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{{SK}} balanoposthitis
{{SK}} balanoposthitis
==Overview==
==Overview==
==Historical Perspective==
==Historical Perspective==
==Classification==
==Classification==
==Pathophysiology==
==Pathophysiology==
Balanitis being a clinical diagnosis, the pathogenesis varies based on etiology:
===Infectious===
Commonly in the presence of risk factors( poor personal hygiene, antibiotic use, corticosteroid use, Immunocompromised, and Diabetes). Infectious organisms like candida, anaerobic,  and aerobic bacteria colonize the region of glans penis, which results in inflammation of the glans penis(Balanitis). When the inflammation involves foreskin and prepuce, it is known as balanoposthitis  .
===Non-infectious===
==== Balanitis xerotica obliterans or Penile lichen sclerosus ====
etiology and pathogenesis of Balanitis xerotica obliterans is not clearly known. Following theories have been postulated:
* Accumlation of epithelial debris and secretions between foreskin and penis proximal to coronal sulcus, results in chronic physical irritation or subclinical trauma, which in turn results in skin lesion along the lines the trauma.
* Accumulated material may also harbor infections agents.
* Association with autoimmune diseases is identifies in few cases. Human leukocyte antigen (HLA)  HLA DQ7 with DR11 and DR12 was found to be associated with Balanitis xerotica obliterans
* Human papillomaviruses(HPV) was to been associated with childhood penile lichen sclerosus
==== Histopathology ====
Early stage
Lymphocytic infiltrate in the epidermis and dermis, associated with basal vacuolar change in epidermis
epidermis becomes atrophic with surface hyperkeratosis.
development of the lesions, there is loss of elastic fibres in the papillary dermis and the dermal inflammatory infiltrate is displaced downwards by subepidermal oedema, which is subsequently replaced by fibrosis.
Late stage findings of penile lichen sclerosus include:
* thickened basement membrane
* subepidermal edema,which becomes more sclerotic over time
[[File:High magnification micrograph of lichen sclerosus, also lichen sclerosus et atrophicus. H&E stain. Related images Low mag. Intermed. mag. High mag. Very high mag..jpg|link=http://www.wikidoc.org/index.php/File:High%20magnification%20micrograph%20of%20lichen%20sclerosus,%20also%20lichen%20sclerosus%20et%20atrophicus.%20H&E%20stain.%20Related%20images%20Low%20mag.%20Intermed.%20mag.%20High%20mag.%20Very%20high%20mag..jpg|center|thumb|High magnification micrograph of '''lichen sclerosus''', also '''lichen sclerosus et atrophicus'''. H&E stain. Related images Low mag. Intermed. mag. High mag. Very high mag.]]
==== Zoon Balanitis ====
Etiology and pathogenesis of Balanitis xerotica obliterans is not clearly known. Following theories have been postulated:
Accumlation of epithelial debris and secretions between foreskin and penis proximal to coronal sulcus, poor genital hygiene, repeated local infections, hot and humid weather results in chronic physical irritation or subclinical trauma, which in turn results in skin lesion along the lines the trauma.
==== Histopathology ====
Epidermal changes
Early changes
thickening, acanthosis, and parakeratosis, which is followed by followed by epidermal atrophy.
epidermal atrophy, can be associated with erosions and spongiosis.
Additional features include:
subepidermal clefts
necrotic keratinocytes,
lozenge keratinocytes


=== Infectious ===
Dermal changes include


=== Non-infectious ===
Patchy infiltrate of lymphocytes and plasma cells in papillary dermis,


==Causes==
Lymphocytes are subsequently replaced by  infiltrate of plasma cells, neutrophils, eosinophils, lymphocytes, and erythrocytes.
Causes of Balanitis include the following:
 
Vascular dilatation with singular vertical or oblique orientation of proliferated individual vessels, is characteristic feature of ZB.


# Candidal balanitis
In late stages, dermis shows fibrosis with subepidermal clefts, epidermal atrophy, and plasma cell infiltrates.
# Anaerobic balanitis
# Aerobic balanitis
# Lichen sclerosus
# Lichen planus
# Zoon’s (plasma cell) balanitis
# Psoriasis and circinate balanitis
# Eczema (including irritant, allergic and seborrhoeic)
# Non-specific balanoposthitis
# Fixed drug eruptions
Premalignant conditions:
# Erythroplasia of Queyrat
# Bowen’s disease
# Bowenoid papulosis
Miscellaneous


Stevens-Johnson syndrome
Pre-malignant


==Causes==
{| class="wikitable"
{| class="wikitable"
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!
!
!
!
|-
|Infections
|Candidal Balanitis
|
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|-
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|Anaerobic Balanitis
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|-
|
|Aerobic Balanitis
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|-
|
|Viral
|
|
|-
|
|Parasitic
|
|
|-
|Non-infectious
|Circinate balanitis
|
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|-
|
|Zoon's balanitis
|
|
|-
|
|Pemphigus
|
|
|-
|
|Pemphigoid
|
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|-
|Pre-malignant conditions
|Erythroplasia of Queyrat (carcinoma in situ)
|
|
|-
|
|Bowen’s disease
|
|
|-
|-
|
|
|Bowenoid papulosis
|
|
|
|-
|Miscellaneous
|Poor hygiene
|
|
|
|
|-
|-
|
|
|Trauma
|
|
|-
|
|
|Irritant
|
|
|
|
|-
|-
|
|Contact dermatitis/allergy
|
|
|
|
|-
|
|Fixed drug eruptions
|
|
|-
|
|Reactive arthritis
|
|
|
|
|}
|}
*
==Differentiating Candida Vulvovaginitis from other Diseases==
Candida Vulvovaginitis must be differentiated from the following diseases which have a similar presentation:<ref name=CDC-BV> Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines. Bacterial Vaginosis. http://www.cdc.gov/std/tg2015/bv.htm Accessed on October 13, 2016 </ref><ref name="pmid10839558">{{cite journal| author=Bachmann GA, Nevadunsky NS| title=Diagnosis and treatment of atrophic vaginitis. | journal=Am Fam Physician | year= 2000 | volume= 61 | issue= 10 | pages= 3090-6 | pmid=10839558 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10839558  }} </ref><ref name="pmid2448502">{{cite journal| author=Krieger JN, Tam MR, Stevens CE, Nielsen IO, Hale J, Kiviat NB et al.| title=Diagnosis of trichomoniasis. Comparison of conventional wet-mount examination with cytologic studies, cultures, and monoclonal antibody staining of direct specimens. | journal=JAMA | year= 1988 | volume= 259 | issue= 8 | pages= 1223-7 | pmid=2448502 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2448502  }} </ref><ref name="pmid21422855">{{cite journal| author=Sobel JD, Reichman O, Misra D, Yoo W| title=Prognosis and treatment of desquamative inflammatory vaginitis. | journal=Obstet Gynecol | year= 2011 | volume= 117 | issue= 4 | pages= 850-5 | pmid=21422855 | doi=10.1097/AOG.0b013e3182117c9e | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422855  }} </ref><ref name="pmid97946645">{{cite journal| author=Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK| title=Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm. | journal=Obstet Gynecol | year= 1998 | volume= 92 | issue= 5 | pages= 757-65 | pmid=9794664 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9794664  }}</ref>


==Differentiating differenting types of balanitis==
==Epidemiology and Demographics==
==Epidemiology and Demographics==
==Risk Factors==
==Risk Factors==
Risk factors for Balanitis include:
Risk factors for Balanitis include:
* Uncircumcised penis  
*Uncircumcised penis
* Antibiotic use  
*Antibiotic use
* Corticosteroid use  
*Corticosteroid use
* Immunocompromised  
*Immunocompromised
* Diabetes  
*Diabetes
* Not usually considered sexually transmitted
*
 
*Not usually considered sexually transmitted
==Screening==
==Screening==
There are no screening procedures for Balanitis.
There are no screening procedures for Balanitis.
==Natural History, Complications and Prognosis==
==Natural History, Complications and Prognosis==
===Natural History===
===Natural History===
===Prognosis===
===Prognosis===
===Complications===
===Complications===
Long-term inflammation or infection can:
Long-term inflammation or infection can:
* Scar and narrow the opening of the penis (meatal stricture)
*Scar and narrow the opening of the penis (meatal stricture)
* Make it difficult and painful to retract the foreskin to expose the tip of the penis (a condition called phimosis)
*Make it difficult and painful to retract the foreskin to expose the tip of the penis (a condition called phimosis)
* Make it difficult to move the foreskin over the head of the penis (a condition called paraphimosis)
*Make it difficult to move the foreskin over the head of the penis (a condition called paraphimosis)
* Affect the blood supply to the tip of the penis
*Affect the blood supply to the tip of the penis
* Increase the risk of penile cancer
*Increase the risk of penile cancer
 
==Diagnosis==
==Diagnosis==
===History and Symptoms===
===History and Symptoms===
Symptoms include:
Symptoms include:
* Redness of foreskin or penis
*Redness of foreskin or penis
* Other rashes on the head of the penis
*Pruritus
* Foul-smelling discharge
*Other rashes on the head of the penis
* Painful penis and foreskin
*Foul-smelling discharge
*Painful penis and foreskin
===Physical Examination===
[[File:Inflammation of the glans penis and the preputial mucosa.jpg|link=http://www.wikidoc.org/index.php/File:Inflammation%20of%20the%20glans%20penis%20and%20the%20preputial%20mucosa.jpg|center|thumb]]


*
===Physical Examination===
*
===Laboratory Findings===
===Laboratory Findings===
*
*
==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===
===Surgical Therapy===
===Surgical Therapy===
==Prevention==
==Prevention==
===Primary Prevention===
===Primary Prevention===
 
===Secondary Prevention===
=== Secondary Prevention ===
*
*


*
*
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Revision as of 19:50, 18 January 2017


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

Synonyms and keywords: balanoposthitis

Overview

Historical Perspective

Classification

Pathophysiology

Balanitis being a clinical diagnosis, the pathogenesis varies based on etiology:

Infectious

Commonly in the presence of risk factors( poor personal hygiene, antibiotic use, corticosteroid use, Immunocompromised, and Diabetes). Infectious organisms like candida, anaerobic, and aerobic bacteria colonize the region of glans penis, which results in inflammation of the glans penis(Balanitis). When the inflammation involves foreskin and prepuce, it is known as balanoposthitis .

Non-infectious

Balanitis xerotica obliterans or Penile lichen sclerosus

etiology and pathogenesis of Balanitis xerotica obliterans is not clearly known. Following theories have been postulated:

  • Accumlation of epithelial debris and secretions between foreskin and penis proximal to coronal sulcus, results in chronic physical irritation or subclinical trauma, which in turn results in skin lesion along the lines the trauma.
  • Accumulated material may also harbor infections agents.
  • Association with autoimmune diseases is identifies in few cases. Human leukocyte antigen (HLA) HLA DQ7 with DR11 and DR12 was found to be associated with Balanitis xerotica obliterans
  • Human papillomaviruses(HPV) was to been associated with childhood penile lichen sclerosus

Histopathology

Early stage

Lymphocytic infiltrate in the epidermis and dermis, associated with basal vacuolar change in epidermis

epidermis becomes atrophic with surface hyperkeratosis.

development of the lesions, there is loss of elastic fibres in the papillary dermis and the dermal inflammatory infiltrate is displaced downwards by subepidermal oedema, which is subsequently replaced by fibrosis.

Late stage findings of penile lichen sclerosus include:

  • thickened basement membrane
  • subepidermal edema,which becomes more sclerotic over time
High magnification micrograph of lichen sclerosus, also lichen sclerosus et atrophicus. H&E stain. Related images Low mag. Intermed. mag. High mag. Very high mag.

Zoon Balanitis

Etiology and pathogenesis of Balanitis xerotica obliterans is not clearly known. Following theories have been postulated:

Accumlation of epithelial debris and secretions between foreskin and penis proximal to coronal sulcus, poor genital hygiene, repeated local infections, hot and humid weather results in chronic physical irritation or subclinical trauma, which in turn results in skin lesion along the lines the trauma.

Histopathology

Epidermal changes

Early changes

thickening, acanthosis, and parakeratosis, which is followed by followed by epidermal atrophy.

epidermal atrophy, can be associated with erosions and spongiosis.

Additional features include:

subepidermal clefts

necrotic keratinocytes,

lozenge keratinocytes

Dermal changes include

Patchy infiltrate of lymphocytes and plasma cells in papillary dermis,

Lymphocytes are subsequently replaced by infiltrate of plasma cells, neutrophils, eosinophils, lymphocytes, and erythrocytes.

Vascular dilatation with singular vertical or oblique orientation of proliferated individual vessels, is characteristic feature of ZB.

In late stages, dermis shows fibrosis with subepidermal clefts, epidermal atrophy, and plasma cell infiltrates.

Pre-malignant

Causes

Infections Candidal Balanitis
Anaerobic Balanitis
Aerobic Balanitis
Viral
Parasitic
Non-infectious Circinate balanitis
Zoon's balanitis
Pemphigus
Pemphigoid
Pre-malignant conditions Erythroplasia of Queyrat (carcinoma in situ)
Bowen’s disease
Bowenoid papulosis
Miscellaneous Poor hygiene
Trauma
Irritant
Contact dermatitis/allergy
Fixed drug eruptions
Reactive arthritis

Differentiating differenting types of balanitis

Epidemiology and Demographics

Risk Factors

Risk factors for Balanitis include:

  • Uncircumcised penis
  • Antibiotic use
  • Corticosteroid use
  • Immunocompromised
  • Diabetes
  • Not usually considered sexually transmitted

Screening

There are no screening procedures for Balanitis.

Natural History, Complications and Prognosis

Natural History

Prognosis

Complications

Long-term inflammation or infection can:

  • Scar and narrow the opening of the penis (meatal stricture)
  • Make it difficult and painful to retract the foreskin to expose the tip of the penis (a condition called phimosis)
  • Make it difficult to move the foreskin over the head of the penis (a condition called paraphimosis)
  • Affect the blood supply to the tip of the penis
  • Increase the risk of penile cancer

Diagnosis

History and Symptoms

Symptoms include:

  • Redness of foreskin or penis
  • Pruritus
  • Other rashes on the head of the penis
  • Foul-smelling discharge
  • Painful penis and foreskin

Physical Examination

Laboratory Findings

Treatment

Medical Therapy

Surgical Therapy

Prevention

Primary Prevention

Secondary Prevention

References