanitis xerotica obliterans
Causes
Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vishal Devarkonda, M.B.B.S[2] Synonyms and keywords: Balanoposthitis

Overview

Balanitis is inflammation of glans penis. When inflammation involves the foreskin and prepuce, it is termed as balanoposthitis. Based on the etiology, balanitis can be mainly categorized into infectious, inflammatory dermatoses, and penile carcinoma in situ. Patients with balanitis may present with asymptomatic or symptomatic lesions with itch or pain in the genital region. Risk factors, pathogenesis, clinical presentation, diagnosis and management varies depending on etiology.

Historical Perspective

Balanitis is an ancient disease,The term Balanitis is derived from a Greek term balanos or acorn.

Causes

There is no established classification system for Balantis. Based on the etiologies, Balanitis can be classified into:

• Infectious
• Inflammatory dermatoses
• Penile carcinoma in situ

Balanitis

Infectious

Inflammatory dermatoses

Premalignant (penile carcinoma in situ)

Candida (albicans, krusei) Streptococci Anaerobes Staphylococci Trichomonas vaginalis Herpes simplex virus Human papillomavirus Mycoplasma genitalium

Lichen sclerosus Lichen planus Psoriasis Circinate balanitis Zoon's balanitis Eczema Allergic reactions

Bowen's disease Bowenoid papulosis Erythroplasia of Queyrat

Synopsis

Symptoms			Signs
	Malaise	Pruritus	Skin lesions	Regional lymphadenopathy	Erythema	Swelling
Candida balanitis	✖	✔	Erythematous rash with soreness and/or itch	✔	✔	✖
Trichomonas vaginalis	✖	✔	Superficial erosive balanitis	✖	✔	✖
Treponema pallidum	✖	✖	Multiple circinate lesions	✔	✖	✖
Herpes simplex	✔	✔	Grouped vesicles on erythematous base	✔	✔	✖
Human papilloma virus	✖	✔	Warts	✖	✖	✖
Lichen sclerosus	✖	✔	White patches on glans	✖	✖	✖
Lichen planus	✖	✔	Purplish lesions on the penis	✖	✖	✖
Psoriasis	✖	✔	Red scaly plaques	✖	✔	✖
Circinate	✔	✔	Greyish white areas on the glans	✖	✖	✖
Zoon's balanitis	✖	✔	Well-circumscribed orange-red glazed areas	✖	✖	✖
Eczema	✖	✔	Mild non-specific erythema to wide spread edema of penis.	✖	✔	✔
Fixed drug eruption	✖	✔	Well demarcated and erythematous lesions	✖	✔	✖
Bowen's disease	✖	✔	Multiple, small, well-demarcated papillomatous papules	✖	✖	✖
Bowenoid papulosis	✖	✔	Single or multiple, sharply demarcated associated with scaling and crusting	✖	✖	✖
Erythroplasia of Queyrat	✖	✔	Velvety patches and plaques of keratinization on penis.	✔	✖	✖

Epidemiology and Demographics

• There are no comprehensive studies studying the incidence and prevalence in general population. A recent study has shown that balanitis commonly occurs in around 10% of the patient population visiting the STD clinic, with infectious etiology responsible for around 50% of the cases.
• Candida is the most common cause being responsible for 30-35% cases with infectious etiology.

Risk Factors

Pathogen Route of transmission Risk factors Virulence factors Candidal Balanitis Sexual transmitted Opportunistic infection Diabetes Immunocompromised conditions Age>40 yrs All strains of C. albicans possess a yeast surface mannoprotein. This allows the various strains to adhere to both the exfoliated and epithelial cells. Other virulence factors inclu:de proteolytic enzymes, toxins and phospholipase. Proteolytic enzymes destroy the proteins that normally impair fungal invasion Anaerobic Infection Sexually transmitted Extension from peri-rectal area Oro-genital sex-(saliva as a lubricant during coitus) . Tight foreskin sub-optimal penile hygienic maintenance Anaerobic gram-negative rods produce various toxins, proteases, and elastase Aerobic Infections Sexually transmitted Autoinoculation from other sites Uncircumcised penis Diabetes Immunocompromise conditions Adherence to epithelial cells, biofilm production, surface hydrophobicity, phospholipase C and protease activity Trichomonas vaginalis Sexually transmitted Multiple sexual partners Unprotected sexual activity Co-existing venereal diseases Adherence, contact-independent factors, hemolysis and acquisition of host macromolecules have been shown to play a role in the pathogenesis of this infection Treponema pallidum Transmitted via direct contact with the infected lesion (sexual contact) Risk factors include:[8][9][10][11][12][13][14]Multiple sexual partners, prostitution, illicit drug use, unprotected sex men who have sex with men, residence in highly prevalent areas, HIV infection, presence of other STIs, previous history of STIs, intravenous drug use, health care professionals who are predisposed to occupational risk, and low socioeconomic status Treponema Pallidum uses fibronectin molecules to attach to the endothelial surface of the vessels in organs resulting in inflammation and obliteration of the small blood vessels causing vasculitis (endarteritis obliterans) Herpes simplex Often transmitted sexually or direct contact with droplet or infected secretions entering thorough skin or mucous membranes Multiple sexual partners Low socio-economic status Inhibition of MHC Class I Impairing function of dendritric cells Human papilloma virus Usually transmitted via sexual route to the human host Risk factors responsible for sexual transmission of HPV include: Number of sex partners[15][16], acqusition of new partner[15] , having non monogamous sex partner[17][18], starting sexual activity in young age[17], vaginal delivery and multiple deliveries[19], age over 40 for women[20], history of Chlamydia infection[21], and long term OCP use[22] Linked to epithelial differentiation and maturation of host keratinocytes, with transcription of specific gene products at every level.

Diagnosis

Diagnostic Criteria | History and Symptoms | Physical Examination | Laboratory Findings | X-ray|CT-Scan| MRI| Other Diagnostic Studies

Treatment

Medical Therapy | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies