Infectious balanitis: Difference between revisions

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__NOTOC__
__NOTOC__
{{SI}}
{{CMG}}{{AE}}{{VD}}


{{BalanitisV}}{{CMG}}{{AE}}{{VD}}
{{SK}}Candida balanitis, Infectious balanoposthitis
 
*'''For Balanitis main page click [[Balanitis|here]]'''
{{SK}}Candida balanitis, Candidal balanitis, Infectious balanoposthitis
==Overview==
==Overview==
[[Balanitis]] is [[inflammation]] of [[glans penis]]. When [[Balanitis|Inflammation]] involves [[foreskin]] or perpuce, it is termed as [[balanoposthitis]]. Studies have shown that [[Balanitis]] commonly occurs around 10% of the patient population visiting the [[Sexually transmitted disease|STD]] clinics, with infectious etiology responsible for around 50% of the cases. [[Risk factors]] for infectious balanitis include [[Diabetes mellitus|diabetes]], [[Immunocompromised]] conditions, age>40 yrs, tight [[foreskin]], sub-optimal hygienic maintenance, multiple sexual partners, and [[Circumcised|uncircumcised penis]]. [[Microorganisms]] causing balanitis could be part of the [[normal flora]] or [[Sexually transmitted infections|sexually transmitted]] or [[autoinoculation]], or transmitted via direct contact with infectious lesions. Patients may be asymptomatic or symptomatic presenting with [[itch]] or [[Pain|painful lesions]] in the [[Genital area|genital region]]. [[Diagnosis]] of the specific [[infectious balanitis]] is based on the clinical features supported by [[Laboratory|laboratory findings]]. [[Infectious balanitis]] is treated with [[Antimicrobial|antimicrobials]]. [[Prognosis]] is usually good with treatment. [[Safe sex|Safe sex practices]] and maintaining proper penile hygiene are helpful in preventing infectious balanitis.
[[Balanitis]] is [[inflammation]] of [[glans penis]]. When [[Balanitis|Inflammation]] involves [[foreskin]] or perpuce, it is termed as [[balanoposthitis]]. Studies have shown that [[balanitis]] commonly occurs around 10% of the patient population visiting the [[Sexually transmitted disease|STD]] clinics, with [[infectious]] etiology responsible for around 50% of the cases. [[Risk factors]] for [[infectious]] [[balanitis]] include [[Diabetes mellitus|diabetes]], [[Immunocompromised]] conditions, age>40 yrs, tight [[foreskin]], sub-optimal hygienic maintenance, multiple sexual partners, and [[Circumcised|uncircumcised penis]]. [[Microorganisms]] causing [[balanitis]] could be part of the [[normal flora]] or [[Sexually transmitted infections|sexually transmitted]] or [[autoinoculation]] or transmitted via direct contact with [[infectious]] [[lesions]]. Patients may be asymptomatic or symptomatic presenting with [[itch]] or [[Pain|painful lesions]] in the [[Genital area|genital region]]. [[Diagnosis]] of the specific [[infectious]] [[balanitis]] is based on the clinical features supported by [[Laboratory|laboratory findings]]. [[Infectious]] [[balanitis]] is treated with [[Antimicrobial|antimicrobials]]. [[Prognosis]] is usually good with treatment. [[Safe sex|Safe sex practices]] and maintaining proper penile hygiene are helpful in preventing [[infectious]] [[balanitis]].
==Historical Perspective==
==Historical Perspective==
Balanitis is an ancient disease,The term Balanitis is derived from a Greek term balanos or acorn.
[[Balanitis]] is an ancient disease. The term [[balanitis]] is derived from a greek term balanos or acorn.
==Classification==
==Classification==
There is no established classification system for Infectious Balanitis.
There is no established classification system for Infectious Balanitis.
==Pathophysiology==
==Pathophysiology==
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="pmid248285532">{{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>
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="pmid248285532">{{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>
{| class="wikitable"
{| class="wikitable"
!Pathogen
!Pathogen
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|
|
*All strains of ''[[C. albicans]]'' possess a [[yeast]] surface mannoprotein. This allows the various strains to adhere to both the exfoliated and [[epithelial cells]].
*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
*Other [[virulence factors]] include: [[Proteolytic enzyme|proteolytic enzymes]], [[toxins]] and [[phospholipase]]. [[Proteolytic enzyme|Proteolytic enzymes]] destroy the [[proteins]] that normally impair [[fungal]] invasion
|-
|-
|[[Anaerobic organism|Anaerobic Infection]]
|[[Anaerobic organism|Anaerobic Infection]]
|
|
*[[Sexually transmitted disease|Sexually transmitted]]
*[[Sexually transmitted disease|Sexually transmitted]]
*Extension from peri-rectal area
*Extension from [[Perirectal|peri-rectal]] area
*Oro-genital [[Sex (activity)|sex]]-[[Saliva|(saliva]] as a lubricant during [[coitus]])
*Oro-genital [[Sex (activity)|sex]] [[Saliva|(saliva]] as a lubricant during [[coitus]])
.
.
|
|
*Tight [[foreskin]]
*Tight [[foreskin]]
*sub-optimal penile hygienic maintenance
*Sub-optimal penile hygienic maintenance
|[[Anaerobic]] [[Gram-negative bacilli|gram-negative rods]] produce various [[toxins]], [[proteases]], and [[elastase]]
|[[Anaerobic]] [[Gram-negative bacilli|gram-negative rods]] produce various [[toxins]], [[proteases]]<nowiki/>and [[elastase]]
|-
|-
|[[Aerobic organism|Aerobic]]
|[[Aerobic organism|Aerobic]]
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*[[Autoinoculation]] from other sites
*[[Autoinoculation]] from other sites
|
|
*Uncircumcised penis
*Uncircumcised [[penis]]


*[[Diabetes]]
*[[Diabetes]]
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*Unprotected sexual activity
*Unprotected sexual activity
*Co-existing [[venereal diseases]]
*Co-existing [[venereal diseases]]
|Adherence, contact-independent factors, [[hemolysis]] and acquisition of host [[macromolecules]] have been shown to play a role in the [[pathogenesis]] of this infection
|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|Treponema]]
[[Treponema pallidum|pallidum]]
[[Treponema pallidum|pallidum]]
|Transmitted via direct contact with the infected lesion (sexual contact)
|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
|[[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|STI<nowiki/>s]], previous history of [[STI|STIs]], [[intravenous drug]] use, health care professionals who are predisposed to occupational risk and low socioeconomic status.
 
|[[Treponema Pallidum|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]])
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]])
|-
|-
|[[Herpes simplex]]
|[[Herpes simplex]]
Line 83: Line 82:
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" />
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>
, 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>
|Linked to [[epithelial]] [[differentiation]] and maturation of host [[keratinocytes]], with [[transcription]] of specific [[Gene|gene products]] at every level.
|Linked to [[epithelial]] [[differentiation]] and maturation of host [[keratinocytes]], with [[transcription]] of specific [[Gene|gene products]] at every level.
|}
|}
==Causes==
==Causes==
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>
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>


'''Common causes of infectious balanitis'''   
'''Common causes of infectious balanitis'''   


'''Fungal'''  
'''Fungal'''  
* [[Candida]](most common cause)
* [[Candida]] (most common cause)
'''Protozoal'''  
'''Protozoal'''  
* [[Trichomonas vaginalis]]  
* [[Trichomonas vaginalis]]  
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==== Spirochaetes ====
==== Spirochaetes ====
* Non-specific [[spirochaetal]] infection
* Non-specific [[spirochaetal]] [[infection]]
'''Gram positive organism'''  
'''Gram positive organism'''  
* [[Streptococci|Haemolytic Streptococci(Group B Streptococci)]]
* [[Streptococci|Haemolytic streptococci (group B streptococci)]]
* [[Staphylococci|Staphylococci epidermidis/aureus]]
* [[Staphylococci|Staphylococci epidermidis/aureus]]
'''Acid fast bacilli'''  
'''Acid fast bacilli'''  
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==Epidemiology and demographics==
==Epidemiology and demographics==
====Epidemiology====
====Epidemiology====
*There are no comprehensive studies studying the [[incidence]] and [[prevalence]] of balanoposthitis 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>
*There are no comprehensive studies studying the [[incidence]] and [[prevalence]] of [[balanoposthitis]] 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>
*[[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>
*[[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>
'''Demographics'''  
'''Demographics'''  


'''Age'''  
'''Age'''  


There are no comprehensive studies studying demographics of balanoposthitis in general population. Studies have shown that balanoposthitis occurs in males of all ages and ethnicity, with most cases occurring in toddlers or in children in age group between 2 and 5 years.<ref name="pmid3353186">{{cite journal| author=Fergusson DM, Lawton JM, Shannon FT| title=Neonatal circumcision and penile problems: an 8-year longitudinal study. | journal=Pediatrics | year= 1988 | volume= 81 | issue= 4 | pages= 537-41 | pmid=3353186 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3353186  }}</ref>
There are no comprehensive studies studying demographics of [[balanoposthitis]] in general population. Studies have shown that [[balanoposthitis]] occurs in males of all ages and ethnicity, with most cases occurring in toddlers or in children in age group between 2 and 5 years.<ref name="pmid3353186">{{cite journal| author=Fergusson DM, Lawton JM, Shannon FT| title=Neonatal circumcision and penile problems: an 8-year longitudinal study. | journal=Pediatrics | year= 1988 | volume= 81 | issue= 4 | pages= 537-41 | pmid=3353186 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3353186  }}</ref>


'''Sex'''
'''Sex'''


Balanoposthitis occurs only in males.
[[Balanoposthitis]] occurs only in males.


'''Race'''
'''Race'''
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==Screening==
==Screening==
There is no established [[screening]] guidelines for Infectious Balanitis.
There is no established [[screening]] guidelines for infectious balanitis.
 
==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
===Natural history===
===Natural history===
If left untreated, Infectious balanitis may result in complications, which include [[pain]], [[phimosis]], and urinary retention.<ref name="pmid248285532" />
If left untreated, [[infectious]] [[balanitis]] may result in complications, which include [[pain]], [[phimosis]], and [[urinary retention]].<ref name="pmid248285532" />
===Complications===
===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>
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]]
*[[Pain]]
*Erosions
*Erosions
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==== Physical examination ====
==== Physical examination ====
Patients with infectious balanitis are usually well appearing, with no systemic signs on examination.
Patients with [[infectious]] [[balanitis]] are usually well appearing, with no specific systemic signs on examination.


Examination of genitourinary system may show:
Examination of [[genitourinary system]] may show:<ref name="pmid248285532" />
* Erythema of prepuce or glans penis
* [[Erythema]] of [[prepuce]] or [[glans]] [[penis]]
* Edema of prepuce or glans penis
* [[Edema]] of [[prepuce]] or [[glans penis]]
* Discharge
* Discharge
* Inguinal lymphadenopathy
* [[Inguinal]] [[lymphadenopathy]]
* Ulcers
* [[Ulcers]]
* Phimosis
* [[Phimosis]]
* Vesicles
* [[Vesicles]]
{| class="wikitable"
{| class="wikitable"
! colspan="2" |Clinical features of Infectious balanitis<ref name="pmid26396455" />(adopted from the Indian journal of sexually transmitted diseases and AIDS)
! colspan="2" |Clinical features of Infectious balanitis<ref name="pmid26396455" />(adopted from the Indian journal of sexually transmitted diseases and AIDS)
|-
|-
|[[Candidiasis|Candidal Balanitis]]
|[[Candidiasis|Candidal Balanitis]]
|[[Erythematous]] [[Rash (patient information)|rash]] with soreness and/or [[itch]], blotchy [[erythema]] with small [[papules]] which may be eroded, or dry dull red areas with a glazed appearance
|[[Erythematous]] [[Rash (patient information)|rash]] with soreness and/or [[itch]], blotchy [[erythema]] with small [[papules]] which may be eroded or dry dull red areas with a glazed appearance.
|-
|-
|[[Anaerobic organism|Anaerobic Infection]]
|[[Anaerobic organism|Anaerobic Infection]]
|
|
*Foul smelling sub-preputial [[inflammation]] and [[discharge]]: in severe cases associated with [[swelling]] and inflamed [[inguinal lymph nodes]]
*Foul smelling sub-preputial [[inflammation]] and [[discharge]]: in severe cases associated with [[swelling]] and inflamed [[inguinal lymph nodes]]
*Preputial edema, superficial erosion's: milder forms also occur
*Preputial [[edema]] and superficial erosion's: milder forms also occur
|-
|-
|[[Aerobic organism|Aerobic]]
|[[Aerobic organism|Aerobic]]
Line 221: Line 222:
|-
|-
|[[Herpes simplex]]
|[[Herpes simplex]]
|Grouped [[vesicles]] on [[erythematous]] base over [[Glans penis|glans]], [[prepuce]] and [[shaft]] which rupture to form shallow erosions. In rare cases primary [[herpes]] can cause a necrotic balanitis, with [[Necrotic|necrotic areas]] on the [[glans]] accompanied by [[vesicles]] elsewhere and associated with [[headache]] and [[malaise]].
|Grouped [[vesicles]] on [[erythematous]] base over [[Glans penis|glans]], [[prepuce]] and [[shaft]] which rupture to form shallow erosions. In rare cases primary [[herpes]] can cause a [[necrotic]] [[balanitis]], with [[Necrotic|necrotic areas]] on the [[glans]] accompanied by [[vesicles]] elsewhere and associated with [[headache]] and [[malaise]].
|-
|-
|[[Human papilloma virus]]
|[[Human papilloma virus]]
|[[Human papillomavirus|Papilloma virus]] may be associated with patchy or chronic [[balanitis]], which becomes acetowhite after application of 5% [[acetic acid]]
|[[Human papillomavirus|Papilloma virus]] may be associated with patchy or chronic [[balanitis]] which becomes acetowhite after application of 5% [[acetic acid]]
|}
|}


Line 234: Line 235:
|
|
* [[Urinalysis]] for [[glucose]]
* [[Urinalysis]] for [[glucose]]
* Sub-preputial culture/swab for [[Candidiasis|primary candidiasis/]][[candidal]] superinfection to be done in all cases
* Sub-preputial culture/swab for [[Candidiasis|primary candidiasis/]][[candidal]] [[superinfection]] to be done in all cases
* Investigation for [[Human Immunodeficiency Virus|HIV]] or other causes of [[immunosuppression]] should be performed
* Investigation for [[Human Immunodeficiency Virus|HIV]] or other causes of [[immunosuppression]] should be performed
|-
|-
Line 248: Line 249:
|
|
* Sub-preputial culture
* Sub-preputial culture
* [[Streptococci|Streptococci spp]]. and [[Staphylococcus aureus|S. aureus]] have both been reported as causing balanitis
* [[Streptococci|Streptococci spp]]. and [[staphylococcus aureus]] have both been reported as causing [[balanitis]]
|-
|-
|[[Trichomonas  vaginalis]]
|[[Trichomonas  vaginalis]]
Line 258: Line 259:
|
|
* [[Dark field microscopy]], TP [[NAAT]] and [[DFA-TP]] will confirm the [[diagnosis]]. This should ideally be done every case.
* [[Dark field microscopy]], TP [[NAAT]] and [[DFA-TP]] will confirm the [[diagnosis]]. This should ideally be done every case.
* [[Treponema pallidum hemagglutination assay (TPHA) test|TPHA]] coupled with non-[[Treponema|treponemal]] [[Serology|serological]] tests though of limited value, should be performed since they are useful for follow-up
* [[Treponema pallidum hemagglutination assay (TPHA) test|TPHA]] coupled with non-[[Treponema|treponemal]] [[Serology|serological]] tests though of limited value should be performed since they are useful for follow-up
|-
|-
|[[Herpes simplex]]
|[[Herpes simplex]]
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|}Distinguishing clinical features, diagnosis, and management of balanitis due to inflammatory dermatoses, include:<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 name="pmid1690905722">{{cite journal| author=Kishimoto M, Lee MJ, Mor A, Abeles AM, Solomon G, Pillinger MH| title=Syphilis mimicking Reiter's syndrome in an HIV-positive patient. | journal=Am J Med Sci | year= 2006 | volume= 332 | issue= 2 | pages= 90-2 | pmid=16909057 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16909057  }}</ref><ref name="pmid2085440022">{{cite journal| author=Neill SM, Lewis FM, Tatnall FM, Cox NH, British Association of Dermatologists| title=British Association of Dermatologists' guidelines for the management of lichen sclerosus 2010. | journal=Br J Dermatol | year= 2010 | volume= 163 | issue= 4 | pages= 672-82 | pmid=20854400 | doi=10.1111/j.1365-2133.2010.09997.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20854400  }}</ref><ref name="pmid2216142422">{{cite journal| author=Chi CC, Kirtschig G, Baldo M, Brackenbury F, Lewis F, Wojnarowska F| title=Topical interventions for genital lichen sclerosus. | journal=Cochrane Database Syst Rev | year= 2011 | volume=  | issue= 12 | pages= CD008240 | pmid=22161424 | doi=10.1002/14651858.CD008240.pub2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22161424  }}</ref><ref name="pmid1245286522">{{cite journal| author=Porter WM, Francis N, Hawkins D, Dinneen M, Bunker CB| title=Penile intraepithelial neoplasia: clinical spectrum and treatment of 35 cases. | journal=Br J Dermatol | year= 2002 | volume= 147 | issue= 6 | pages= 1159-65 | pmid=12452865 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12452865  }}</ref><ref name="pmid1245459622">{{cite journal| author=Weyers W, Ende Y, Schalla W, Diaz-Cascajo C| title=Balanitis of Zoon: a clinicopathologic study of 45 cases. | journal=Am J Dermatopathol | year= 2002 | volume= 24 | issue= 6 | pages= 459-67 | pmid=12454596 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12454596  }}</ref><ref name="pmid775095022">{{cite journal| author=Kumar B, Sharma R, Rajagopalan M, Radotra BD| title=Plasma cell balanitis: clinical and histopathological features--response to circumcision. | journal=Genitourin Med | year= 1995 | volume= 71 | issue= 1 | pages= 32-4 | pmid=7750950 | doi= | pmc=1195366 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7750950  }}</ref><ref name="pmid1749716222">{{cite journal| author=Nast A, Kopp I, Augustin M, Banditt KB, Boehncke WH, Follmann M et al.| title=German evidence-based guidelines for the treatment of Psoriasis vulgaris (short version). | journal=Arch Dermatol Res | year= 2007 | volume= 299 | issue= 3 | pages= 111-38 | pmid=17497162 | doi=10.1007/s00403-007-0744-y | pmc=1910890 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17497162  }}</ref><ref name="pmid1530796922">{{cite journal| author=Zawar V, Kirloskar M, Chuh A| title=Fixed drug eruption - a sexually inducible reaction? | journal=Int J STD AIDS | year= 2004 | volume= 15 | issue= 8 | pages= 560-3 | pmid=15307969 | doi=10.1258/0956462041558285 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15307969  }}</ref>
|}Distinguishing clinical features, diagnosis, and management of balanitis due to inflammatory dermatoses, include:<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 name="pmid1690905722">{{cite journal| author=Kishimoto M, Lee MJ, Mor A, Abeles AM, Solomon G, Pillinger MH| title=Syphilis mimicking Reiter's syndrome in an HIV-positive patient. | journal=Am J Med Sci | year= 2006 | volume= 332 | issue= 2 | pages= 90-2 | pmid=16909057 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16909057  }}</ref><ref name="pmid2085440022">{{cite journal| author=Neill SM, Lewis FM, Tatnall FM, Cox NH, British Association of Dermatologists| title=British Association of Dermatologists' guidelines for the management of lichen sclerosus 2010. | journal=Br J Dermatol | year= 2010 | volume= 163 | issue= 4 | pages= 672-82 | pmid=20854400 | doi=10.1111/j.1365-2133.2010.09997.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20854400  }}</ref><ref name="pmid2216142422">{{cite journal| author=Chi CC, Kirtschig G, Baldo M, Brackenbury F, Lewis F, Wojnarowska F| title=Topical interventions for genital lichen sclerosus. | journal=Cochrane Database Syst Rev | year= 2011 | volume=  | issue= 12 | pages= CD008240 | pmid=22161424 | doi=10.1002/14651858.CD008240.pub2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22161424  }}</ref><ref name="pmid1245286522">{{cite journal| author=Porter WM, Francis N, Hawkins D, Dinneen M, Bunker CB| title=Penile intraepithelial neoplasia: clinical spectrum and treatment of 35 cases. | journal=Br J Dermatol | year= 2002 | volume= 147 | issue= 6 | pages= 1159-65 | pmid=12452865 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12452865  }}</ref><ref name="pmid1245459622">{{cite journal| author=Weyers W, Ende Y, Schalla W, Diaz-Cascajo C| title=Balanitis of Zoon: a clinicopathologic study of 45 cases. | journal=Am J Dermatopathol | year= 2002 | volume= 24 | issue= 6 | pages= 459-67 | pmid=12454596 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12454596  }}</ref><ref name="pmid775095022">{{cite journal| author=Kumar B, Sharma R, Rajagopalan M, Radotra BD| title=Plasma cell balanitis: clinical and histopathological features--response to circumcision. | journal=Genitourin Med | year= 1995 | volume= 71 | issue= 1 | pages= 32-4 | pmid=7750950 | doi= | pmc=1195366 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7750950  }}</ref><ref name="pmid1749716222">{{cite journal| author=Nast A, Kopp I, Augustin M, Banditt KB, Boehncke WH, Follmann M et al.| title=German evidence-based guidelines for the treatment of Psoriasis vulgaris (short version). | journal=Arch Dermatol Res | year= 2007 | volume= 299 | issue= 3 | pages= 111-38 | pmid=17497162 | doi=10.1007/s00403-007-0744-y | pmc=1910890 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17497162  }}</ref><ref name="pmid1530796922">{{cite journal| author=Zawar V, Kirloskar M, Chuh A| title=Fixed drug eruption - a sexually inducible reaction? | journal=Int J STD AIDS | year= 2004 | volume= 15 | issue= 8 | pages= 560-3 | pmid=15307969 | doi=10.1258/0956462041558285 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15307969  }}</ref>
==Treatment==
==Treatment==
Treatment of infectious balanitis is predominately antimicrobials.
Treatment of [[infectious]] [[balanitis]] is predominately [[antimicrobials]]. Specific [[antimicrobial]] therapy include:<ref name="pmid26396455" />
{| class="wikitable"
! colspan="3" |Treatment<ref name="pmid26396455" />(adopted from the Indian journal of sexually transmitted diseases and AIDS)
|-
!
!Preferred regimen
!Alternative regimen
|-
|[[Candidiasis|Candidal Balanitis]]
|[[Clotrimazole|Clotrimazole cream]] 1% or
[[Miconazole|Miconazole cream]] 2%
|[[Fluconazole]] 150 mg stat orally or
[[Nystatin]] cream-if resistance suspected topical or [[clotrimazole]]/[[miconazole]] with 1% [[hydrocortisone]]-if marked [[inflammation]]
|-
|[[Anaerobic organism|Anaerobic Infection]]
|Advice about genital hygiene
[[metronidazole]] 400 mg twice daily for 1 week


Milder cases- topical [[metronidazole]]
===Medical therapy===
|Co-amoxiclav([[amoxycillin]]/[[clavulanic acid]]) 375 mg 3 times daily for 1 week or
====Empirical therapy====
[[Clindamycin]] cream applied twice daily until resolved
*[[Aerobic]] or [[anaerobic]] [[infections]]:
|-
**Preferred regimen 1: [[Metronidazole]] 500 mg oral BID for 1 week.
|[[Aerobic organism|Aerobic]]
**Preferred regimen 2: [[Amoxicillin-Clavulanate]] 375 mg oral TID for 1 week
[[Aerobic organism|Infections]]
**Preferred regimen 3: [[Clindamycin]] topical cream BID until resolved
|Usually topical
Triple combination ([[clotrimazole]] 1%, [[Beclometasone dipropionate (nasal)|beclometasone dipropionate]] 0.025%, [[gentamicin]] sulfate 0.3%) applied once daily


Severe cases-systemic antibiotics
====Pathogen directed therapy====
*[[Candidal]] [[infection]]:
**Preferred regimen: [[Clotrimazole|Clotrimazole cream]] 1% or [[Miconazole|Miconazole cream]] 2% BID
**Alternative regimen 1: [[Fluconazole]] 150 mg orally
**Alternative regimen 2: [[Clotrimazole]]/[[miconazole]] with 1% [[hydrocortisone]] in case of [[inflammation]]
**Alternative regimen 3: [[Nystatin]] 100,000 units per gram topical in case of resistance


[[Erythromycin]] 500 mg QDS for 1 week or
*[[Trichomonas vaginalis|Trichomonas  vaginalis]]:
**Preferred regimen 1: [[Metronidazole]] 2 g oral once daily
**Preferred regimen 2: [[Secnidazole]] 2 g oral once daily
**Alternative regimen: [[Metronidazole]] 400 mg oral BID for 1 week  


Co-amoxiclav([[amoxycillin]]/[[clavulanic acid]] 375 mg 3 times daily for 1 week
*[[Treponema pallidum]]:
|Alternative regimens depend on the sensitivities of the organisms isolated
**Preferred regimen 1: [[Benzathine penicillin G|Benzathine penicillin]] 2.4 million units intramuscular once
|-
**Preferred regimen 2: [[Doxycycline]] 100 mg oral BID for 2 weeks
|[[Trichomonas  vaginalis]]
**Preferred regimen 3: [[Tetracycline]] 500 mg orally QID for 2 weeks
|[[Metronidazole]] 2 g orally single dose or
**Preferred regimen 4: [[Erythromycin]] 500 mg QID
[[Secnidazole]] 2 g orally single dose
**Preferred regimen 5: [[Ceftriaxone]] 1 g intramuscular or intravenous daily for 8-10 days
|[[Metronidazole]] 400 mg orally twice a day for 7 days
|-
|[[Treponema pallidum]]
|Single IM administration of 2.4 MU of [[Benzathine penicillin G|benzathine penicillin]] or
[[Doxycycline]] 100 mg orally BID for 2 weeks or


[[Tetracycline]] 500 mg orally QID for 2 weeks or
*[[Herpes simplex virus]]:
**Preferred regimen 1: [[Acyclovir]] 400 mg oral TID  daily for 7-10 days
**Preferred regimen 2: [[Acyclovir]] 200 mg oral 5 times daily for 7-10 days
**Preferred regimen 3: [[Famciclovir]] 250 mg oral TID daily for 7-10 days
**Preferred regimen 4: [[Valacyclovir]] 1 g oral BID for 7-10 days


[[Erythromycin]] 500 mg QID or
*[[Human papillomavirus|Human papilloma virus]]:
**Preferred regimen 1: [[Podophyllin]] resin 20% with [[benzoin]] once per week for 6-8 weeks
**Preferred regimen 2: TCA-bichloroacetic acid 80-90% once per week for 6-10 weeks


[[Ceftriaxone]] 1 g IM/IV daily for 8-10 days
|
|-
|[[Herpes simplex]]
|[[Acyclovir]] 400 mg orally 3 times a day for 7-10 days or
[[Acyclovir]] 200 mg orally 5 times a day for 7-10 days or
[[Famciclovir]] 250 mg orally 3 times a day for 7-10 days or
[[Valacyclovir]] 1 g orally twice a day for 7-10 days
|
|-
|[[Human papillomavirus|Human papilloma virus]]
|'''Patients applied'''
[[Podophyllotoxin]](podofilox) 0.5% gel-twice daily for three consecutive days, but no more than 4 weeks or [[Imiquimod]] 5% cream-applied at bedtime 3 times/week for a maximum of 16 weeks, and must be left in place for 6-10 h following application.
'''Provider-administered'''
[[Podophyllin]] resin 20% in a compound tincture
of [[benzoin]]-once a week for 6-8 week or
[[Cryotherapy]] with liquid [[nitrogen]] cryoprobe.
Repeat applications every 1-2 weeks or
TCA/bichloroacetic acid-80-90% once per week for an average course of 6-10 weeks or
Surgical removal either by tangential scissor excision, tangential shave excision, [[curettage]], or [[electrosurgery]].
|
|}
==Prevention==
==Prevention==
===Primary Prevention===
===Primary Prevention===
[[Primary prevention]] of Infectious balanitis include:<ref name="pmid26396455" />
[[Primary prevention]] of [[infectious]] [[balanitis]] include:<ref name="pmid26396455" />
*[[Safe sex|Safe sex practices]]
*[[Safe sex|Safe sex practices]]
*Maintaining proper penile hygiene
*Maintaining proper penile hygiene
===Secondary prevention===
===Secondary prevention===
There are no specific [[Secondary prevention|secondary preventive]] measures for [[Infectious balanitis|Infective balanitis]]
There are no specific [[Secondary prevention|secondary preventive]] measures for [[infectious]] [[balanitis]].
 
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Latest revision as of 18:06, 30 March 2017

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List of terms related to Infectious balanitis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Vishal Devarkonda, M.B.B.S[2]

Synonyms and keywords:Candida balanitis, Infectious balanoposthitis

  • For Balanitis main page click here

Overview

Balanitis is inflammation of glans penis. When Inflammation involves foreskin or perpuce, it is termed as balanoposthitis. Studies have shown that balanitis commonly occurs around 10% of the patient population visiting the STD clinics, with infectious etiology responsible for around 50% of the cases. Risk factors for infectious balanitis include diabetes, Immunocompromised conditions, age>40 yrs, tight foreskin, sub-optimal hygienic maintenance, multiple sexual partners, and uncircumcised penis. Microorganisms causing balanitis could be part of the normal flora or sexually transmitted or autoinoculation or transmitted via direct contact with infectious lesions. Patients may be asymptomatic or symptomatic presenting with itch or painful lesions in the genital region. Diagnosis of the specific infectious balanitis is based on the clinical features supported by laboratory findings. Infectious balanitis is treated with antimicrobials. Prognosis is usually good with treatment. Safe sex practices and maintaining proper penile hygiene are helpful in preventing infectious balanitis.

Historical Perspective

Balanitis is an ancient disease. The term balanitis is derived from a greek term balanos or acorn.

Classification

There is no established classification system for Infectious Balanitis.

Pathophysiology

Pathophysiology of infectious balanitis varies from pathogen to pathogen:[1][2][3][4][5][6][7]

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, proteasesand elastase
Aerobic

Infections

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:[8][9][10][11][12][13][14]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[15][16], acqusition of new partner[15]

, having non monogamous sex partner[17][18], starting sexual activity in young age[17], vaginal delivery and multiple deliveries[19], age over 40 for women[20], history of chlamydia infection[21], and long term OCP use[22]

Linked to epithelial differentiation and maturation of host keratinocytes, with transcription of specific gene products at every level.

Causes

Causes of infectious balanitis include:[23][24][5][25]

Common causes of infectious balanitis

Fungal

Protozoal

spirochaetes

Viral

Less common causes of infectious balanitis

Fungal

Viral

Protozoal

Parasitic

Bacterial

Gram negative bacteria

Spirochaetes

Gram positive organism

Acid fast bacilli

Anaerobes

Epidemiology and demographics

Epidemiology

Demographics

Age

There are no comprehensive studies studying demographics of balanoposthitis in general population. Studies have shown that balanoposthitis occurs in males of all ages and ethnicity, with most cases occurring in toddlers or in children in age group between 2 and 5 years.[28]

Sex

Balanoposthitis occurs only in males.

Race

There is no racial predilection.

Screening

There is no established screening guidelines for infectious balanitis.

Natural History, Complications, and Prognosis

Natural history

If left untreated, infectious balanitis may result in complications, which include pain, phimosis, and urinary retention.[5]

Complications

Complication of infectious balanitis include:[29]

Prognosis

Prognosis is usually good with treatment.

Diagnosis

History and symptoms

Patients may be asymptomatic or symptomatic presenting with itch or painful lesions in the genital region.[5]

Physical examination

Patients with infectious balanitis are usually well appearing, with no specific systemic signs on examination.

Examination of genitourinary system may show:[5]

Clinical features of Infectious balanitis[25](adopted from the Indian journal of sexually transmitted diseases and AIDS)
Candidal Balanitis Erythematous rash with soreness and/or itch, blotchy erythema with small papules which may be eroded or dry dull red areas with a glazed appearance.
Anaerobic Infection
Aerobic

Infections

Variable inflammatory changes including uniform erythema and edema
Trichomonas vaginalis Superficial erosive balanitis which may lead to phimosis
Treponema pallidum Multiple circinate lesions which erode to cause irregular ulcers have been described in the late primary or early secondary stage. A primary chancre may also be present.
Herpes simplex Grouped vesicles on erythematous base over glans, prepuce and shaft which rupture to form shallow erosions. In rare cases primary herpes can cause a necrotic balanitis, with necrotic areas on the glans accompanied by vesicles elsewhere and associated with headache and malaise.
Human papilloma virus Papilloma virus may be associated with patchy or chronic balanitis which becomes acetowhite after application of 5% acetic acid

Laboratory findings

Laboratory findings[25](adopted from the Indian journal of sexually transmitted diseases and AIDS)
Candidal Balanitis
Anaerobic Infection
Aerobic

Infections

Trichomonas vaginalis
  • Wet preparation from the subpreputial sac demonstrates the organism
  • Culture and NAAT can also be carried out
Treponema pallidum
Herpes simplex
Human papilloma virus Diagnosed clinically

Distinguishing clinical features, diagnosis, and management of balanitis due to inflammatory dermatoses, include:[30][31][32][33][34][35][36][37][38]

Treatment

Treatment of infectious balanitis is predominately antimicrobials. Specific antimicrobial therapy include:[25]

Medical therapy

Empirical therapy

Pathogen directed therapy

Prevention

Primary Prevention

Primary prevention of infectious balanitis include:[25]

Secondary prevention

There are no specific secondary preventive measures for infectious balanitis.

References

  1. ↑ Taylor PK, Rodin P (1975). "Herpes genitalis and circumcision". Br J Vener Dis. 51 (4): 274–7. PMC 1046564. PMID 1156848.
  2. ↑ 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.
  3. ↑ GENITOURINARY MEDICINE, Volume 72, Number 3: Pages 155-9,
  4. ↑ 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.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 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.
  6. ↑ 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.
  7. ↑ Sobel JD (1985). "Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis". Am. J. Obstet. Gynecol. 152 (7 Pt 2): 924–35. PMID 3895958.
  8. ↑ 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.
  9. ↑ 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.
  10. ↑ Hook EW, Peeling RW (2004). "Syphilis control--a continuing challenge". N Engl J Med. 351 (2): 122–4. doi:10.1056/NEJMp048126. PMID 15247352.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ 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.
  14. ↑ 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.
  15. ↑ 15.0 15.1 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.
  16. ↑ 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.
  17. ↑ 17.0 17.1 Koutsky L (1997). "Epidemiology of genital human papillomavirus infection". Am. J. Med. 102 (5A): 3–8. PMID 9217656.
  18. ↑ 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.
  19. ↑ 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.
  20. ↑ 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.
  21. ↑ 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.
  22. ↑ 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.
  23. ↑ GENITOURINARY MEDICINE, Volume 72, Number 3: Pages 155-9, June 1996.
  24. ↑ International Journal of Research in Health Sciences. Jan–Mar 2014 Volume-2, Issue-1
  25. ↑ 25.0 25.1 25.2 25.3 25.4 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.
  26. ↑ Edwards S (1996). "Balanitis and balanoposthitis: a review". Genitourin Med. 72 (3): 155–9. PMC 1195642. PMID 8707315.
  27. ↑ Dockerty WG, Sonnex C (1995). "Candidal balano-posthitis: a study of diagnostic methods". Genitourin Med. 71 (6): 407–9. PMC 1196117. PMID 8566986.
  28. ↑ Fergusson DM, Lawton JM, Shannon FT (1988). "Neonatal circumcision and penile problems: an 8-year longitudinal study". Pediatrics. 81 (4): 537–41. PMID 3353186.
  29. ↑ 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.
  30. ↑ 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.
  31. ↑ Kishimoto M, Lee MJ, Mor A, Abeles AM, Solomon G, Pillinger MH (2006). "Syphilis mimicking Reiter's syndrome in an HIV-positive patient". Am J Med Sci. 332 (2): 90–2. PMID 16909057.
  32. ↑ Neill SM, Lewis FM, Tatnall FM, Cox NH, British Association of Dermatologists (2010). "British Association of Dermatologists' guidelines for the management of lichen sclerosus 2010". Br J Dermatol. 163 (4): 672–82. doi:10.1111/j.1365-2133.2010.09997.x. PMID 20854400.
  33. ↑ Chi CC, Kirtschig G, Baldo M, Brackenbury F, Lewis F, Wojnarowska F (2011). "Topical interventions for genital lichen sclerosus". Cochrane Database Syst Rev (12): CD008240. doi:10.1002/14651858.CD008240.pub2. PMID 22161424.
  34. ↑ Porter WM, Francis N, Hawkins D, Dinneen M, Bunker CB (2002). "Penile intraepithelial neoplasia: clinical spectrum and treatment of 35 cases". Br J Dermatol. 147 (6): 1159–65. PMID 12452865.
  35. ↑ Weyers W, Ende Y, Schalla W, Diaz-Cascajo C (2002). "Balanitis of Zoon: a clinicopathologic study of 45 cases". Am J Dermatopathol. 24 (6): 459–67. PMID 12454596.
  36. ↑ Kumar B, Sharma R, Rajagopalan M, Radotra BD (1995). "Plasma cell balanitis: clinical and histopathological features--response to circumcision". Genitourin Med. 71 (1): 32–4. PMC 1195366. PMID 7750950.
  37. ↑ Nast A, Kopp I, Augustin M, Banditt KB, Boehncke WH, Follmann M; et al. (2007). "German evidence-based guidelines for the treatment of Psoriasis vulgaris (short version)". Arch Dermatol Res. 299 (3): 111–38. doi:10.1007/s00403-007-0744-y. PMC 1910890. PMID 17497162.
  38. ↑ Zawar V, Kirloskar M, Chuh A (2004). "Fixed drug eruption - a sexually inducible reaction?". Int J STD AIDS. 15 (8): 560–3. doi:10.1258/0956462041558285. PMID 15307969.
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