Pathogenesis / Pathophysiology

Balanoposthitis is a condition occurring in uncircumcised males where there is marked inflammation of the foreskin and the head of the penis, called the glans. [1]

In uncircumcised males, inflammation of the foreskin/prepuce (posthitis) and the glans penis (balanitis) is called balanoposthitis. Infections of varying or multiple organisms, trauma and/or contact dermatitides may cause this condition in men of all ages. The most common culprit is said to be Candida spp., though Gardnerella vaginalis, Bacteroides, Trichomonas spp., staphylococci, mycobacteria, Entamoeba histolytica, Borrelia vincentii, Treponema pallidum (syphilis), herpes simplex virus, Human Papilloma Virus (HPV), anaerobes and streptococci have also been implicated. Other causes include dermatoses (psoriasis, lichen planus, some forms of balanitis, drug eruptions, and SJS), trauma, poor hygiene, obesity, severe edema, and precancerous diseases (such as Bowen’s disease and Erythroplasia of Queyrat).

Risk factors for having balanoposthitis include poor hygiene and poorly mobile or tight foreskin (phimosis). In the latter, the secretions (smegma) may become infected and cause inflammation. Other risk factors include chronic irritation of the glans penis, diabetes mellitus, use of systemic antibiotics and immunosuppression.

Causes

Balanoposthitis is commonly caused by foreskin unretractability and poor personal hygiene leading to bacterial or fungal colonization of the area. [2] A study revealed that the cause in 67% of patients is a combination of infectious, contact dermatitides and mechanical factors. [1] Some medical conditions like diabetes mellitus are thought to increase susceptibility of getting balanoposthitis. Other contributory factors include use of harsh soaps, improper rinsing off the soap during washing and infection of Staphylococcus aureus and Candida albicans. [2]

Epidemiology

Most patients are children 0–5 years old and sexually active adult males. Morbidity is limited and mortality is only noted on immunocompromised patients. [2]

Balanoposthitis is more frequent in men than boys and is said to account for 11% of genitourinary clinic consults.

Signs and Symptoms

The following may be noted [2]:

• Red and moist unelevated lesion on the glans and foreskin
• Redness of the penis with rashes
• Painful penis and prepuce
• Presence of discharge beneath the prepuce
• Tightening of the foreskin or phimosis
• Discharge with unpleasant odour
• Ulcerations or skin erosions
• Lymph node enlargement on the groin
• Fatigue and anxiety
• Pain at the lower back

An erythematous (red) and moist macular (flat) lesion in the glans penis and the prepuce will usually be seen on physical examination. The affected area/s will be sore and irritated, and purulent or foul-smelling subpreputial discharge may be present early in the disease, after which shallow ulcers, phimosis and lymphadenopathy may ensue. The individual may complain of pain with urination (dysuria), coital pain (dyspareunia) or impotence. There may be rashes, scaling, fissuring, crusting or discoloration on the affected areas. In more severe cases, ulcerations and erosions may be noted. Other findings would usually depend on the causative organism.

Organisms, Signs/Symptoms, Diagnosis, and Treatment

Diagnosis

History taking and physical exam are performed.

Laboratory exams are done to identify causative agent. To identify Candida (a type of fungi) invasion, potassium hydroxide (KOH) preparation or culture is made. In some cases, serology test and biopsy are indicated. [1]

Treatment

Topical and systemic antibiotics, antifungals or steroid creams are helpful in the management of the lesions.

It is important that proper hygiene be pressed upon the individual. A warm bath with salt could help improve the symptoms. Soaps and other irritants should be avoided.

In chronic or recurrent cases, circumcision may be recommended.

Biopsy may be necessary in non-responsive cases or uncertain diagnoses.

Complications

Morbidity from balanoposthitis is rare. Recurrent or long-standing balanoposthitis may increase the risk of phimosis, paraphimosis and cancer. The presence of inflammation during intercourse may also increase the risk of acquiring sexually transmitted infections and HIV infection.

Mortality is usually brought about by underlying diseases/conditions. Cancer should be suspected in cases where there is failure to respond to treatment.

Prognosis

With good medication compliance, balanoposthitis often resolves without complications. If not, further examination is warranted like targeting the correct causative agent. Malignancy might also be suspected in cases of treatment failure. For immunocompromised patients, treatment should include managing the systemic disease. [1]

Prevention

Avoidance of risk factors is the key to prevention. Proper hygiene is important to avoid recurrence of balanoposthitis. Some physicians believe that circumcision could help prevent chronic balanoposthitis in some cases.

References

1. http://emedicine.medscape.com/article/1124734-overview#a0104
2. http://ehealthwall.com/balanoposthitis-treatment-pictures-symptoms-causes-diagnosis/
3. http://bestpractice.bmj.com/best-practice/monograph/401/treatment/step-by-step.html
4. Edwards S. Balanitis and balanoposthitis: a review. Genitourin Med 1996;72(3):155-159. Retrieved from http://www.cirp.org/library/disease/balanitis/edwards1/ on March 27, 2011.
5. National Guideline on the Management of Balanoposthitis, Clinical Effectiveness Group British Association for Sexual Health and HIV (2008). Retrieved from http://www.tripdatabase.com/doc/829810-Balanoposthitis--Overview- on March 27, 2011.
6. Osipov VO. Balanoposthitis. eMedicine. Retrieved from http://emedicine.medscape.com/article/1124734-overview on March 27, 2011.
7. Balanitis, Posthitis, and Balanoposthitis. Merck Manuals Medical Online Library. Retrieved from http://www.merckmanuals.com/professional/sec17/ch239/ch239b.html on March 27, 2011