Infectious balanitis: Difference between revisions

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


==Historical Perspective==
==Historical Perspective==
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|[[Candidiasis|Candidal Balanitis]]
|[[Candidiasis|Candidal Balanitis]]
|
|
* Sexual transmitted
* [[Sexual transmitted infection|Sexual transmitted]]
* Opportunistic infection
* [[Opportunistic infection]]
|
|
* [[Diabetes]]
* [[Diabetes]]
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* Age>40 yrs
* Age>40 yrs
|
|
* All strains of ''[[C. albicans]]'' possess a yeast surface mannoprotein. This allows the various strains to adhere to both the exfoliated and buccal epithelial cells of the vagina.
* All strains of ''[[C. albicans]]'' possess a [[yeast]] surface mannoprotein. This allows the various strains to adhere to both the exfoliated and [[epithelial cells]].
* Several virulence factors of [[Candida]] are implicated in Balanitis. These include proteolytic enzymes, toxins and phospholipase. Proteolytic enzymes destroy the proteins that normally impair fungal invasion
* Several [[virulence factors]] of [[Candida]] are implicated in [[Balanitis]]. These 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 the perirectal area
* Extension from the peri-rectal area
* Orogenital sex-saliva as a lubricant during [[coitus]]
* Orogenital [[Sex (activity)|sex]]-[[saliva]] as a lubricant during [[coitus]]
.
.


|
|
* Tight foreskin
* Tight [[foreskin]]
* sub-optimal hygienic maintenance
* sub-optimal penile hygienic maintenance
|[[Anaerobic]] [[Gram-negative bacilli|gram-negative rods]] produce various [[toxins]], [[proteases]], [[elastase]], and other [[virulence factors]]
|[[Anaerobic]] [[Gram-negative bacilli|gram-negative rods]] produce various [[toxins]], [[proteases]], [[elastase]], and other [[virulence factors]]
|-
|-
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* Unprotected sexual activity
* Unprotected sexual activity
* Co-existing [[venereal diseases]]
* Co-existing [[venereal diseases]]
|[[Virulence factors]] such as adherence, contact-independent factors, [[hemolysis]] and acquisition of host [[macromolecules]] have been shown to play a role in the pathogenesis of this infection
|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]]  
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|[[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>
|[[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
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.
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]])
|[[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]]
|Often transmitted sexually
|Often transmitted sexually or direct contact with droplet or infected secretions entering thorough [[skin]] or [[Mucous membrane|mucous membranes]].
 
direct contact with, or droplets from, infected secretions entering via skin or mucous membrane
|
|
* Multiple sexual partners
* Multiple sexual partners
* Low socio-economic status  
* Low [[socio-economic status]]
|Inhibition of [[MHC class I|MHC Class I]], Impairing funtion of [[Dendritic cell|dendritric cells]]  
|
* Inhibition of [[MHC class I|MHC Class I]]  
* Impairing funtion of [[Dendritic cell|dendritric cells]]
|-
|-
|[[Human papilloma virus]]
|[[Human papilloma virus]]
|Usually transmitted via the sexual route to the human host. 
|Usually transmitted via the [[Sexual|sexual route]] to the human host. 
|Risk factors responsible for sexual transmission of HPV include:
|[[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">{{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>
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">{{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>


,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">{{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>,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>, 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">{{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>, 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.<sup>[[Human papillomavirus pathophysiology|[2][3]]]</sup>
|Linked to [[epithelial]] [[differentiation]] and maturation of host [[keratinocytes]], with [[transcription]] of specific [[Gene|gene products]] at every level.<sup>[[Human papillomavirus pathophysiology|[2][3]]]</sup>
|}
|}


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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.<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>
If left untreated, Infectious balanitis may result in complications, which include [[pain]], [[phimosis]], and urinary retention.<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>


===Complications===
===Complications===
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==== History and symptoms ====
==== History and symptoms ====
Patients may be asymptomatic or present with [[Itch|pruritic]], or painful lesions in the [[Genital area|genital region]].
Patients may be asymptomatic or symptomatic presenting with [[itch]], or painful lesions in the [[Genital area|genital region]].
 
[[Physical examination]]
{| class="wikitable"
{| class="wikitable"
! colspan="2" |Clinical features of Infectious balanitis<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>(adopted from the Indian journal of sexually transmitted diseases and AIDS)
! colspan="2" |Clinical features of Infectious balanitis<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>(adopted from the Indian journal of sexually transmitted diseases and AIDS)
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|-
|-
|[[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]]
|
Preputial edema, superficial erosions: milder forms also occur
* Foul smelling sub-preputial [[inflammation]] and [[discharge]]: in severe cases associated with [[swelling]] and inflamed [[inguinal lymph nodes]]
* Preputial edema, superficial erosions: milder forms also occur
|-
|-
|[[Aerobic organism|Aerobic]]
|[[Aerobic organism|Aerobic]]
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|-
|-
|[[Herpes simplex]]
|[[Herpes simplex]]
|Grouped [[vesicles]] on [[erythematous]] base over [[Glans penis|glans]], prepuce and shaft which rupture to form shallow erosins. In rare cases primary herpes can cause a necrotic balanitis, with necrotic areas on the glans accompained by vesicles elsewhere and associated with headache and malaise.
|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]] accompained by [[vesicles]] elsewhere and associated with [[headache]] and [[malaise]].
|-
|-
|[[Human papilloma virus]]
|[[Human papilloma virus]]
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|[[Candidiasis|Candidal Balanitis]]
|[[Candidiasis|Candidal Balanitis]]
|[[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]]
Investigation for [[Human Immunodeficiency Virus|HIV]] or other causes of [[immunosuppression]] should be performed
|-
|-
|[[Anaerobic organism|Anaerobic Infection]]
|[[Anaerobic organism|Anaerobic Infection]]
Line 196: Line 199:
|[[Treponema pallidum]]
|[[Treponema pallidum]]
|[[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 nontreponemal [[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]]
Line 217: Line 220:
[[Miconazole|Miconazole cream]] 2%
[[Miconazole|Miconazole cream]] 2%
|[[Fluconazole]] 150 mg stat orally
|[[Fluconazole]] 150 mg stat orally
[[Nystatin]] cream-if resistance suspected topical [[clotrimazole]]/[[miconazole]] with 1% hydrocortisone-if marked inflammation
[[Nystatin]] cream-if resistance suspected topical [[clotrimazole]]/[[miconazole]] with 1% [[hydrocortisone]]-if marked [[inflammation]]
|-
|-
|[[Anaerobic organism|Anaerobic Infection]]
|[[Anaerobic organism|Anaerobic Infection]]
Line 223: Line 226:
[[metronidazole]] 400 mg twice daily for 1 week
[[metronidazole]] 400 mg twice daily for 1 week


Milder cases- topical metronidazole
Milder cases- topical [[metronidazole]]
|Coamoxiclav(amoxycillin/clavulanic acid) 375 mg 3 times daily for 1 week
|Coamoxiclav([[amoxycillin]]/[[clavulanic acid]]) 375 mg 3 times daily for 1 week
[[Clindamycin]] cream applied twice daily until resolved
[[Clindamycin]] cream applied twice daily until resolved
|-
|-
Line 236: Line 239:
[[Erythromycin]] 500 mg QDS for 1 week
[[Erythromycin]] 500 mg QDS for 1 week


Co-amoxiclav(amoxycillin/clvulanic acid 375 mg 3 times daily for 1 week
Co-amoxiclav([[amoxycillin]]/[[clavulanic acid]] 375 mg 3 times daily for 1 week
|Alternative regimens depend on the sensitivities of the organisms isolated
|Alternative regimens depend on the sensitivities of the organisms isolated
|-
|-
|[[Trichomonas vaginalis|Trichomonas  vaginalis]]
|[[Trichomonas vaginalis|Trichomonas  vaginalis]]
|[[Metronidazole]] 2 g orally single dose
|[[Metronidazole]] 2 g orally single dose
Secidazole 2 g orally single dose
[[Secnidazole]] 2 g orally single dose
|[[Metronidazole]] 400 mg orally twice a day for 7 days
|[[Metronidazole]] 400 mg orally twice a day for 7 days
|-
|-
Line 265: Line 268:
|-
|-
|[[Human papillomavirus|Human papilloma virus]]
|[[Human papillomavirus|Human papilloma virus]]
|Patients applied
|'''Patients applied'''
[[Podophyllotoxin]](podofilox) 0.5% or gel-twice daily for three consecutive days, but no more than 4 weeks or Imiquimod 5% cream-applied at bedtime 3 times/week for a maximum of 16 weeks, and must be left in place for 6-10 h following application or [[Sinecatechins]] 15% ointment
[[Podophyllotoxin]](podofilox) 0.5% or gel-twice daily for three consecutive days, but no more than 4 weeks or [[Imiquimod]] 5% cream-applied at bedtime 3 times/week for a maximum of 16 weeks, and must be left in place for 6-10 h following application or [[Sinecatechins]] 15% ointment


Provider-administered
'''Provider-administered'''


[[Podophyllin]] resin 20% in a compound tincture
[[Podophyllin]] resin 20% in a compound tincture
Line 274: Line 277:
of [[benzoin]]-once a week for 6-8 week or
of [[benzoin]]-once a week for 6-8 week or


[[Cryotherapy]] with liquid nitrogen ot cryoprobe.
[[Cryotherapy]] with liquid [[nitrogen]] ot cryoprobe.


Repeat applications every 1-2 weeks or
Repeat applications every 1-2 weeks or
Line 286: Line 289:
==Prevention==
==Prevention==
===Primary Prevention===
===Primary Prevention===
[[Primary prevention]] of Infectious balanitis include:
[[Primary prevention]] of Infectious balanitis include:<ref name="pmid26396455" />
* Safe sex practices.
* Safe sex practices.
* Maintaining proper penile hygiene.
* Maintaining proper penile hygiene.

Revision as of 20:41, 12 February 2017


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

Synonyms and keywords:Candida balanitis, Candidal balanitis, Infectious balanoposthitis

Overview

Balanitis is inflammation of glans penis. When balanitis involves the foreskin and perpuce, it is termed as balanoposthitis. Studies have showed that Balanitis commonly occurs around 10% of the patient population visiting the STD clinic, with infectious etiology responsible for around 50% of the cases. Risk factors for balanitis include diabetes, Immunocompromised, Age>40 yrs, tight foreskin, sub-optimal hygienic maintenance, multiple sexual partners, and uncircumcised penis. Organisms could be part of the normal flora or sexually transmitted or autoinoculation, or 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 clinical presentation 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 infective balanitis.

Historical Perspective

Balanitis is an ancient disease,The term Balanitis is derived from a Greek term balanos or acorn.

Classification

There is no established classification system for Infectious Balanitis.

Pathophysiology

Pathophysiology of Infectious balanitis varies from pathogen to pathogen:[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, proteases, elastase, and other virulence factors
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:[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 the 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.[2][3]

Causes

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

 
 
 
 
 
 
Balanitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fungal
 
Virus
 
Parasite/Protozoal
 
 
 
 
Bacteria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Candida (albicans, krusei)
Dermatophytosis
Pityriasis versicolor
Histoplasma capsulatum
Blastomyces dermatitidis
Cryptococcus neoformans
 
Herpes simplex virus
Varicella zoster virus (VZV)
Human papilloma virus (HPV)
 
Protozoal
Entamoeba histolytica
Trichomonas vaginalis
Leishmania species
Parastic
Sarcoptes scabiei var hominis
Pediculosis
Ankylostoma species
 
Gram negative bacteria
E.coli, Pseudomonas, Haemophilus parainfluenzae, Klebsiella, Neisseria gonorrhoea, Haemophilus ducreyi, Mycoplasma genitalium, Chlamydia, Ureaplasma, Gardnerella vaginalis, Citrobacter, Enterobacter
 
Spirochaetes
Treponema pallidum, Non specific spirochaetal infection
 
Gram positive organism
Haemolytic Streptococci(Group B Streptococci), Staphylococci epidermidis/aureus
 
Acid fast bacilli
Mycobacterium tuberculosis, Leprosy
Anaerobes
(Bacteroides)
 

Epidemiology

Epidemiology

  • There are no comprehensive studies, studying the incidence and prevalence in general population. Studies have showed that Balanitis commonly occurs around 10% of the patient population visiting the STD clinc, with infectious etiology responsible for around 50% of the cases.[26]
  • Candida being the most common cause responsible for 30-35% of cases.[27]

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:[28]

Prognosis

Prognosis is good with treatment.

Diagnosis

History and symptoms

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

Physical examination

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 accompained by vesicles elsewhere and associated with headache and malaise.
Human papilloma virus Papilloma virus may be associated with patchy or chronic balanitis, which becomes acetowhite after the application of 5% acetic acid

Laboratory findings

Laboratory findings[25](adopted from the Indian journal of sexually transmitted diseases and AIDS)
Candidal Balanitis Urinalysis for glucose

Sub-preputial culture/swab for primary candidiasis/candidal superinfection to be done in all cases

Investigation for HIV or other causes of immunosuppression should be performed

Anaerobic Infection
Aerobic

Infections

Sub-preputial culture

Streptococci spp. and S. aureus have both been reported as causing balanitis

Trichomonas vaginalis Wet preparation from the subpreputial sac demonstrates the organism

Culture and NAAT can also be carried out

Treponema pallidum Dark field microscopy, TP NAAT and DFA-TP will confirm the diagnosis. This should ideally be done every case.

TPHA coupled with non-treponemal serological tests though of limited value, should be performed since they are useful for follow-up

Herpes simplex Tissue scraping from base of erosion subjected to Tzanck smear IgG and IgM for HSV cell culture and PCR-preferred HSV tests for persons who seek medical treatment for gential ulcers or other mucocutaneous lesions
Human papilloma virus Diagnosed clinically

Treatment

Treatment[25](adopted from the Indian journal of sexually transmitted diseases and AIDS)
Preferred regimen Alternative regimen
Candidal Balanitis Clotrimazole cream 1%

Miconazole cream 2%

Fluconazole 150 mg stat orally

Nystatin cream-if resistance suspected topical clotrimazole/miconazole with 1% hydrocortisone-if marked inflammation

Anaerobic Infection Advice about genital hygiene

metronidazole 400 mg twice daily for 1 week

Milder cases- topical metronidazole

Coamoxiclav(amoxycillin/clavulanic acid) 375 mg 3 times daily for 1 week

Clindamycin cream applied twice daily until resolved

Aerobic

Infections

Usually topical

Triple combination (clotrimazole 1%, beclometasone dipropionate 0.025%, gentamicinsilfate 0.3%) applied once daily

Severe cases-systemic antibiotics

Erythromycin 500 mg QDS for 1 week

Co-amoxiclav(amoxycillin/clavulanic acid 375 mg 3 times daily for 1 week

Alternative regimens depend on the sensitivities of the organisms isolated
Trichomonas vaginalis Metronidazole 2 g orally single dose

Secnidazole 2 g orally single dose

Metronidazole 400 mg orally twice a day for 7 days
Treponema pallidum Single IM administration of 2.4 MU of benzathine penicillin

Doxycycline 100 mg orally BID for 2 weeks or

Tetracycline 500 mg orally QID for 2 weeks or

Erythromycin 500 mg QID or

Ceftriaxone 1 g IM/IV daily for 8-10 days

Herpes simplex Acyclovir 400 mg orally 3 times a day for 7-10 days or

Acyclovir 200 mg orally 5 times a day for 7-10 days or

Famciclovir 250 mg orally 3 times a day for 7-10 days or

Valacyclovir 1 g orally twice a day for 7-10 days

Human papilloma virus Patients applied

Podophyllotoxin(podofilox) 0.5% or gel-twice daily for three consecutive days, but no more than 4 weeks or Imiquimod 5% cream-applied at bedtime 3 times/week for a maximum of 16 weeks, and must be left in place for 6-10 h following application or Sinecatechins 15% ointment

Provider-administered

Podophyllin resin 20% in a compound tincture

of benzoin-once a week for 6-8 week or

Cryotherapy with liquid nitrogen ot cryoprobe.

Repeat applications every 1-2 weeks or

TCA/bichloroacetic acid-80-90% once per week for an average course of 6-10 weeks or

Surgical removal either by tangential scissor excision, tangential shave excision, curettage, or electrosurgery.

Prevention

Primary Prevention

Primary prevention of Infectious balanitis include:[25]

  • Safe sex practices.
  • Maintaining proper penile hygiene.

Secondary prevention

There are no specific secondary preventive measures for Infective 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 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. ↑ 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.
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