Sandbox:Balanitis
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Balanitis Microchapters |
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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.
Classification
There is no established classification system for Balantis. Based on the etiologies, Balanitis can be classified into:[1]
Pathophysiology
Pathophysiology of Infectious balanitis varies from pathogen to pathogen:[2][3][4][5][6][7][8]
| Pathogen | Route of transmission | Risk factors | Virulence factors |
|---|---|---|---|
| Candidal Balanitis |
|
| |
| Anaerobic Infection |
. |
|
Anaerobic gram-negative rods produce various toxins, proteases, and elastase |
| Aerobic |
|
|
Adherence to epithelial cells, biofilm production, surface hydrophobicity, phospholipase C and protease activity |
| Trichomonas vaginalis | Sexually transmitted |
|
Adherence, contact-independent factors, hemolysis and acquisition of host macromolecules have been shown to play a role in the pathogenesis of this infection |
| Treponema | Transmitted via direct contact with the infected lesion (sexual contact) | Risk factors include:[9][10][11][12][13][14][15]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 |
|
|
| 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[16][17], acqusition of new partner[16] , having non monogamous sex partner[18][19], starting sexual activity in young age[18], vaginal delivery and multiple deliveries[20], age over 40 for women[21], history of Chlamydia infection[22], and long term OCP use[23] |
Linked to epithelial differentiation and maturation of host keratinocytes, with transcription of specific gene products at every level. |
Causes
Causes of balanitis are:
| 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 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Causes of Infectious balanitis include:[24][25][26][27]
| Balanitis | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Fungal | Virus | Parasite/Protozoal | Bacteria | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Candida (albicans, krusei) Dermatophytosis Pityriasis versicolor Histoplasma capsulatum Blastomyces dermatitidis Cryptococcus neoformans | Herpes simplex virus Varicella zoster virus (VZV) Human papilloma virus (HPV) | Protozoal Entamoeba histolytica Trichomonas vaginalis Leishmania species Parastic Sarcoptes scabiei var hominis Pediculosis Ankylostoma species | Gram negative bacteria E.coli, Pseudomonas, Haemophilus parainfluenzae, Klebsiella, Neisseria gonorrhoea, Haemophilus ducreyi, Mycoplasma genitalium, Chlamydia, Ureaplasma, Gardnerella vaginalis, Citrobacter, Enterobacter | Spirochaetes Treponema pallidum, Non specific spirochaetal infection | Gram positive organism Haemolytic Streptococci(Group B Streptococci), Staphylococci epidermidis/aureus | Acid fast bacilli Mycobacterium tuberculosis, Leprosy Anaerobes (Bacteroides) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Differentiating diagnosis
| 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.[28]
- Candida is the most common cause being responsible for 30-35% cases with infectious etiology.[29]
Risk Factors
Pathophysiology of Infectious balanitis varies from pathogen to pathogen:[2][3][30][5][6][31][32]
| Pathogen | Risk factors |
|---|---|
| Candidal Balanitis |
|
| Anaerobic Infection |
|
| Aerobic |
|
| Trichomonas vaginalis |
|
| Treponema | Risk factors include:[9][10][11][12][13][15]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 |
| Herpes simplex |
|
| Human papilloma virus | Risk factors responsible for sexual transmission of HPV include:
Number of sex partners[16][17], acqusition of new partner[16] , having non monogamous sex partner[18][19], starting sexual activity in young age[18], vaginal delivery and multiple deliveries[20], age over 40 for women[21], history of Chlamydia infection[22], and long term OCP use[23] |
Screening
There is no established clinical guidelines for screening patients for balanitis.
Natural History, Complications and Prognosis
Natural history
If left untreated, Infectious balanitis may result in complications, which include pain, phimosis, and urinary retention.[26]
Complications
Complication of Infectious balanitis include:[1]
- Phimosis
- Paraphimosis
- Painful erection
- Reduced urinary flow
- Urinary retention
Prognosis
Prognosis is usually good with treatment.
Natural history
Bowenoid papulosis
If left untreated, papules may increase, or decrease, or disappear with time, or progress into squamous cell carcinoma(Studies have reported risk of progression of bowenoid papulosis to squamous cell carcinoma at 2.6%).[33]
Erythroplasia of Queyrat
If left untreated, Erythroplasia of Queyrat may progress into invasive Squamous cell carcinoma, with an incidence ranging from 10% to 33%.[33]
Bowen's Disease
If left untreated, Bowen's disease may progress into invasive Squamous cell carcinoma(Incidence of Bowen's disease to develop into invasive squamous cell carcinoma is 3% to 5% for cutaneous and 10% for genital lesions). The malignant potential of Bowen's disease is increased when its existence is compounded by concomitant disease such as HPV infection, Lichen sclerosis or Lichen planus, or in patients with poor genital hygiene and smokers.[33]
Complications
Complication of penile carcinoma in situ include:[33]
- Pain
- Transformation into invasive squamous cell carcinoma
Prognosis
The prognosis is usually good with treatment.
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
References
- ↑ 1.0 1.1 Edwards SK, Bunker CB, Ziller F, van der Meijden WI (2014). "2013 European guideline for the management of balanoposthitis". Int J STD AIDS. 25 (9): 615–26. doi:10.1177/0956462414533099. PMID 24828553.
- ↑ 2.0 2.1 Taylor PK, Rodin P (1975). "Herpes genitalis and circumcision". Br J Vener Dis. 51 (4): 274–7. PMC 1046564. PMID 1156848.
- ↑ 3.0 3.1 Cree GE, Willis AT, Phillips KD, Brazier JS (1982). "Anaerobic balanoposthitis". Br Med J (Clin Res Ed). 284 (6319): 859–60. PMC 1496281. PMID 6121604.
- ↑ GENITOURINARY MEDICINE, Volume 72, Number 3: Pages 155-9,
- ↑ 5.0 5.1 Lisboa C, Santos A, Dias C, Azevedo F, Pina-Vaz C, Rodrigues A (2010). "Candida balanitis: risk factors". J Eur Acad Dermatol Venereol. 24 (7): 820–6. doi:10.1111/j.1468-3083.2009.03533.x. PMID 20002652.
- ↑ 6.0 6.1 Edwards SK, Bunker CB, Ziller F, van der Meijden WI (2014). "2013 European guideline for the management of balanoposthitis". Int J STD AIDS. 25 (9): 615–26. doi:10.1177/0956462414533099. PMID 24828553.
- ↑ Hernandez BY, Wilkens LR, Zhu X, Thompson P, McDuffie K, Shvetsov YB; et al. (2008). "Transmission of human papillomavirus in heterosexual couples". Emerg Infect Dis. 14 (6): 888–94. doi:10.3201/eid1406.070616. PMC 2600292. PMID 18507898.
- ↑ Sobel JD (1985). "Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis". Am. J. Obstet. Gynecol. 152 (7 Pt 2): 924–35. PMID 3895958.
- ↑ 9.0 9.1 Rolfs RT, Goldberg M, Sharrar RG (1990). "Risk factors for syphilis: cocaine use and prostitution". Am J Public Health. 80 (7): 853–7. PMC 1404975. PMID 2356911.
- ↑ 10.0 10.1 Zhou H, Chen XS, Hong FC, Pan P, Yang F, Cai YM; et al. (2007). "Risk factors for syphilis infection among pregnant women: results of a case-control study in Shenzhen, China". Sex Transm Infect. 83 (6): 476–80. doi:10.1136/sti.2007.026187. PMC 2598725. PMID 17675391.
- ↑ 11.0 11.1 Hook EW, Peeling RW (2004). "Syphilis control--a continuing challenge". N Engl J Med. 351 (2): 122–4. doi:10.1056/NEJMp048126. PMID 15247352.
- ↑ 12.0 12.1 Buchacz K, Greenberg A, Onorato I, Janssen R (2005). "Syphilis epidemics and human immunodeficiency virus (HIV) incidence among men who have sex with men in the United States: implications for HIV prevention". Sex Transm Dis. 32 (10 Suppl): S73–9. PMID 16205297.
- ↑ 13.0 13.1 Solomon MM, Mayer KH (2015). "Evolution of the syphilis epidemic among men who have sex with men". Sex Health. 12 (2): 96–102. doi:10.1071/SH14173. PMC 4470884. PMID 25514173.
- ↑ Hakre S, Arteaga GB, Núñez AE, Arambu N, Aumakhan B, Liu M; et al. (2014). "Prevalence of HIV, syphilis, and other sexually transmitted infections among MSM from three cities in Panama". J Urban Health. 91 (4): 793–808. doi:10.1007/s11524-014-9885-4. PMC 4134449. PMID 24927712.
- ↑ 15.0 15.1 Newell, J., et al. "A population-based study of syphilis and sexually transmitted disease syndromes in north-western Tanzania. 2. Risk factors and health seeking behaviour." Genitourinary medicine 69.6 (1993): 421-426.
- ↑ 16.0 16.1 16.2 16.3 Bell MC, Schmidt-Grimminger D, Jacobsen C, Chauhan SC, Maher DM, Buchwald DS (2011). "Risk factors for HPV infection among American Indian and white women in the Northern Plains". Gynecol. Oncol. 121 (3): 532–6. doi:10.1016/j.ygyno.2011.02.032. PMC 4498572. PMID 21414655.
- ↑ 17.0 17.1 Tarkowski TA, Koumans EH, Sawyer M, Pierce A, Black CM, Papp JR, Markowitz L, Unger ER (2004). "Epidemiology of human papillomavirus infection and abnormal cytologic test results in an urban adolescent population". J. Infect. Dis. 189 (1): 46–50. doi:10.1086/380466. PMID 14702152.
- ↑ 18.0 18.1 18.2 18.3 Koutsky L (1997). "Epidemiology of genital human papillomavirus infection". Am. J. Med. 102 (5A): 3–8. PMID 9217656.
- ↑ 19.0 19.1 Winer RL, Lee SK, Hughes JP, Adam DE, Kiviat NB, Koutsky LA (2003). "Genital human papillomavirus infection: incidence and risk factors in a cohort of female university students". Am. J. Epidemiol. 157 (3): 218–26. PMID 12543621.
- ↑ 20.0 20.1 Tseng CJ, Liang CC, Soong YK, Pao CC (1998). "Perinatal transmission of human papillomavirus in infants: relationship between infection rate and mode of delivery". Obstet Gynecol. 91 (1): 92–6. PMID 9464728.
- ↑ 21.0 21.1 Ting J, Kruzikas DT, Smith JS (2010). "A global review of age-specific and overall prevalence of cervical lesions". Int. J. Gynecol. Cancer. 20 (7): 1244–9. PMID 21495248.
- ↑ 22.0 22.1 Kjaer SK, van den Brule AJ, Bock JE, Poll PA, Engholm G, Sherman ME, Walboomers JM, Meijer CJ (1997). "Determinants for genital human papillomavirus (HPV) infection in 1000 randomly chosen young Danish women with normal Pap smear: are there different risk profiles for oncogenic and nononcogenic HPV types?". Cancer Epidemiol. Biomarkers Prev. 6 (10): 799–805. PMID 9332762.
- ↑ 23.0 23.1 Ley C, Bauer HM, Reingold A, Schiffman MH, Chambers JC, Tashiro CJ, Manos MM (1991). "Determinants of genital human papillomavirus infection in young women". J. Natl. Cancer Inst. 83 (14): 997–1003. PMID 1649312.
- ↑ GENITOURINARY MEDICINE, Volume 72, Number 3: Pages 155-9, June 1996.
- ↑ International Journal of Research in Health Sciences. Jan–Mar 2014 Volume-2, Issue-1
- ↑ 26.0 26.1
- ↑ Pandya I, Shinojia M, Vadukul D, Marfatia YS (2014). "Approach to balanitis/balanoposthitis: Current guidelines". Indian J Sex Transm Dis. 35 (2): 155–7. doi:10.4103/0253-7184.142415. PMC 4553848. PMID 26396455.
- ↑ Edwards S (1996). "Balanitis and balanoposthitis: a review". Genitourin Med. 72 (3): 155–9. PMC 1195642. PMID 8707315.
- ↑ Dockerty WG, Sonnex C (1995). "Candidal balano-posthitis: a study of diagnostic methods". Genitourin Med. 71 (6): 407–9. PMC 1196117. PMID 8566986.
- ↑ GENITOURINARY MEDICINE, Volume 72, Number 3: Pages 155-9,
- ↑ Hernandez BY, Wilkens LR, Zhu X, Thompson P, McDuffie K, Shvetsov YB; et al. (2008). "Transmission of human papillomavirus in heterosexual couples". Emerg Infect Dis. 14 (6): 888–94. doi:10.3201/eid1406.070616. PMC 2600292. PMID 18507898.
- ↑ Sobel JD (1985). "Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis". Am. J. Obstet. Gynecol. 152 (7 Pt 2): 924–35. PMID 3895958.
- ↑ 33.0 33.1 33.2 33.3 Kutlubay Z, Engin B, Zara T, Tüzün Y (2013). "Anogenital malignancies and premalignancies: facts and controversies". Clin Dermatol. 31 (4): 362–73. doi:10.1016/j.clindermatol.2013.01.003. PMID 23806153.