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:BXO, Penile lichen sclerosus

Pathophysiology

• Fusospirochetes were isolated more frequently in the patients who practiced orogenital sex or used saliva as a lubricant during coitus
• tight foreskin and sub-optimal hygiene.
• Presence of a tight foreskin and phimosis seems to be a prerequisite for this condition to develop. Hygienic practices were poor in most case reports and in both of our patients. Chakraborty and Data showed an association between low socioeconomic status and development of infectious balanoposthitis in general, and contamination with saliva and isolation of Fusarium spp. in particular [11]. Anaerobic Gram-negative rods produce various toxins, proteases, elastase, and other virulence factors [19,20]. Porphyromonas asaccharolytica, Prevotella intermedia, and P. melaninogenica have been shown to cleave lgA1. In addition, P. asaccharolytica and P. intermedia can cleave lgG [21]. The implication of these pathogenic properties and the interactions they may cause with the host remain to be studied. There are case reports of severe balanoposthitis in neutropenic patients caused by aerobic Gram-negative rods and Candida balanitis is associated with diabetes, but we could not find an association between anaerobic balanoposthitis and any systemic diseases [22,23]

Causes

Infectious causes of Balanitis
Bacterial	Anaerobic bacteria Gardnerella vaginalis `Bacteroides melaninogenicus unidentified Bacteroides Bacteroides fragilis Fusobacterium spp Aerobic bacteria Group B streptococci Group A haemolytic streptococci Staphyloccocus aureus Mycobacterium tuberculosis Mycobacterium leprae
Viral	Human papilloma virus Herpes simplex virus Human immunodeficiency virus
Fungal	Candida Pityriasis versicolor
Parasitic	Entamoeba histolytica Trichomonas

Candidal species [7]

●Anaerobic infection [8]

•Aerobic infection

•Neisseria gonorrhea

●Human papillomavirus (HPV) [9,10]

●Herpes simplex (HSV) [11]

●[12,13]

●Treponema pallidum (syphilis) [14,15]

●Trichomonal species [16]

●Streptococci (group A and B) [17-20]

•Borrelia vincenti (tropical ulcer, trench mouth)

•Borrelia burgdorferi (Lyme disease)

●Mycobacterium [Bacillus-Calmette-Guerin (BCG)] [21]

•Staphylococcus aureus

●Entamoeba histolytica [22]

●Human immunodeficiency virus (HIV) [23]

Diagnosis

Clinical features of Infectious balanitis
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 inflmmatory changes including uniform erythema and edema
T. vaginalis	Superficial erosive balanitis which may lead to phimosis
TP	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
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

Laboratory findings
	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 appiled 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 wees 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 electrourgery.