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__NOTOC__
__NOTOC__
{{Balanitis}}
{{CMG}}; {{AE}}{{VD}}


{{CMG}}; {{AE}}{{AKI}}
{{SK}} 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.


{{SK}} Vulvovaginal candidiasis, Candidal Vulvovaginitis, Fungal Vaginitis, Yeast infection, Vulvovaginal Candidosis, candida vaginitis, Genital candidiasis
==[[Balanitis historical perspective|Historical Perspective]]==
==Overview==
Balanitis is an ancient disease,The term Balanitis is derived from a Greek term balanos or acorn.
Candida vulvovagintis is an infection of the [[vagina]] and the vestibulum, common in women in the reproductive age group. It is caused by various [[Candida]] species with [[Candida albicans]] most common pathogen followed by other species like [[C.glabarta]], C.krusei etc. Patients present with vulvar [[pruritus]], burning micturition and [[vaginal discharge]].The diagnosis of candidal infection requires a collaboration of clinical and diagnostic findings. Patients have typical white cottage chesee like discharge with [[hyphae]] and spores demonstrated on microscopy. Patients with uncomplicated infection respond well to topical and oral [[azole]] therapy. 5 to 8% of women develop recurrent vaginitis, which is defined as more than 4 episodes in a year. These patients require a longer duration of therapy with an induction and maintenance phase.
==Historical Perspective==
*In 1839, B. Lagenbeck from Germany described a yeast-like fungus for the first time in the human oral infection "thrush." and its ability to cause it.<ref name="pmid18509848">{{cite journal |vauthors=Barnett JA |title=A history of research on yeasts 12: medical yeasts part 1, Candida albicans |journal=Yeast |volume=25 |issue=6 |pages=385–417 |year=2008 |pmid=18509848 |doi=10.1002/yea.1595 |url=}}</ref>
*In 1923 the Candida albicans was described by Christine Marie Berkhout.  Over the years the classification of the genera and species has evolved. Obsolete names for this genus include ''Mycotorula'' and ''Torulopsis''. The species has also been known in the past as ''Monilia albicans'' and ''Oidium albicans''. The current classification is ''nomen conservandum'', which means the name is authorized for use by the [http://www.bgbm.org/iapt/nomenclature/code/SaintLouis/0000St.Luistitle.htm International Botanical Congress (IBC)].
*The full current taxonomic classification is available at ''[[Candida albicans]]''.
*The genus ''Candida'' includes about 150 different species. However, only a few of those are known to cause human infections. ''C. albicans'' is the most significant pathogenic (=disease-causing) species. Other ''Candida'' species causing diseases in humans include ''C. tropicalis'', ''C. glabrata'', ''C. krusei'', ''C. parapsilosis'', ''C. dubliniensis'', and ''C. lusitaniae''.
==Classification==
[[Candida]] [[vulvovaginitis]] can be classified based on the duration, as well as the strain of [[Candida]] causing the infection. 
===Duration===
[[Candida]] [[vulvovaginitis]] can be divided based on the duration and number of episodes of the infection into:<ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref><ref name="pmid9500475">{{cite journal |vauthors=Sobel JD, Faro S, Force RW, Foxman B, Ledger WJ, Nyirjesy PR, Reed BD, Summers PR |title=Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations |journal=Am. J. Obstet. Gynecol. |volume=178 |issue=2 |pages=203–11 |year=1998 |pmid=9500475 |doi= |url=}}</ref><ref name="pmid17560449">{{cite journal |vauthors=Sobel JD |title=Vulvovaginal candidosis |journal=Lancet |volume=369 |issue=9577 |pages=1961–71 |year=2007 |pmid=17560449 |doi=10.1016/S0140-6736(07)60917-9 |url=}}</ref><ref name="pmid7995997">{{cite journal |vauthors=Vazquez JA, Sobel JD, Demitriou R, Vaishampayan J, Lynch M, Zervos MJ |title=Karyotyping of Candida albicans isolates obtained longitudinally in women with recurrent vulvovaginal candidiasis |journal=J. Infect. Dis. |volume=170 |issue=6 |pages=1566–9 |year=1994 |pmid=7995997 |doi= |url=}}</ref>
*'''Acute, uncomplicated''': these are usually sporadic cases of [[Candida]] [[vulvovaginitis]], which respond to topical anti-fungal therapy and have a high cure rate.
*'''Acute, complicated''': symptoms are more severe than uncomplicated infections and typically require a combination of oral and topical [[anti-fungal]] treatment.
*'''Recurrent Vulvovaginal Candidiasis (RVVC)''': defined as 4 or more episodes of [[Candida]] [[vulvovaginitis]] per year, usually caused by the same strain of [[Candida]]. Treatment also requires a combination of oral and topical anti-fungal agents.
*According to 2015, Treatment of STD guidelines - Candida vulovaginitis can be classified into uncomplicated and complicated based on the following features:<ref name="pmid26602614">{{cite journal| author=Workowski KA| title=Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines. | journal=Clin Infect Dis | year= 2015 | volume= 61 Suppl 8 | issue=  | pages= S759-62 | pmid=26602614 | doi=10.1093/cid/civ771 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26602614  }}</ref>


{| class="wikitable"
== Classification ==
!Uncomplicated Candida Vulvovaginitis
There is no established classification system for Balantis. Based on the etiologies, Balanitis can be classified into:<ref name="pmid24828553">{{cite journal| author=Edwards SK, Bunker CB, Ziller F, van der Meijden WI| title=2013 European guideline for the management of balanoposthitis. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 9 | pages= 615-26 | pmid=24828553 | doi=10.1177/0956462414533099 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24828553 }}</ref>
!Complicated Candida Vulvovaginitis
* [[Infectious balanitis|Infectious]]
|-  
* [[Inflammatory dermatoses]]
|
* [[Penile carcinoma in situ]]
*Sporadic or infrequent VVC  
*Mild-to-moderate VVC 
*Likely to be  Candida albicans 
*Nonimmunocompromised women
|
*Recurrent VVC 
*Severe VVC 
*Nonalbicans candidiasis   
*Women  with  diabetes,  immunocompromised conditions (e.g.,  HIV  infection),
debilitation,  or  immunosuppressive therapy (e.g., corticosteroids
|}


==Pathophysiology==
==[[Balanitis pathophysiology|Pathophysiology]]==
===Vaginal Defensive mechanisms aganist Candida===
Pathophysiology of Infectious balanitis varies from pathogen to pathogen:<ref name="pmid1156848">{{cite journal| author=Taylor PK, Rodin P| title=Herpes genitalis and circumcision. | journal=Br J Vener Dis | year= 1975 | volume= 51 | issue= 4 | pages= 274-7 | pmid=1156848 | doi= | pmc=1046564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1156848  }}</ref><ref name="pmid6121604">{{cite journal| author=Cree GE, Willis AT, Phillips KD, Brazier JS| title=Anaerobic balanoposthitis. | journal=Br Med J (Clin Res Ed) | year= 1982 | volume= 284 | issue= 6319 | pages= 859-60 | pmid=6121604 | doi= | pmc=1496281 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6121604  }}</ref><ref>GENITOURINARY MEDICINE, Volume 72, Number 3: Pages 155-9,</ref><ref name="pmid20002652">{{cite journal| author=Lisboa C, Santos A, Dias C, Azevedo F, Pina-Vaz C, Rodrigues A| title=Candida balanitis: risk factors. | journal=J Eur Acad Dermatol Venereol | year= 2010 | volume= 24 | issue= 7 | pages= 820-6 | pmid=20002652 | doi=10.1111/j.1468-3083.2009.03533.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20002652  }}</ref><ref name="pmid2482855322">{{cite journal| author=Edwards SK, Bunker CB, Ziller F, van der Meijden WI| title=2013 European guideline for the management of balanoposthitis. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 9 | pages= 615-26 | pmid=24828553 | doi=10.1177/0956462414533099 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24828553  }}</ref><ref>{{cite journal| author=Hernandez BY, Wilkens LR, Zhu X, Thompson P, McDuffie K, Shvetsov YB et al.| title=Transmission of human papillomavirus in heterosexual couples. | journal=Emerg Infect Dis | year= 2008 | volume= 14 | issue= 6 | pages= 888-94 | pmid=18507898 | doi=10.3201/eid1406.070616 | pmc=2600292 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18507898  }}</ref><ref>Sobel JD (1985). "Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis". Am. J. Obstet. Gynecol. 152 (7 Pt 2): 924–35. <nowiki>PMID 3895958</nowiki>.</ref>
====Innate Mechanisms====
{| class="wikitable"
{| class="wikitable"
!Defense
!Pathogen
!Mechanism of protection
!Route of transmission
!Evidence of protection
!Risk factors
!Virulence factors
|-
|-
|Vaginal epithelial cells
|[[Candidiasis|Candidal Balanitis]]
|
|
*In Vitro inhibition of Candida growth<ref name="pmid16239581">{{cite journal| author=Barousse MM, Espinosa T, Dunlap K, Fidel PL| title=Vaginal epithelial cell anti-Candida albicans activity is associated with protection against symptomatic vaginal candidiasis. | journal=Infect Immun | year= 2005 | volume= 73 | issue= 11 | pages= 7765-7 | pmid=16239581 | doi=10.1128/IAI.73.11.7765-7767.2005 | pmc=1273905 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16239581  }}</ref>
*[[Sexual transmitted infection|Sexual transmitted]]
*[[Opportunistic infection]]
|
|
*Protective role in vivo unknown
*[[Diabetes]]
*Patients with recurrent candida infections have a decreased anti Candida activity
*[[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 enzyme|proteolytic enzymes]], [[toxins]] and [[phospholipase]]. [[Proteolytic enzyme|Proteolytic enzymes]] destroy the [[proteins]] that normally impair [[fungal]] invasion
|-
|-
|Mannose-binding lectin
|[[Anaerobic organism|Anaerobic Infection]]
|
|
*Epithelial-cell associated protein which binds to candida surface mannan.<ref name="pmid18715406" />
*[[Sexually transmitted disease|Sexually transmitted]]
*Inhibits Candida growth by activating complement<ref name="pmid15243942">{{cite journal| author=Ip WK, Lau YL| title=Role of mannose-binding lectin in the innate defense against Candida albicans: enhancement of complement activation, but lack of opsonic function, in phagocytosis by human dendritic cells. | journal=J Infect Dis | year= 2004 | volume= 190 | issue= 3 | pages= 632-40 | pmid=15243942 | doi=10.1086/422397 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15243942  }}</ref>
*Extension from peri-rectal area
*Activity is genetically determined
*Oro-genital [[Sex (activity)|sex]]-[[Saliva|(saliva]] as a lubricant during [[coitus]])
.
|
|
*Decreased expression can increase the susceptibility for vaginal colonization of candida and leading to vaginitis.
*Tight [[foreskin]]
*sub-optimal penile hygienic maintenance
|[[Anaerobic]] [[Gram-negative bacilli|gram-negative rods]] produce various [[toxins]], [[proteases]], and [[elastase]]
|-
|-
|Activated lactoferrin<ref name="pmid15603095">{{cite journal| author=Naidu AS, Chen J, Martinez C, Tulpinski J, Pal BK, Fowler RS| title=Activated lactoferrin's ability to inhibit Candida growth and block yeast adhesion to the vaginal epithelial monolayer. | journal=J Reprod Med | year= 2004 | volume= 49 | issue= 11 | pages= 859-66 | pmid=15603095 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15603095  }}</ref>
|[[Aerobic organism|Aerobic]]
[[Aerobic organism|Infections]]
|
|
*Fungistatic and fungicidal activity
*[[Sexually transmitted]]
*[[Autoinoculation]] from other sites
|
|
*Role in protection aganist infection is not clear
*Uncircumcised penis
 
*[[Diabetes]]
*[[Immunocompromised|Immunocompromise]] conditions
|Adherence to [[epithelial cells]], [[Biofilm|biofilm production]], surface hydrophobicity, [[phospholipase C]] and [[protease]] activity
|-
|-
|Vaginal bacterial flora
|[[Trichomonas vaginalis]]
|[[Sexually transmitted]]
|
|
*Lactobacillus species compete for nutrients.
*Multiple sexual partners
*Bacteriocins and hydrogen peroxide inhibits yeast growth/germination
*Unprotected sexual activity
|
*Co-existing [[venereal diseases]]
*Role in protection aganist vaginitis still unclear
|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|Treponema]]
[[Treponema pallidum|pallidum]]
|Transmitted via direct contact with the infected lesion (sexual contact)
|[[Risk factors]] include:<ref name="pmid2356911">{{cite journal| author=Rolfs RT, Goldberg M, Sharrar RG| title=Risk factors for syphilis: cocaine use and prostitution. | journal=Am J Public Health | year= 1990 | volume= 80 | issue= 7 | pages= 853-7 | pmid=2356911 | doi= | pmc=1404975 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2356911  }}</ref><ref name="pmid17675391">{{cite journal| author=Zhou H, Chen XS, Hong FC, Pan P, Yang F, Cai YM et al.| title=Risk factors for syphilis infection among pregnant women: results of a case-control study in Shenzhen, China. | journal=Sex Transm Infect | year= 2007 | volume= 83 | issue= 6 | pages= 476-80 | pmid=17675391 | doi=10.1136/sti.2007.026187 | pmc=2598725 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17675391  }}</ref><ref name="pmid15247352">{{cite journal| author=Hook EW, Peeling RW| title=Syphilis control--a continuing challenge. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 2 | pages= 122-4 | pmid=15247352 | doi=10.1056/NEJMp048126 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15247352  }}</ref><ref name="pmid16205297">{{cite journal| author=Buchacz K, Greenberg A, Onorato I, Janssen R| title=Syphilis epidemics and human immunodeficiency virus (HIV) incidence among men who have sex with men in the United States: implications for HIV prevention. | journal=Sex Transm Dis | year= 2005 | volume= 32 | issue= 10 Suppl | pages= S73-9 | pmid=16205297 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16205297  }}</ref><ref name="pmid25514173">{{cite journal| author=Solomon MM, Mayer KH| title=Evolution of the syphilis epidemic among men who have sex with men. | journal=Sex Health | year= 2015 | volume= 12 | issue= 2 | pages= 96-102 | pmid=25514173 | doi=10.1071/SH14173 | pmc=4470884 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25514173  }}</ref><ref name="pmid24927712">{{cite journal| author=Hakre S, Arteaga GB, Núñez AE, Arambu N, Aumakhan B, Liu M et al.| title=Prevalence of HIV, syphilis, and other sexually transmitted infections among MSM from three cities in Panama. | journal=J Urban Health | year= 2014 | volume= 91 | issue= 4 | pages= 793-808 | pmid=24927712 | doi=10.1007/s11524-014-9885-4 | pmc=4134449 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24927712  }}</ref><ref name="newell">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.</ref>Multiple sexual partners, prostitution, illicit drug use, unprotected sex
men who have sex with men, residence in highly prevalent areas, [[Human Immunodeficiency Virus (HIV)|HIV]] infection, presence of other [[STI]]<nowiki/>s, 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]])
|-
|-
|Phagocytic systems/polymononuclear leucocytes, mononuclear cells, complement
|[[Herpes simplex]]
|Often transmitted sexually or direct contact with droplet or infected secretions entering thorough [[skin]] or [[Mucous membrane|mucous membranes]]
|
|
*Mainly found in lamina propria in experimental vaginitis, help in reducing the yeast load and its invasion by phagocytosis and intracellular killing<ref name="pmid340470">{{cite journal| author=Diamond RD, Krzesicki R, Jao W| title=Damage to pseudohyphal forms of Candida albicans by neutrophils in the absence of serum in vitro. | journal=J Clin Invest | year= 1978 | volume= 61 | issue= 2 | pages= 349-59 | pmid=340470 | doi=10.1172/JCI108945 | pmc=372545 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=340470  }}</ref>
*Multiple sexual partners
*Nitric oxide has anti-candida activity
*Low [[socio-economic status]]
|
|
*Role in protection still unclear
*Inhibition of [[MHC class I|MHC Class I]]
|}
*Impairing function of [[Dendritic cell|dendritric cells]]
====Adaptive Mechanisms====
{| class="wikitable"
!Defense
!Mechanism
!Role in Protection
|-
|-
|Immunoglobulin mediated immunity
|[[Human papilloma virus]]
|Systemic IgM, IgG and local IgA antibodies are produced in response to the infection<ref name="pmid4556009">{{cite journal| author=Waldman RH, Cruz JM, Rowe DS| title=Immunoglobulin levels and antibody to Candida albicans in human cervicovaginal secretions. | journal=Clin Exp Immunol | year= 1972 | volume= 10 | issue= 3 | pages= 427-34 | pmid=4556009 | doi= | pmc=1713147 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4556009  }}</ref>
|Usually transmitted via [[Sexual|sexual route]] to the human host
|[[Risk factors]] responsible for sexual transmission of [[Human papillomavirus|HPV]] include:
Number of sex partners<ref name="pmid21414655">{{cite journal |vauthors=Bell MC, Schmidt-Grimminger D, Jacobsen C, Chauhan SC, Maher DM, Buchwald DS |title=Risk factors for HPV infection among American Indian and white women in the Northern Plains |journal=Gynecol. Oncol. |volume=121 |issue=3 |pages=532–6 |year=2011 |pmid=21414655 |pmc=4498572 |doi=10.1016/j.ygyno.2011.02.032 |url=}}</ref><ref name="pmid14702152">{{cite journal |vauthors=Tarkowski TA, Koumans EH, Sawyer M, Pierce A, Black CM, Papp JR, Markowitz L, Unger ER |title=Epidemiology of human papillomavirus infection and abnormal cytologic test results in an urban adolescent population |journal=J. Infect. Dis. |volume=189 |issue=1 |pages=46–50 |year=2004 |pmid=14702152 |doi=10.1086/380466 |url=}}</ref>, acqusition of new partner<ref name="pmid21414655" />


|
, having non monogamous sex partner<ref name="pmid9217656">{{cite journal |vauthors=Koutsky L |title=Epidemiology of genital human papillomavirus infection |journal=Am. J. Med. |volume=102 |issue=5A |pages=3–8 |year=1997 |pmid=9217656 |doi= |url=}}</ref><ref name="pmid12543621">{{cite journal |vauthors=Winer RL, Lee SK, Hughes JP, Adam DE, Kiviat NB, Koutsky LA |title=Genital human papillomavirus infection: incidence and risk factors in a cohort of female university students |journal=Am. J. Epidemiol. |volume=157 |issue=3 |pages=218–26 |year=2003 |pmid=12543621 |doi= |url=}}</ref>, starting sexual activity in young age<ref name="pmid9217656" />, vaginal delivery and multiple deliveries<ref name="pmid9464728">{{cite journal |vauthors=Tseng CJ, Liang CC, Soong YK, Pao CC |title=Perinatal transmission of human papillomavirus in infants: relationship between infection rate and mode of delivery |journal=Obstet Gynecol |volume=91 |issue=1 |pages=92–6 |year=1998 |pmid=9464728 |doi= |url=}}</ref>, age over 40 for women<ref name="pmid21495248">{{cite journal |vauthors=Ting J, Kruzikas DT, Smith JS |title=A global review of age-specific and overall prevalence of cervical lesions |journal=Int. J. Gynecol. Cancer |volume=20 |issue=7 |pages=1244–9 |year=2010 |pmid=21495248 |doi= |url=}}</ref>, history of [[Chlamydia infection|Chlamydia]] infection<ref name="pmid9332762">{{cite journal |vauthors=Kjaer SK, van den Brule AJ, Bock JE, Poll PA, Engholm G, Sherman ME, Walboomers JM, Meijer CJ |title=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? |journal=Cancer Epidemiol. Biomarkers Prev. |volume=6 |issue=10 |pages=799–805 |year=1997 |pmid=9332762 |doi= |url=}}</ref>,  and long term [[Oral contraceptive|OCP]] use<ref name="pmid1649312">{{cite journal |vauthors=Ley C, Bauer HM, Reingold A, Schiffman MH, Chambers JC, Tashiro CJ, Manos MM |title=Determinants of genital human papillomavirus infection in young women |journal=J. Natl. Cancer Inst. |volume=83 |issue=14 |pages=997–1003 |year=1991 |pmid=1649312 |doi= |url=}}</ref>
*Protective role not proven.
|Linked to [[epithelial]] [[differentiation]] and maturation of host [[keratinocytes]], with [[transcription]] of specific [[Gene|gene products]] at every level.
*Elevated titres of vaginal anti-candida IgG, IgA are detected in women with recurrent vaginitis
*Persistent symptoms could be attributed to Anti-candida IgE<ref name="pmid8809464">{{cite journal| author=Fidel PL, Sobel JD| title=Immunopathogenesis of recurrent vulvovaginal candidiasis. | journal=Clin Microbiol Rev | year= 1996 | volume= 9 | issue= 3 | pages= 335-48 | pmid=8809464 | doi= | pmc=172897 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8809464  }}</ref>  
|-
|Cell Mediated Immunity
|
Interleukin 4 (Th2) inhibits anti-candida activity of nitric oxide and protective pro-inflammatory Th1 cytokines.<ref name="pmid15735412">{{cite journal| author=Fidel PL| title=Immunity in vaginal candidiasis. | journal=Curr Opin Infect Dis | year= 2005 | volume= 18 | issue= 2 | pages= 107-11 | pmid=15735412 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15735412  }}</ref>
|
*Role in protection from vulvovaginitis is still not clear
*It is still a hypothesis<ref name="pmid15102806">{{cite journal| author=Fidel PL, Barousse M, Espinosa T, Ficarra M, Sturtevant J, Martin DH et al.| title=An intravaginal live Candida challenge in humans leads to new hypotheses for the immunopathogenesis of vulvovaginal candidiasis. | journal=Infect Immun | year= 2004 | volume= 72 | issue= 5 | pages= 2939-46 | pmid=15102806 | doi= | pmc=387876 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15102806  }}</ref>
*Patients with recurrent infection have undetectable Th2 cytokines.
|}
|}
===Candida Virulence Factors===
*C.albicans exists as blastospores, germ tubes, pseudomycelia, true mycelia and  chlamydospores on special culture media. C. glabrata exists exclusively in blastospores.
*All strains of Candida species possess a yeast surface mannoprotein which helps in adhering to epithelial cells of the [[vagina]].<ref name="pmid17560449">{{cite journal |vauthors=Sobel JD |title=Vulvovaginal candidosis |journal=Lancet |volume=369 |issue=9577 |pages=1961–71 |year=2007 |pmid=17560449 |doi=10.1016/S0140-6736(07)60917-9 |url=}}</ref><ref name="pmid3895958">{{cite journal |vauthors=Sobel JD |title=Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis |journal=Am. J. Obstet. Gynecol. |volume=152 |issue=7 Pt 2 |pages=924–35 |year=1985 |pmid=3895958 |doi= |url=}}</ref>
*[[Germination]] of the spores helps in colonizing the vagina.<ref name="pmid6327527">{{cite journal| author=Sobel JD, Muller G, Buckley HR| title=Critical role of germ tube formation in the pathogenesis of candidal vaginitis. | journal=Infect Immun | year= 1984 | volume= 44 | issue= 3 | pages= 576-80 | pmid=6327527 | doi= | pmc=263631 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6327527  }} </ref>
*Proteolytic enzymes, toxins and phospholipase destroy the proteins that normally impair fungal invasion, enhancing the ability of [[Candida]] to colonize the [[vagina]].<ref name="pmid17560449">{{cite journal |vauthors=Sobel JD |title=Vulvovaginal candidosis |journal=Lancet |volume=369 |issue=9577 |pages=1961–71 |year=2007 |pmid=17560449 |doi=10.1016/S0140-6736(07)60917-9 |url=}}</ref><ref name="pmid3895958">{{cite journal |vauthors=Sobel JD |title=Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis |journal=Am. J. Obstet. Gynecol. |volume=152 |issue=7 Pt 2 |pages=924–35 |year=1985 |pmid=3895958 |doi= |url=}}</ref><ref name="pmid2688924">{{cite journal |vauthors=Sobel JD |title=Pathogenesis of Candida vulvovaginitis |journal=Curr Top Med Mycol |volume=3 |issue= |pages=86–108 |year=1989 |pmid=2688924 |doi= |url=}}</ref><ref name="pmid12761103">{{cite journal| author=Schaller M, Bein M, Korting HC, Baur S, Hamm G, Monod M et al.| title=The secreted aspartyl proteinases Sap1 and Sap2 cause tissue damage in an in vitro model of vaginal candidiasis based on reconstituted human vaginal epithelium. | journal=Infect Immun | year= 2003 | volume= 71 | issue= 6 | pages= 3227-34 | pmid=12761103 | doi= | pmc=155757 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12761103  }}</ref>
*Phenotypic switching of Candida is described in patients with recurrent vaginitis.<ref name="pmid3284370">{{cite journal| author=Soll DR| title=High-frequency switching in Candida albicans and its relations to vaginal candidiasis. | journal=Am J Obstet Gynecol | year= 1988 | volume= 158 | issue= 4 | pages= 997-1001 | pmid=3284370 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3284370  }}</ref>
*C.albicans can form bio-films on the intra uterine devices or sponges causing disease recurrence.<ref name="pmid25935553">{{cite journal| author=Muzny CA, Schwebke JR| title=Biofilms: An Underappreciated Mechanism of Treatment Failure and Recurrence in Vaginal Infections. | journal=Clin Infect Dis | year= 2015 | volume= 61 | issue= 4 | pages= 601-6 | pmid=25935553 | doi=10.1093/cid/civ353 | pmc=4607736 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25935553  }}</ref>
===Pathogenesis===
*[[Candida (genus)|Candida]] vulvovaginitis is a microbial disease and not all patients with detectable pathogen are symptomatic. Multiple risk factors and the imbalance in the protective vaginal defenses predispose patients to develop active disease.
*[[Candida]] vaginal infections are more common in the reproductive age group because of the high concentration of estrogen as it increases the amount of glycogen in the vagina providing a carbon source for candida organisms to colonize. It also increases the adherence of candida to the vaginal epithelial cells.<ref name="pmid11592551">{{cite journal| author=Dennerstein GJ, Ellis DH| title=Oestrogen, glycogen and vaginal candidiasis. | journal=Aust N Z J Obstet Gynaecol | year= 2001 | volume= 41 | issue= 3 | pages= 326-8 | pmid=11592551 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11592551  }}</ref>
*The most common source of the infection is from the peri-anal area. Other less common source is sexual transmission and persistence of organisms in the vagina after treatment which is responsible for recurrence.<ref name="pmid333134">{{cite journal| author=Miles MR, Olsen L, Rogers A| title=Recurrent vaginal candidiasis. Importance of an intestinal reservoir. | journal=JAMA | year= 1977 | volume= 238 | issue= 17 | pages= 1836-7 | pmid=333134 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=333134  }}</ref>
*The initial step of infection is colonization and symptoms appear with the invasion of the blastospores or pseudohyphae of the vaginal wall.<ref name="pmid9880475">{{cite journal| author=Fidel PL, Vazquez JA, Sobel JD| title=Candida glabrata: review of epidemiology, pathogenesis, and clinical disease with comparison to C. albicans. | journal=Clin Microbiol Rev | year= 1999 | volume= 12 | issue= 1 | pages= 80-96 | pmid=9880475 | doi= | pmc=88907 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9880475  }}</ref>
*The understanding of the transition from asymptomatic vaginal colonization with [[Candida]] to symptomatic [[vulvovaginitis]] is not clear.<ref name="pmid3895958">{{cite journal |vauthors=Sobel JD |title=Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis |journal=Am. J. Obstet. Gynecol. |volume=152 |issue=7 Pt 2 |pages=924–35 |year=1985 |pmid=3895958 |doi= |url=}}</ref><ref name="pmid2688924">{{cite journal |vauthors=Sobel JD |title=Pathogenesis of Candida vulvovaginitis |journal=Curr Top Med Mycol |volume=3 |issue= |pages=86–108 |year=1989 |pmid=2688924 |doi= |url=}}</ref>
===Genetics===
*Few genetic factors are thought to be involved in patients with recurrent [[Candida]] [[vulvovaginitis]].<ref name="pmid12964847">{{cite journal| author=Calderon L, Williams R, Martinez M, Clemons KV, Stevens DA| title=Genetic susceptibility to vaginal candidiasis. | journal=Med Mycol | year= 2003 | volume= 41 | issue= 2 | pages= 143-7 | pmid=12964847 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12964847  }}</ref>
*Supporting evidence is that candida vaginitis is common in African-American women, runs in families and its association in patients with ABO-Lewis non-secretor phenotype, a rare blood group.
*In addition, women with recurrent [[Candida]] [[vulvovaginitis]] were found to have decreased concentrations of [[mannose binding lectin]] (MBL), hence, the variant (MBL) gene is thought to be a contributing factor in the development of [[Candida]] [[vulvovaginitis]].<ref name="pmid17560449">{{cite journal |vauthors=Sobel JD |title=Vulvovaginal candidosis |journal=Lancet |volume=369 |issue=9577 |pages=1961–71 |year=2007 |pmid=17560449 |doi=10.1016/S0140-6736(07)60917-9 |url=}}</ref><ref name="pmid16256117">{{cite journal |vauthors=Liu F, Liao Q, Liu Z |title=Mannose-binding lectin and vulvovaginal candidiasis |journal=Int J Gynaecol Obstet |volume=92 |issue=1 |pages=43–7 |year=2006 |pmid=16256117 |doi=10.1016/j.ijgo.2005.08.024 |url=}}</ref><ref name="pmid18715406">{{cite journal |vauthors=Donders GG, Babula O, Bellen G, Linhares IM, Witkin SS |title=Mannose-binding lectin gene polymorphism and resistance to therapy in women with recurrent vulvovaginal candidiasis |journal=BJOG |volume=115 |issue=10 |pages=1225–31 |year=2008 |pmid=18715406 |doi=10.1111/j.1471-0528.2008.01830.x |url=}}</ref>
===Gross Pathology===
On speculum examination typical curdy white discharge is present.
<gallery>
[http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
Image:speculum_vagina.jpg|left|thumb|350px|This photograph is a speculum examination of the vagina with Candida infection and the typical thick, curdy vaginal discharge.
</gallery>
===Microscopic Pathology===
Microscopic examination of the wet mount with 10% KOH or saline demonstrates hyphae, pseudohyphae and blastospores.<gallery>
Image:Calbicans.jpg|left|thumb|350px|This is a a microscopic image of Candida albicans, grown on cornmeal agar medium.
<br clear="left"/>
Image:Renal candidiasis 005.jpeg|left|thumb|350px|This higher-power photomicrograph shows the yeasts and pseudohyphae of Candida organisms.
<br clear="left"/>
Image:Renal candidiasis 006.jpeg|left|thumb|350px|This high-power photomicrograph shows the yeasts (1) and pseudohyphae (2).
<br clear="left"/>
</gallery>


===Associated Conditions===
==[[Balanitis causes|Causes]]==
*[[Candida]] [[vulvovaginitis]] may be associated with other pathogens that cause [[vulvovaginitis]] including ''[[Trichomonas vaginalis]]'' and ''[[Gardnerella vaginalis]]''. The presence of these diseases in combination is common therefore it is important to rule out other etiologies before initiation of anti fungal treatment.<ref name="pmid23354954">{{cite journal |vauthors=Sobel JD, Subramanian C, Foxman B, Fairfax M, Gygax SE |title=Mixed vaginitis-more than coinfection and with therapeutic implications |journal=Curr Infect Dis Rep |volume=15 |issue=2 |pages=104–8 |year=2013 |pmid=23354954 |doi=10.1007/s11908-013-0325-5 |url=}}</ref><ref name="pmid15026404">{{cite journal |vauthors=Anderson MR, Klink K, Cohrssen A |title=Evaluation of vaginal complaints |journal=JAMA |volume=291 |issue=11 |pages=1368–79 |year=2004 |pmid=15026404 |doi=10.1001/jama.291.11.1368 |url=}}</ref>
Causes of balanitis are: {{familytree/start}}
==Causes==
{{familytree | | | | | | | | | | | | | | | | | A01 |A01='''Balanitis'''}}
Candida vulvovaginitis is caused by many different species of Candida. They are divided into [[Candida albicans]] and Candida non-albicans species based on the causative pathogen:
{{familytree | | | | |,|-|-|-|-|-|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|-|-|-|.| | | }}
===Common Causes===
{{familytree | | | | B01 | | | | | | | | | | | B02 | | | | | | | | | B03 |B01='''Infectious'''|B02='''Inflammatory dermatoses'''|B03='''Premalignant (penile carcinoma in situ)'''}}
*Candida albicans: These strains are isolated in 85 to 95% patients with yeast infection.<ref name="pmid12932875">{{cite journal| author=Corsello S, Spinillo A, Osnengo G, Penna C, Guaschino S, Beltrame A et al.| title=An epidemiological survey of vulvovaginal candidiasis in Italy. | journal=Eur J Obstet Gynecol Reprod Biol | year= 2003 | volume= 110 | issue= 1 | pages= 66-72 | pmid=12932875 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12932875  }} </ref>
{{familytree | | | | |!| | | | | | | | | | | | |!| | | | | | | | | | |!| | | }}
*Candida non albicans: Candida glabrata is the most common isolated pathogen in this group affecting 10 to 20% of women and is associated with recurrent Candida vulvovaginitis.<ref name="pmid15456373">{{cite journal| author=Okungbowa FI, Isikhuemhen OS, Dede AP| title=The distribution frequency of Candida species in the genitourinary tract among symptomatic individuals in Nigerian cities. | journal=Rev Iberoam Micol | year= 2003 | volume= 20 | issue= 2 | pages= 60-3 | pmid=15456373 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15456373  }} </ref>
{{familytree | | | | |!| | | | | | | | | | | | |!| | | | | | | | | | |!| | | }}
===Less Common Causes===
{{familytree | | | | C01 | | | | | | | | | | | C02 | | | | | | | | | C03 |C01=[[Candida]] (albicans, krusei)<br>[[Streptococci]]<br>Anaerobes<br>[[Staphylococci]]<br>[[Trichomonas vaginalis]]<br>[[Herpes simplex virus]]<br>[[Human papillomavirus]]<br>[[Mycoplasma genitalium]]|C02=[[Lichen sclerosus]]<br>[[Lichen planus]]<br>[[Psoriasis]]<br>[[Circinate balanitis]]<br>[[Zoon's balanitis]]<br>[[Eczema]]<br>[[Allergic reactions]]|C03= [[Bowen's disease]]<br>[[Bowenoid papulosis]]<br>[[Erythroplasia of Queyrat]]}}
These are less commonly isolated in patients but is important to identify the species as they are less sensitive to standard azole therapy and cause recurrent infection.<ref name="pmid12237629">{{cite journal| author=Bauters TG, Dhont MA, Temmerman MI, Nelis HJ| title=Prevalence of vulvovaginal candidiasis and susceptibility to fluconazole in women. | journal=Am J Obstet Gynecol | year= 2002 | volume= 187 | issue= 3 | pages= 569-74 | pmid=12237629 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12237629  }} </ref><ref name="pmid12794215">{{cite journal| author=Holland J, Young ML, Lee O, C-A Chen S| title=Vulvovaginal carriage of yeasts other than Candida albicans. | journal=Sex Transm Infect | year= 2003 | volume= 79 | issue= 3 | pages= 249-50 | pmid=12794215 | doi= | pmc=1744683 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12794215  }} </ref>
{{familytree/end}}
*Candida parapsilosis<ref name="pmid16040326">{{cite journal| author=Nyirjesy P, Alexander AB, Weitz MV| title=Vaginal Candida parapsilosis: pathogen or bystander? | journal=Infect Dis Obstet Gynecol | year= 2005 | volume= 13 | issue= 1 | pages= 37-41 | pmid=16040326 | doi=10.1080/10647440400025603 | pmc=1784559 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16040326  }} </ref>
 
*Candida tropicalis
 
*Candida krusei<ref name="pmid12384840">{{cite journal| author=Singh S, Sobel JD, Bhargava P, Boikov D, Vazquez JA| title=Vaginitis due to Candida krusei: epidemiology, clinical aspects, and therapy. | journal=Clin Infect Dis | year= 2002 | volume= 35 | issue= 9 | pages= 1066-70 | pmid=12384840 | doi=10.1086/343826 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12384840  }} </ref>
==Differentiating Candida Vulvovaginitis from other Diseases==
Candida Vulvovaginitis must be differentiated from the following diseases which have a similar presentation:<ref name=CDC-BV> Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines. Bacterial Vaginosis. http://www.cdc.gov/std/tg2015/bv.htm Accessed on October 13, 2016 </ref><ref name="pmid10839558">{{cite journal| author=Bachmann GA, Nevadunsky NS| title=Diagnosis and treatment of atrophic vaginitis. | journal=Am Fam Physician | year= 2000 | volume= 61 | issue= 10 | pages= 3090-6 | pmid=10839558 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10839558  }} </ref><ref name="pmid2448502">{{cite journal| author=Krieger JN, Tam MR, Stevens CE, Nielsen IO, Hale J, Kiviat NB et al.| title=Diagnosis of trichomoniasis. Comparison of conventional wet-mount examination with cytologic studies, cultures, and monoclonal antibody staining of direct specimens. | journal=JAMA | year= 1988 | volume= 259 | issue= 8 | pages= 1223-7 | pmid=2448502 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2448502  }} </ref><ref name="pmid21422855">{{cite journal| author=Sobel JD, Reichman O, Misra D, Yoo W| title=Prognosis and treatment of desquamative inflammatory vaginitis. | journal=Obstet Gynecol | year= 2011 | volume= 117 | issue= 4 | pages= 850-5 | pmid=21422855 | doi=10.1097/AOG.0b013e3182117c9e | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422855  }} </ref><ref name="pmid97946645">{{cite journal| author=Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK| title=Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm. | journal=Obstet Gynecol | year= 1998 | volume= 92 | issue= 5 | pages= 757-65 | pmid=9794664 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9794664  }}</ref>


{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
Causes of Infectious balanitis include:<ref>GENITOURINARY MEDICINE, Volume 72, Number 3: Pages 155-9, June 1996.</ref><ref>International Journal of Research in Health Sciences. Jan–Mar 2014 Volume-2, Issue-1</ref><ref name="pmid248285532" /><ref name="pmid26396455">{{cite journal| author=Pandya I, Shinojia M, Vadukul D, Marfatia YS| title=Approach to balanitis/balanoposthitis: Current guidelines. | journal=Indian J Sex Transm Dis | year= 2014 | volume= 35 | issue= 2 | pages= 155-7 | pmid=26396455 | doi=10.4103/0253-7184.142415 | pmc=4553848 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26396455  }}</ref>{{familytree/start}}
|+
{{familytree | | | | | | | A01 | | | | | | | | | | | | | | | |A01=Balanitis}}
! style="background: #4479BA; width: 120px;" | {{fontcolor|#FFF|Disease}}
{{familytree | |,|-|-|-|v|-|^|-|v|-|-|-|-|-|-|.| | | | | | | | | | }}
! style="background: #4479BA; width: 550px;" | {{fontcolor|#FFF|Findings}}
{{familytree | |!| | | |!| | | |!| | | | | | |!| | | | | | | | | | | | | }}
{{familytree | B01 | | B02 | | B03 | | | | | B04 | | | | |B01=Fungal|B02=Virus|B03=Parasite/Protozoal|B04=Bacteria}}                     
{{familytree | |!| | | |!| | | |!| | |,|-|-|-|+|-|-|-|v|-|-|-|.|}}
{{familytree | |!| | | |!| | | |!| | |!| | | |!| | | |!| | | |!|}}
{{familytree | C01 | | C02 | | C03 | |C04| | C05 | | C06 | | C07 | |C01=Candida (albicans, krusei)<br> Dermatophytosis <br>Pityriasis versicolor<br>Histoplasma capsulatum<br>Blastomyces dermatitidis<br>Cryptococcus neoformans|C02=Herpes simplex virus<br>Varicella zoster virus (VZV)<br>Human papilloma virus (HPV)|C03='''Protozoal'''<br>Entamoeba histolytica<br>Trichomonas vaginalis<br>Leishmania species<br>'''Parastic'''<br>Sarcoptes scabiei var hominis<br>Pediculosis<br>Ankylostoma species|C04='''Gram negative bacteria'''<br>E.coli, Pseudomonas, Haemophilus parainfluenzae, Klebsiella, Neisseria gonorrhoea, Haemophilus ducreyi, Mycoplasma genitalium, Chlamydia, Ureaplasma, Gardnerella vaginalis, Citrobacter, Enterobacter<br>|C05='''Spirochaetes'''<br>Treponema pallidum, Non specific spirochaetal infection<br>|C06='''Gram positive organism'''<br> Haemolytic Streptococci(Group B Streptococci), Staphylococci epidermidis/aureus|C07='''Acid fast bacilli'''<br> Mycobacterium tuberculosis, Leprosy<br>'''Anaerobes'''<br>(Bacteroides)}}
{{familytree/end}}
 
==[[Balanitis differential diagnosis|Differentiating diagnosis]] ==
{| class="wikitable"
! colspan="3" |Symptoms
! colspan="4" |Signs
|-
!
!Malaise
!Pruritus
!Skin lesions
!Regional lymphadenopathy
!Erythema
!Swelling
|-
|[[Candidiasis|Candida balanitis]]
|✖
|✔
|[[Erythematous]] [[Rash (patient information)|rash]] with soreness and/or [[itch]]
|✔
|✔
|✖
|-
|[[Trichomonas vaginalis]]
|✖
|✔
|Superficial erosive [[balanitis]] 
|✖
|✔
|✖
|-
|[[Treponema pallidum]]
|✖
|✖
|Multiple circinate lesions
|✔
|✖
|✖
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''[[Trichomoniasis]]'''
|[[Herpes simplex]]
| style="padding: 5px 5px; background: #F5F5F5;" |
|✔
*Presents with purulent, malodorous, thin discharge associated with burning, [[pruritus]], and [[dysuria]], with the signs of vaginal [[inflammation]] and elevated vaginal [[pH]] (>4.5)
|✔
*Motile trichomonads on wet mount are demonstrated
|Grouped [[vesicles]] on [[erythematous]] base
*Positive culture (Gold standard)
|✔
*Positive nucleic acid amplification test (NAAT)
|✔
|✖
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''[[Atrophic vaginitis]]'''
|[[Human papillomavirus|Human papilloma virus]]
| style="padding: 5px 5px; background: #F5F5F5;" |
|✖
*Progressive symptoms 
|✔
*Presents with yellow and malodorous vaginal discharge, vaginal dryness, postcoital bleeding, and [[dyspareunia]] with the signs of vaginal [[inflammation]] and elevated vaginal pH (>5)
|[[Warts]]  
*Diagnosis is critical and laboratory tests help to confirm hypoestrogenic state
|✖
|✖
|✖
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Desquamative inflammatory vaginitis'''
|[[Lichen sclerosus]]
| style="padding: 5px 5px; background: #F5F5F5;" |  
|✖
*Chronic clinical syndrome with unknown etiology
|✔
*Presents with [[dyspareunia]], dyspareunia, yellow, grey, or green profuse vaginal discharge with the signs of vaginal [[inflammation]] and elevated vaginal pH (>4.5)
|White patches on glans
*Microscopy shows large number of parabasal (immature squamous epithelial cells) and inflammatory cells
|✖
|✖
|✖
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Bacterial Vaginosis]]'''
|[[Lichen planus]]
| style="padding: 5px 5px; background: #F5F5F5;" |
|✖
*Presents with [[dysuria]], vaginal discharge
|✔
*Fishy odor (positive whiff test)
|Purplish lesions on the [[penis]]
*Normal vaginal PH (<4.5)
|✖
*On speculum examination signs of vaginal inflammation are demonstrated.
|✖
|✖
|-
|[[Psoriasis]]
|✖
|✔
|Red scaly plaques
|✖
|✔
|✖
|-
|[[Reiter's Syndrome|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 [[Erythema|erythematous]] lesions
|✖
|✔
|✖
|-
|[[Bowen's disease]]
|✖
|✔
|Multiple, small, well-demarcated [[Papillomatosis|papillomatous]] [[papules]]
|✖
|✖
|✖
|-
|[[Bowenoid papulosis]]
|✖
|✔
|Single or multiple, sharply demarcated associated with [[Scaling skin|scaling]] and crusting
|✖
|✖
|✖
|-
|[[Erythroplasia of Queyrat]]
|✖
|✔
|Velvety patches and [[plaques]] of [[keratinization]] on [[penis]].
|✔
|✖
|✖
|}
|}


==Epidemiology and Demographics==
 
*Epidemiological studies on [[Candida]] [[vulvovaginitis]] are hard to perform, because of several factors:<ref name="pmid9500475">{{cite journal |vauthors=Sobel JD, Faro S, Force RW, Foxman B, Ledger WJ, Nyirjesy PR, Reed BD, Summers PR |title=Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations |journal=Am. J. Obstet. Gynecol. |volume=178 |issue=2 |pages=203–11 |year=1998 |pmid=9500475 |doi= |url=}}</ref><ref name="pmid17560449">{{cite journal |vauthors=Sobel JD |title=Vulvovaginal candidosis |journal=Lancet |volume=369 |issue=9577 |pages=1961–71 |year=2007 |pmid=17560449 |doi=10.1016/S0140-6736(07)60917-9 |url=}}</ref>
==[[Balanitis epidemiology and demographics|Epidemiology and Demographics]]==
**[[Candida]] [[vulvovaginitis]] is not a reportable disease.
*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.<ref name="pmid8707315">{{cite journal| author=Edwards S| title=Balanitis and balanoposthitis: a review. | journal=Genitourin Med | year= 1996 | volume= 72 | issue= 3 | pages= 155-9 | pmid=8707315 | doi= | pmc=1195642 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8707315 }}</ref>
**The diagnosis of [[Candida]] [[vulvovaginitis]] is based on clinical presentation and positive laboratory findings. Relying on a positive culture alone would likely overestimate the prevalence of [[Candida]] [[vulvovaginitis]].
*[[Candidiasis|Candida]] is the most common cause being responsible for 30-35% cases with infectious etiology.<ref name="pmid8566986">{{cite journal| author=Dockerty WG, Sonnex C| title=Candidal balano-posthitis: a study of diagnostic methods. | journal=Genitourin Med | year= 1995 | volume= 71 | issue= 6 | pages= 407-9 | pmid=8566986 | doi= | pmc=1196117 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8566986 }}</ref>
**The use of over-the-counter (OTC) topical anti-fungals makes it difficult to conduct epidemiological studies.
 
*Candida is the second most common cause of vaginal infection in young women following [[Bacterial vaginosis|Bacterial Vaginosis]].<ref name="pmid17197596">{{cite journal| author=Allsworth JE, Peipert JF| title=Prevalence of bacterial vaginosis: 2001-2004 National Health and Nutrition Examination Survey data. | journal=Obstet Gynecol | year= 2007 | volume= 109 | issue= 1 | pages= 114-20 | pmid=17197596 | doi=10.1097/01.AOG.0000247627.84791.91 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17197596 }} </ref>
==[[Balanitis risk factors|Risk Factors]]==
=== Age ===
Pathophysiology of Infectious balanitis varies from pathogen to pathogen:<ref name="pmid1156848">{{cite journal| author=Taylor PK, Rodin P| title=Herpes genitalis and circumcision. | journal=Br J Vener Dis | year= 1975 | volume= 51 | issue= 4 | pages= 274-7 | pmid=1156848 | doi= | pmc=1046564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1156848 }}</ref><ref name="pmid6121604">{{cite journal| author=Cree GE, Willis AT, Phillips KD, Brazier JS| title=Anaerobic balanoposthitis. | journal=Br Med J (Clin Res Ed) | year= 1982 | volume= 284 | issue= 6319 | pages= 859-60 | pmid=6121604 | doi= | pmc=1496281 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6121604 }}</ref><ref>GENITOURINARY MEDICINE, Volume 72, Number 3: Pages 155-9,</ref><ref name="pmid20002652">{{cite journal| author=Lisboa C, Santos A, Dias C, Azevedo F, Pina-Vaz C, Rodrigues A| title=Candida balanitis: risk factors. | journal=J Eur Acad Dermatol Venereol | year= 2010 | volume= 24 | issue= 7 | pages= 820-6 | pmid=20002652 | doi=10.1111/j.1468-3083.2009.03533.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20002652 }}</ref><ref name="pmid2482855322">{{cite journal| author=Edwards SK, Bunker CB, Ziller F, van der Meijden WI| title=2013 European guideline for the management of balanoposthitis. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 9 | pages= 615-26 | pmid=24828553 | doi=10.1177/0956462414533099 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24828553 }}</ref><ref>{{cite journal| author=Hernandez BY, Wilkens LR, Zhu X, Thompson P, McDuffie K, Shvetsov YB et al.| title=Transmission of human papillomavirus in heterosexual couples. | journal=Emerg Infect Dis | year= 2008 | volume= 14 | issue= 6 | pages= 888-94 | pmid=18507898 | doi=10.3201/eid1406.070616 | pmc=2600292 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18507898 }}</ref><ref>Sobel JD (1985). "Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis". Am. J. Obstet. Gynecol. 152 (7 Pt 2): 924–35. <nowiki>PMID 3895958</nowiki>.</ref>
*[[Incidence]] of Candida vulvovaginitis is higher in pregnant women.<ref name="pmid523355">{{cite journal| author=Hurley R, De Louvois J| title=Candida vaginitis. | journal=Postgrad Med J | year= 1979 | volume= 55 | issue= 647 | pages= 645-7 | pmid=523355 | doi= | pmc=2425644 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=523355  }} </ref><ref name="pmid16784126">{{cite journal| author=García Heredia M, García SD, Copolillo EF, Cora Eliseth M, Barata AD, Vay CA et al.| title=[Prevalence of vaginal candidiasis in pregnant women. Identification of yeasts and susceptibility to antifungal agents]. | journal=Rev Argent Microbiol | year= 2006 | volume= 38 | issue= 1 | pages= 9-12 | pmid=16784126 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16784126 }} </ref>
*Women in reproductive age group are prone for Candida vulvovaginits and at least one episode is reported in 70 to 75% in this population group.<ref name="ZuckermanRomano2016">{{cite journal|last1=Zuckerman|first1=Andrea|last2=Romano|first2=Mary|title=Clinical Recommendation: Vulvovaginitis|journal=Journal of Pediatric and AdolescentGynecology|volume=29|issue=6|year=2016|pages=673–679|issn=10833188|doi=10.1016/j.jpag.2016.08.002}}</ref>
*40 to 50% of patients with a prior yeast infection have multiple episodes of yeast infection.<ref name="pmid523355">{{cite journal| author=Hurley R, De Louvois J| title=Candida vaginitis. | journal=Postgrad Med J | year= 1979 | volume= 55 | issue= 647 | pages= 645-7 | pmid=523355 | doi= | pmc=2425644 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=523355 }} </ref>
*Among the adult population 5 to 8% women have more than four episodes of infection.<ref name="pmid9861594">{{cite journal| author=Foxman B, Marsh JV, Gillespie B, Sobel JD| title=Frequency and response to vaginal symptoms among white and African American women: results of a random digit dialing survey. | journal=J Womens Health | year= 1998 | volume= 7 | issue= 9 | pages= 1167-74 | pmid=9861594 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9861594 }} </ref>
*In 20% asymptomatic healthy [[adolescent]] women, candida species can be isolated from the vagina.<ref name="Barousse2004">{{cite journal|last1=Barousse|first1=M M|title=Vaginal yeast colonisation, prevalence of vaginitis, and associated local immunity in adolescents|journal=Sexually Transmitted Infections|volume=80|issue=1|year=2004|pages=48–53|issn=1368-4973|doi=10.1136/sti.2002.003855}}</ref>
===Race===
Candida vulvovaginitis is more prevalent among African American women than white American women.<ref name="pmid9861594">{{cite journal| author=Foxman B, Marsh JV, Gillespie B, Sobel JD| title=Frequency and response to vaginal symptoms among white and African American women: results of a random digit dialing survey. | journal=J Womens Health | year= 1998 | volume= 7 | issue= 9 | pages= 1167-74 | pmid=9861594 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9861594 }} </ref>
==Risk Factors==
The following risk factors have been implicated in predisposing patients to [[Candida]] [[vulvovaginitis]]:
*Previous infection with [[Candida]] [[vulvovaginitis]]<ref name="pmid2305918">{{cite journal |vauthors=Foxman B |title=The epidemiology of vulvovaginal candidiasis: risk factors |journal=Am J Public Health |volume=80 |issue=3 |pages=329–31 |year=1990 |pmid=2305918 |pmc=1404680 |doi= |url=}}</ref>
*Previous infection with ''[[Neisseria gonorrheae|Neisseria gonorrhea]]''<ref name="pmid97946644">{{cite journal| author=Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK| title=Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm. | journal=Obstet Gynecol | year= 1998 | volume= 92 | issue= 5 | pages= 757-65 | pmid=9794664 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9794664 }}</ref>
*Nulliparity<ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref>
*Luteal phase of the menstrual cycle <ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref>
*Recent [[antibiotic]] use<ref name="pmid12825971">{{cite journal| author=Wilton L, Kollarova M, Heeley E, Shakir S| title=Relative risk of vaginal candidiasis after use of antibiotics compared with antidepressants in women: postmarketing surveillance data in England. | journal=Drug Saf | year= 2003 | volume= 26 | issue= 8 | pages= 589-97 | pmid=12825971 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12825971 }} </ref>
*[[Pregnancy]]<ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref>
*[[Diabetes Mellitus]]<ref name="pmid11835694">{{cite journal |vauthors=de Leon EM, Jacober SJ, Sobel JD, Foxman B |title=Prevalence and risk factors for vaginal Candida colonization in women with type 1 and type 2 diabetes |journal=BMC Infect. Dis. |volume=2 |issue= |pages=1 |year=2002 |pmid=11835694 |pmc=65518 |doi= |url=}}</ref><ref name="pmid12433331">{{cite journal |vauthors=Donders GG |title=Lower Genital Tract Infections in Diabetic Women |journal=Curr Infect Dis Rep |volume=4 |issue=6 |pages=536–539 |year=2002 |pmid=12433331 |doi= |url=}}</ref>
*[[Obesity]]
*[[Immunosuppression]], such as [[HIV]] or [[glucocorticoid]] use<ref name="pmid12636961">{{cite journal |vauthors=Duerr A, Heilig CM, Meikle SF, Cu-Uvin S, Klein RS, Rompalo A, Sobel JD |title=Incident and persistent vulvovaginal candidiasis among human immunodeficiency virus-infected women: Risk factors and severity |journal=Obstet Gynecol |volume=101 |issue=3 |pages=548–56 |year=2003 |pmid=12636961 |doi= |url=}}</ref>
*Condom use<ref name="pmid9794664">{{cite journal |vauthors=Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK |title=Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm |journal=Obstet Gynecol |volume=92 |issue=5 |pages=757–65 |year=1998 |pmid=9794664 |doi= |url=}}</ref>
====Risk Factors for Recurrent Candida Vulvovaginitis<ref name="pmid26164695">{{cite journal| author=Sobel JD| title=Recurrent vulvovaginal candidiasis. | journal=Am J Obstet Gynecol | year= 2016 | volume= 214 | issue= 1 | pages= 15-21 | pmid=26164695 | doi=10.1016/j.ajog.2015.06.067 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26164695  }} </ref>====
{| class="wikitable"
{| class="wikitable"
!Microbial Factors
!Pathogen
!Genetic Factors
!Risk factors
!Host Behavioural Factors
|-
!Other Risk Factors
|[[Candidiasis|Candidal Balanitis]]
|
*[[Diabetes]]
*[[Immunocompromised]] conditions
*Age>40 yrs
|-
|-
|[[Anaerobic organism|Anaerobic Infection]]
|
|
*Non-albicans Candida species
*Tight [[foreskin]]
*sub-optimal penile hygienic maintenance
|-
|[[Aerobic organism|Aerobic]]
[[Aerobic organism|Infections]]
|
|
*Lewis blood group non-secretor status
*Uncircumcised penis
*African American race
 
*Familial history of recurrent Candida vulvovaginitis
*[[Diabetes]]
*[[Immunocompromised|Immunocompromise]] conditions
|-
|[[Trichomonas vaginalis]]
|
|
*Oral contraceptive
*Multiple sexual partners
*Sponge/intrauterine device use
*Unprotected sexual activity
*Intercourse frequency/ periodicity<ref name="pmid14709186">{{cite journal| author=Reed BD, Zazove P, Pierson CL, Gorenflo DW, Horrocks J| title=Candida transmission and sexual behaviors as risks for a repeat episode of Candida vulvovaginitis. | journal=J Womens Health (Larchmt) | year= 2003 | volume= 12 | issue= 10 | pages= 979-89 | pmid=14709186 | doi=10.1089/154099903322643901 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14709186 }}</ref>
*Co-existing [[venereal diseases]]
*Orogenital sexual activity
|-
|[[Treponema pallidum|Treponema]]
[[Treponema pallidum|pallidum]]
|[[Risk factors]] include:<ref name="pmid2356911">{{cite journal| author=Rolfs RT, Goldberg M, Sharrar RG| title=Risk factors for syphilis: cocaine use and prostitution. | journal=Am J Public Health | year= 1990 | volume= 80 | issue= 7 | pages= 853-7 | pmid=2356911 | doi= | pmc=1404975 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2356911  }}</ref><ref name="pmid17675391">{{cite journal| author=Zhou H, Chen XS, Hong FC, Pan P, Yang F, Cai YM et al.| title=Risk factors for syphilis infection among pregnant women: results of a case-control study in Shenzhen, China. | journal=Sex Transm Infect | year= 2007 | volume= 83 | issue= 6 | pages= 476-80 | pmid=17675391 | doi=10.1136/sti.2007.026187 | pmc=2598725 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17675391  }}</ref><ref name="pmid15247352">{{cite journal| author=Hook EW, Peeling RW| title=Syphilis control--a continuing challenge. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 2 | pages= 122-4 | pmid=15247352 | doi=10.1056/NEJMp048126 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15247352  }}</ref><ref name="pmid16205297">{{cite journal| author=Buchacz K, Greenberg A, Onorato I, Janssen R| title=Syphilis epidemics and human immunodeficiency virus (HIV) incidence among men who have sex with men in the United States: implications for HIV prevention. | journal=Sex Transm Dis | year= 2005 | volume= 32 | issue= 10 Suppl | pages= S73-9 | pmid=16205297 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16205297  }}</ref><ref name="pmid25514173">{{cite journal| author=Solomon MM, Mayer KH| title=Evolution of the syphilis epidemic among men who have sex with men. | journal=Sex Health | year= 2015 | volume= 12 | issue= 2 | pages= 96-102 | pmid=25514173 | doi=10.1071/SH14173 | pmc=4470884 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25514173 }}</ref><ref name="newell">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.</ref>Multiple sexual partners, prostitution, illicit drug use, unprotected sex
men who have sex with men, residence in highly prevalent areas, [[Human Immunodeficiency Virus (HIV)|HIV]] infection, presence of other [[STI]]<nowiki/>s, previous history of STIs, [[intravenous drug]] use, health care professionals who are predisposed to occupational risk, and low socioeconomic status
|-
|[[Herpes simplex]]
|
|
*Antibacterial use
*Multiple sexual partners
*Uncontrolled diabetes
*Low [[socio-economic status]]
*HIV
|-
*Corticosteroids
|[[Human papilloma virus]]
*Hormone replacement therapy
|[[Risk factors]] responsible for sexual transmission of [[Human papillomavirus|HPV]] include:
Number of sex partners<ref name="pmid21414655">{{cite journal |vauthors=Bell MC, Schmidt-Grimminger D, Jacobsen C, Chauhan SC, Maher DM, Buchwald DS |title=Risk factors for HPV infection among American Indian and white women in the Northern Plains |journal=Gynecol. Oncol. |volume=121 |issue=3 |pages=532–6 |year=2011 |pmid=21414655 |pmc=4498572 |doi=10.1016/j.ygyno.2011.02.032 |url=}}</ref><ref name="pmid14702152">{{cite journal |vauthors=Tarkowski TA, Koumans EH, Sawyer M, Pierce A, Black CM, Papp JR, Markowitz L, Unger ER |title=Epidemiology of human papillomavirus infection and abnormal cytologic test results in an urban adolescent population |journal=J. Infect. Dis. |volume=189 |issue=1 |pages=46–50 |year=2004 |pmid=14702152 |doi=10.1086/380466 |url=}}</ref>, acqusition of new partner<ref name="pmid21414655" />
 
, having non monogamous sex partner<ref name="pmid9217656">{{cite journal |vauthors=Koutsky L |title=Epidemiology of genital human papillomavirus infection |journal=Am. J. Med. |volume=102 |issue=5A |pages=3–8 |year=1997 |pmid=9217656 |doi= |url=}}</ref><ref name="pmid12543621">{{cite journal |vauthors=Winer RL, Lee SK, Hughes JP, Adam DE, Kiviat NB, Koutsky LA |title=Genital human papillomavirus infection: incidence and risk factors in a cohort of female university students |journal=Am. J. Epidemiol. |volume=157 |issue=3 |pages=218–26 |year=2003 |pmid=12543621 |doi= |url=}}</ref>, starting sexual activity in young age<ref name="pmid9217656" />, vaginal delivery and multiple deliveries<ref name="pmid9464728">{{cite journal |vauthors=Tseng CJ, Liang CC, Soong YK, Pao CC |title=Perinatal transmission of human papillomavirus in infants: relationship between infection rate and mode of delivery |journal=Obstet Gynecol |volume=91 |issue=1 |pages=92–6 |year=1998 |pmid=9464728 |doi= |url=}}</ref>, age over 40 for women<ref name="pmid21495248">{{cite journal |vauthors=Ting J, Kruzikas DT, Smith JS |title=A global review of age-specific and overall prevalence of cervical lesions |journal=Int. J. Gynecol. Cancer |volume=20 |issue=7 |pages=1244–9 |year=2010 |pmid=21495248 |doi= |url=}}</ref>, history of [[Chlamydia infection|Chlamydia]] infection<ref name="pmid9332762">{{cite journal |vauthors=Kjaer SK, van den Brule AJ, Bock JE, Poll PA, Engholm G, Sherman ME, Walboomers JM, Meijer CJ |title=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? |journal=Cancer Epidemiol. Biomarkers Prev. |volume=6 |issue=10 |pages=799–805 |year=1997 |pmid=9332762 |doi= |url=}}</ref>,  and long term [[Oral contraceptive|OCP]] use<ref name="pmid1649312">{{cite journal |vauthors=Ley C, Bauer HM, Reingold A, Schiffman MH, Chambers JC, Tashiro CJ, Manos MM |title=Determinants of genital human papillomavirus infection in young women |journal=J. Natl. Cancer Inst. |volume=83 |issue=14 |pages=997–1003 |year=1991 |pmid=1649312 |doi= |url=}}</ref>
|}
|}
<small>Table adopted from Vulvovaginal candidiasis Lancet 2007; 369: 1961–71<ref name="pmid17560449">{{cite journal| author=Sobel JD| title=Vulvovaginal candidosis. | journal=Lancet | year= 2007 | volume= 369 | issue= 9577 | pages= 1961-71 | pmid=17560449 | doi=10.1016/S0140-6736(07)60917-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17560449  }} </ref></small>


==Screening==
==[[Balanitis screening|Screening]]==
There are no screening procedures for Candida vulvovaginitis.
There is no established clinical guidelines for screening patients for balanitis. 
 
==[[Balanitis natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
===Natural history===
If left untreated, Infectious balanitis may result in complications, which include [[pain]], [[phimosis]], and urinary retention.<ref name="pmid248285532" />
===Complications===
Complication of Infectious balanitis include:<ref name="pmid24828553">{{cite journal| author=Edwards SK, Bunker CB, Ziller F, van der Meijden WI| title=2013 European guideline for the management of balanoposthitis. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 9 | pages= 615-26 | pmid=24828553 | doi=10.1177/0956462414533099 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24828553  }}</ref>
*[[Pain]]
*Erosions
*[[Fissures]]


==Natural History, Complications and Prognosis==
*[[Phimosis]]
===Natural History===
*[[Paraphimosis]]
Candida vulvovaginitis is a common infection of women in reproductive age group. Patients present with vulvar pruritus, [[dysuria]], and [[vaginal discharge]]. Half of the affected patients have multiple episodes of the infection and less than 10% have recurrent infection.<ref name="pmid98804752">{{cite journal| author=Fidel PL, Vazquez JA, Sobel JD| title=Candida glabrata: review of epidemiology, pathogenesis, and clinical disease with comparison to C. albicans. | journal=Clin Microbiol Rev | year= 1999 | volume= 12 | issue= 1 | pages= 80-96 | pmid=9880475 | doi= | pmc=88907 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9880475  }}</ref>
*Painful [[erection]]
*Reduced urinary flow
*[[Urinary retention]]
===Prognosis===
===Prognosis===
[[Candida albicans]] vulvovaginitis has excellent prognosis with [[azole]] therapy. Patients with non Candida albicans infections are prone to have recurrence and treatment with boric acid and oral [[fluconazole]] has good prognosis.<ref name="pmid98804753">{{cite journal| author=Fidel PL, Vazquez JA, Sobel JD| title=Candida glabrata: review of epidemiology, pathogenesis, and clinical disease with comparison to C. albicans. | journal=Clin Microbiol Rev | year= 1999 | volume= 12 | issue= 1 | pages= 80-96 | pmid=9880475 | doi= | pmc=88907 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9880475 }}</ref>
[[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%).<ref name="pmid23806153">{{cite journal| author=Kutlubay Z, Engin B, Zara T, Tüzün Y| title=Anogenital malignancies and premalignancies: facts and controversies. | journal=Clin Dermatol | year= 2013 | volume= 31 | issue= 4 | pages= 362-73 | pmid=23806153 | doi=10.1016/j.clindermatol.2013.01.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23806153  }} </ref>
====Erythroplasia of Queyrat====
If left untreated, Erythroplasia of Queyrat may progress into invasive [[Squamous cell carcinoma]], with an incidence ranging from 10% to 33%.<ref name="pmid23806153">{{cite journal| author=Kutlubay Z, Engin B, Zara T, Tüzün Y| title=Anogenital malignancies and premalignancies: facts and controversies. | journal=Clin Dermatol | year= 2013 | volume= 31 | issue= 4 | pages= 362-73 | pmid=23806153 | doi=10.1016/j.clindermatol.2013.01.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23806153  }} </ref>
====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.<ref name="pmid23806153">{{cite journal| author=Kutlubay Z, Engin B, Zara T, Tüzün Y| title=Anogenital malignancies and premalignancies: facts and controversies. | journal=Clin Dermatol | year= 2013 | volume= 31 | issue= 4 | pages= 362-73 | pmid=23806153 | doi=10.1016/j.clindermatol.2013.01.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23806153 }} </ref>
 
===Complications===
===Complications===
Candida vulvovaginitis is a self limiting disease with no complications.
Complication of penile carcinoma in situ include:<ref name="pmid23806153">{{cite journal| author=Kutlubay Z, Engin B, Zara T, Tüzün Y| title=Anogenital malignancies and premalignancies: facts and controversies. | journal=Clin Dermatol | year= 2013 | volume= 31 | issue= 4 | pages= 362-73 | pmid=23806153 | doi=10.1016/j.clindermatol.2013.01.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23806153 }} </ref>
==Diagnosis==
* [[Pain]]
Diagnosis of Candida vulvovaginitis requires a correlation of clinical features, microscopic examination, and vaginal culture.
* Transformation into invasive [[squamous cell carcinoma]]  
===History and Symptoms===
===Prognosis===
Symptoms of [[vulvovaginitis]] caused by Candida species are indistinguishable and include the following:<ref name="pmid97946642">{{cite journal| author=Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK| title=Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm. | journal=Obstet Gynecol | year= 1998 | volume= 92 | issue= 5 | pages= 757-65 | pmid=9794664 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9794664 }}</ref><ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref><ref name="pmid9500475">{{cite journal |vauthors=Sobel JD, Faro S, Force RW, Foxman B, Ledger WJ, Nyirjesy PR, Reed BD, Summers PR |title=Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations |journal=Am. J. Obstet. Gynecol. |volume=178 |issue=2 |pages=203–11 |year=1998 |pmid=9500475 |doi= |url=}}</ref>
The [[prognosis]] is usually good with treatment.
*[[Pruritus]] is the most significant symptom
 
*Change in the amount and the color of [[vaginal discharge]]: It is characterized by a thick, white "cottage cheese-like" vaginal discharge
== Diagnosis ==
*Pain on urination ([[dysuria]])
 
*Pain on sexual intercourse (dyspareunia)
[[Balanitis diagnostic criteria| Diagnostic Criteria]] | [[Balanitis history and symptoms| History and Symptoms]] | [[Balanitis physical examination | Physical Examination]] | [[Balanitis laboratory findings | Laboratory Findings]] | [[Balanitis chest x ray|X-ray]]|[[CT-Scan]]| [[MRI]]|  [[Balanitis other diagnostic studies|Other Diagnostic Studies]]
*[[Vulvovaginal]] soreness
*Symptoms aggravate a week before the menses
===Physical Examination===
[[Candida]] [[vulvovaginitis]] requires a careful examination of the external genitalia, the vaginal sidewalls and the cervix. Signs include:<ref name="pmid97946643">{{cite journal| author=Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK| title=Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm. | journal=Obstet Gynecol | year= 1998 | volume= 92 | issue= 5 | pages= 757-65 | pmid=9794664 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9794664  }}</ref><ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref>
*[[Edema]] and [[erythema]] of the vulva and labia
*[[Fissures]] and excoriations of the external genitalia
*Thick whitish vaginal discharge adherent to the vaginal walls
*[[Cervix]] is not affected and is normal
===Laboratory Findings===
The laboratory findings consistent with the diagnosis of [[Candida]] [[vulvovaginitis]] include:<ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref><ref name="pmid22519657">{{cite journal |vauthors=Mendling W, Brasch J |title=Guideline vulvovaginal candidosis (2010) of the German Society for Gynecology and Obstetrics, the Working Group for Infections and Infectimmunology in Gynecology and Obstetrics, the German Society of Dermatology, the Board of German Dermatologists and the German Speaking Mycological Society |journal=Mycoses |volume=55 Suppl 3 |issue= |pages=1–13 |year=2012 |pmid=22519657 |doi=10.1111/j.1439-0507.2012.02185.x |url=}}</ref><ref name="pmid17560449">{{cite journal |vauthors=Sobel JD |title=Vulvovaginal candidosis |journal=Lancet |volume=369 |issue=9577 |pages=1961–71 |year=2007 |pmid=17560449 |doi=10.1016/S0140-6736(07)60917-9 |url=}}</ref>
*[[Vaginal]] pH: [[vaginal]] pH is normal (ranges from 4.0-4.5)
*Wet mount or Saline preparation: It will help in detection of [[hyphae]], clue cells and motile [[trichomonas]] differentiating different causes of vaginitis.
*10% Potassium hydroxide preparation: It is more sensitive than wet mount to demonstrate budding blastospores or pseudohyphae.
*Culture: Culture for diagnosing [[Candida]] [[vulvovaginitis]] not recommended in patients with positive microscopy. However, it should be done in a symptomatic woman with a negative microscopy and a normal vaginal pH.  Culture using Sabouraud agar, Nickerson’s medium, or Microstix-candida medium identify Candida species with equal sensitivity.
===Approach to patient with Candida Vulvovaginitis===
The following is a algorithm for diagnosis and treatment of vulvovaginal candidiasis :
{{Family tree/start}}
{{Family tree | | | | | | A01 | | | |A01= Symptomatic Vaginitis}}
{{Family tree | | | | | | |!| | | | | }}
{{Family tree | | | | | | |!| | | | | }}
{{Family tree | | | | | | C01 | | | |C01= Whitish discharge adherent to the vaginal walls, excoriations and fissures in the genital area}}
{{Family tree | | | | | | |!| | | | | }}
{{Family tree | | | | | | |!| | | | | }}
{{Family tree | | | | | | E01 | | | |E01= Perform direct microscopy of the vaginal discharge with saline or 10% KOH<br> Estimate pH of vaginal discharge}}
{{Family tree | | | | | | |!| | | | | }}
{{Family tree | | |,|-|-|-|^|-|-|.|}}
{{Family tree | |F01| | | | |F02| |F01=Negative direct microscopy<br> pH < 4.5| F02= Positive direct microscopy}}
{{Family tree | | |!| | | | | | |!| | | | | | }}
{{Family tree | |G01| | | | |G02| | | |G01= Send for culture<br>Consider azole therapy|G02= No culture necessary }}
{{Family tree | | | | | | | | | |!| | | | }}
{{Family tree | | | | | | | |,|-|^|-|-|.| }}
{{Family tree | | | | | | | H01| | |H02|H01=pH < 4.5<br>No excess WBC's|H02= pH > 4.5<br>Excess WBC's}}
{{Family tree | | | | | | | |!| | | | |!| }}
{{Family tree | | | | | | |I01| | |I02|I01=Start azole therapy|I02=Consider mixed infection}}
{{Family tree/end}}
<small>Algorithm adopted from Vulvovaginal candidiasis Lancet 2007; 369: 1961–71<ref name="pmid17560449">{{cite journal| author=Sobel JD| title=Vulvovaginal candidosis. | journal=Lancet | year= 2007 | volume= 369 | issue= 9577 | pages= 1961-71 | pmid=17560449 | doi=10.1016/S0140-6736(07)60917-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17560449  }} </ref></small>


==Treatment==
==Treatment==
===Medical Therapy===
[[Balanitis medical therapy|Medical Therapy]] | [[Balanitis primary prevention|Primary Prevention]] | [[Balanitis secondary prevention|Secondary Prevention]] | [[Balanitis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Balanitis future or investigational therapies|Future or Investigational Therapies]]
According to, 2016 Update by the Infectious Diseases Society of America medical therapy for Candida vulvovaginitis includes<ref name="PappasKauffman2015">{{cite journal|last1=Pappas|first1=Peter G.|last2=Kauffman|first2=Carol A.|last3=Andes|first3=David R.|last4=Clancy|first4=Cornelius J.|last5=Marr|first5=Kieren A.|last6=Ostrosky-Zeichner|first6=Luis|last7=Reboli|first7=Annette C.|last8=Schuster|first8=Mindy G.|last9=Vazquez|first9=Jose A.|last10=Walsh|first10=Thomas J.|last11=Zaoutis|first11=Theoklis E.|last12=Sobel|first12=Jack D.|title=Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America|journal=Clinical Infectious Diseases|year=2015|pages=civ933|issn=1058-4838|doi=10.1093/cid/civ933}}</ref>:
*Uncomplicated candida Vulvovaginits:
**1st line :Any topical [[Antifungals|antifungal]] agents can be used and all of them have equal efficacy
**Alternative : Single 150mg dose of oral [[fluconazole]] is recommended
*Severe acute Candida vulvovaginitis:
**1st line: Oral [[fluconazole]] 150mg, given every 72 hours for a total of 2 or 3 doses
*Candida glabrata: When unresponsive to oral [[azoles]]
**1st line: Topical intravaginal [[boric acid]] administered in a gelatin capsule, 600mg daily for 14 days
**2nd line: [[Nystatin]] intravaginal suppositories, 100,000 units daily for 14 days
**3rd line: Topical 17% [[flucytosine]] cream alone or in combination with [[amphotericin B]] cream daily for 14 days
*Recurring vulvovaginal candidiasis:
**1st line: 10 to 14 days of induction therapy with a topical agent or oral [[fluconazole]], followed by [[fluconazole]], 150mg weekly for 6 months
====Candida Vulvovaginitis in HIV positive women====
*Treatment of symptomatic Candida vulvovaginitis  in [[Human Immunodeficiency Virus (HIV)|HIV]]-positive women is similar to HIV-negative individuals.
===Surgical Therapy===
There are no surgical options for Candida vulvovaginitis.
==Prevention==
===Primary Prevention===
*There are no primary preventive measures for candidal infection.
===Secondary Prevention===
*Prophylactic maintainence of fluconazole is helpful in patients with idiopathic recurrent candida vulvovaginitis and in secondary recurrent vulvovaginitis associated with [[lichen sclerosus]] or topical estrogen application.<ref name="pmid17560449">{{cite journal |vauthors=Sobel JD |title=Vulvovaginal candidosis |journal=Lancet |volume=369 |issue=9577 |pages=1961–71 |year=2007 |pmid=17560449 |doi=10.1016/S0140-6736(07)60917-9 |url=}}</ref>


==References==
== References ==
{{Reflist|2}}
{{Reflist|2}}
[[Category:Balanitis]]
[[Category:Infectious diseases]]
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Latest revision as of 17:25, 1 March 2017

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.

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

.

  • Tight foreskin
  • sub-optimal penile hygienic maintenance
 Anaerobic gram-negative rods produce various toxins, proteases, and elastase
Aerobic

Infections

  • Uncircumcised penis
 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

pallidum

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
  • Tight foreskin
  • sub-optimal penile hygienic maintenance
Aerobic

Infections

  • Uncircumcised penis
Trichomonas vaginalis
Treponema

pallidum

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]

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]

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. ↑ 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. ↑ 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. ↑ 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.
  4. ↑ GENITOURINARY MEDICINE, Volume 72, Number 3: Pages 155-9,
  5. ↑ 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. ↑ 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.
  7. ↑ 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.
  8. ↑ Sobel JD (1985). "Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis". Am. J. Obstet. Gynecol. 152 (7 Pt 2): 924–35. PMID 3895958.
  9. ↑ 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. ↑ 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. ↑ 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. ↑ 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. ↑ 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.
  14. ↑ 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. ↑ 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. ↑ 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. ↑ 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. ↑ 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. ↑ 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. ↑ 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. ↑ 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. ↑ 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. ↑ 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.
  24. ↑ GENITOURINARY MEDICINE, Volume 72, Number 3: Pages 155-9, June 1996.
  25. ↑ International Journal of Research in Health Sciences. Jan–Mar 2014 Volume-2, Issue-1
  26. ↑ 26.0 26.1 Invalid <ref> tag; no text was provided for refs named pmid248285532
  27. ↑ 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.
  28. ↑ Edwards S (1996). "Balanitis and balanoposthitis: a review". Genitourin Med. 72 (3): 155–9. PMC 1195642. PMID 8707315.
  29. ↑ Dockerty WG, Sonnex C (1995). "Candidal balano-posthitis: a study of diagnostic methods". Genitourin Med. 71 (6): 407–9. PMC 1196117. PMID 8566986.
  30. ↑ GENITOURINARY MEDICINE, Volume 72, Number 3: Pages 155-9,
  31. ↑ 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.
  32. ↑ Sobel JD (1985). "Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis". Am. J. Obstet. Gynecol. 152 (7 Pt 2): 924–35. PMID 3895958.
  33. ↑ 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.

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