Sandbox:Infectious Balanitis

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:Candida balanitis, Candidal balanitis, Infectious balanoposthitis

Overview

Balanitis is inflammation of glans penis, whenever balanitis involves foreskin and perpuce, it is termed as balanoposthitis. Studies have showed that Balanitis commonly occurs around 10% of the patient population visiting the STD clinc, with infectious etiology responsible for around 50% of the cases. Risk factors for balanitis include Diabetes, Immunocompromised, Age>40 yrs,tight foreskin, sub-optimal hygienic maintenance, Multiple sexual partners, and Uncircumcised penis. Orgnaism could be part of the normal flora or transmitted by sexually, or autoinoculation, or via direct contact. Patients may be asymptomatic or present with pruritic, or painful lesions in the genital region. Specific infectious balanitis etiology is diagnosed based on clinical presentation supported with laboratory findings. Infectious balanitis is usually treated with antimicrobials. Prognosis is usually good with treatment. Safe sex practices and maintaining proper penile hygiene are helpful in preventing Infective balanitis.

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 Infectious Balanitis.

Pathophysiology

Pathophysiology of Infectious balanitis varies from pathogen to pathogen:

Pathogen	Route of transmission	Risk factors	Virulence factors
Candidal Balanitis	Sexual transmitted Normal flora	Diabetes Immunocompromised 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 buccal epithelial cells of the vagina. Several virulence factors of Candida are implicated in Balanitis. These include proteolytic enzymes, toxins and phospholipase. Proteolytic enzymes destroy the proteins that normally impair fungal invasion
Anaerobic Infection	Sexually transmitted Extension from the perirectal area Orogenital sex-saliva as a lubricant during coitus .	Tight foreskin sub-optimal hygienic maintenance	Anaerobic gram-negative rods produce various toxins, proteases, elastase, and other virulence factors
Aerobic Infections	Sexually transmitted Autoinoculation from other sites	Uncircumcised penis Diabetes Immunocompromised	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	Virulence factors such as 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: 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 Direct contact with, or droplets from, infected secretions entering via skin or mucous membrane	Multiple sexual partners Low socio-economic status	Inhibition of MHC Class I, Impairing funtion of dentric cells
Human papilloma virus	Usually transmitted via the sexual route to the human host.	Risk factors responsible for sexual transmission of HPV include: Number of sex partners,Acqusition of new partner ,Having non monogamous sex partner, Starting sexual activity in young age,Vaginal delivery and multiple deliveries, Age over 40 for women, History of Chlamydia infection, Long term OCP use	linked to epithelial differentiation and maturation of host keratinocytes, with transcription of specific gene products at every level.[2][3]

Causes

Causes of Infectious balanitis include:

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)

Epidemiology and Demographics

Epidemiology

There are no comprehensive studies, studying the incidence and prevalence in general population. Studies have showed that Balanitis commonly occurs around 10% of the patient population visiting the STD clinc, with infectious etiology responsible for around 50% of the cases.

Candida being the most common cause responsible for 30-35% of cases.

Screening

There is no established screening guidelines for Infectious Balanitis

Natural History, Complications, and Prognosis

Natural history

If left untreated, Infection balanitis may result in complications.

Complications

Complication of Infectious balanitis include:

• Pain
• Erosions
• Fissures

• Phimosis
• Paraphimosis
• Painful erection
• Reduced urinary flow
• Urinary retention

Prognosis

Prognosis is good with treatment.

Diagnosis

History and symptoms

Patients may be asymptomatic or present with pruritic, or painful lesions in the genital region.

Clinical features of Infectious balanitis(adopted from the Indian journal of sexually transmitted diseases and AIDS)
Candidal Balanitis	Erythematous rash with soreness and/or itch, blotchy erythema with small papules which may be eroded, or dry dull red areas with a glazed appearance
Anaerobic Infection	Foul smelling sub-preputial inflammation and discharg: in severe cases associated with swelling and inflamed inguinal lymph nodes Preputial edema, superficial erosions: milder forms also occur
Aerobic Infections	Variable inflammatory changes including uniform erythema and edema
Trichomonas vaginalis	Superficial erosive balanitis which may lead to phimosis
Treponema paliidum	Multiple circinate lesions which erode to cause irregular ulcers have been described in the late primary or early secondary stage. A primary chancre may also be present
Herpes simplex	Grouped vesicles on erythematous base over glans, prepuce and shaft which rupture to form shallow erosins. In rare cases primary herpes can cause a necrotic balanitis, with necrotic areas on the glans accompained by vesicles elsewhere and associated with headache and malaise.
Human papilloma virus	Papilloma virus may be associated with patchy or chronic balanitis, which becomes acetowhite after the application of 5% acetic acid

Laboratory findings

Laboratory findings(adopted from the Indian journal of sexually transmitted diseases and AIDS)
Candidal Balanitis	Urinalysis for glucose Sub-preputial culture/swab for primary candidasis/candidal superinfection-to be done in all cases Investigation for HIV or other causes of immunosuppression
Anaerobic Infection	Gram stain may show fusiform/mixed bacterial picture Sub-preputial culture wet prep or NAAt(to exclude other causes) G. vaginalis is a facultative anaerobe which may be isolated Swab for HSV infection if ulcerated
Aerobic Infections	Sub-preputial culture Streptococci spp. and S. aureus have both been reported as causing balanitis
T. vaginalis	Wet preparation from the subpreputial sac demonstrates the organism Culture and NAAT can also be carried out
TP	Dark field microscopy, TP NAAT and DFA-TP will confirm the diagnosis. This should ideally be done every case. TPHA coupled with nontreponemal serological tests though of limited value, should be performed since they are useful for follow-up
Herpes simplex	Tissue scraping from base of erosion subjected to Tzanck smear IgG and IgM for HSV cell culture and PCR-preferred HSV tests for persons who seek medical treatment for gential ulcers or other mucocutaneous lesions
Human papilloma virus	Diagnosed clinically

Treatment

Treatment(adopted from the Indian journal of sexually transmitted diseases and AIDS)
	Preferred regimen	Alternative regimen
Candidal Balanitis	Clotimazole cream 1% Miconazole cream 2%	Fluconazole 150 mg stat orally Nystatin cream-if resistance suspected topical clotrimazole/miconazole with 1% hydrocortisone-if marked inflammation
Anaerobic Infection	Advice about genital hygiene metronidazole 400 mg twice daily for 1 week Milder cases- topical metronidazole	Coamoxiclav(amoxycillin/clavulanic acid) 375 mg 3 times daily for 1 week Clindamycin cream applied twice daily until resolved
Aerobic Infections	Usually topical Triple combination (clotrimazole 1%, beclometasone dipropionate 0.025%, gentamicinsilfate 0.3%) applied once daily Severe cases-systemic antibiotics Erythromycin 500 mg QDS for 1 week Co-amoxiclav(amoxycillin/clvulanic acid 375 mg 3 times daily for 1 week	Alternative regimens depend on the sensitivities of the organisms isolated
T. vaginalis	Metronidazole 2 g orally single dose Secidazole 2 g orally single dose	Metronidazole 400 mg orally twice a day for 7 days
TP	Single IM administration of 2.4 MU of benzathine penicillin Doxycycline 100 mg orally BID for 2 weeks or Tetracycline 500 mg orally QID for 2 weeks or Erythromycin 500 mg QID or Ceftriaxone 1 g IM/IV daily for 8-10 days
Herpes simplex	Acyclovir 400 mg orally 3 times a day for 7-10 days or Acyclovir 200 mg orally 5 times a day for 7-10 days or Famciclovir 250 mg orally 3 times a day for 7-10 days or Valacyclovir 1 g orally twice a day for 7-10 days
Human papilloma virus	Patients applied Podophyllotoxin(podofilox) 0.5% or gel-twice daily for three consecutive days, but no more than 4 weeks or Imiquimod 5% cream-applied at bedtime 3 times/week for a maximum of 16 weeks, and must be left in place for 6-10 h following application or Sinecatechins 15% ointment Provider-administered Podophyllin resin 20% in a compound tincture of benzoin-once a week for 6-8 week or Cryotherapy with liquid nitrogen ot cryoprobe. Repeat applications every 1-2 weeks or TCA/bichloroacetic acid-80-90% once per week for an average course of 6-10 weeks or Surgical removal either by tangential scissor excision, tangential shave excision, curettage, or electrosurgery.

Prevention

Primary Prevention

Primary prevention of Infectious balanitis include:

Safe sex practices.

Maintaining proper penile hygiene.

Secondary prevention

There ares no specific secondary preventive measures for Infective balanitis.