Sandbox: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: balanoposthitis

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

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

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

Common symptoms of balanitis include:

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

Physical Examination

	History, symptoms and associations	Physical examination	laboratory findings	Medical therapy	Surgical therapy	Primary prevention	Secondary prevention
Candidal balanitis			Culture: potassium hydroxide (KOH) slide:	Clotrimazole topical cream applied bid for 10-14 days OR Miconazole topical cream applied bid for 10-14 days
Balanitis due to poor hydiene
Balanitis due to allergy or dermatitis
Balanitits due to anerobic infectious
Balanitits due to reactive arthritis
Balanitis due to fixed drug eruption
Balanitis xerotica obliterans
Zoon balanitis				carbon dioxide laser as an alternative therapy
Carcinoma in situ

	Candidal balanitis	Poor hygiene	Dermatitis/allergy	Anaerobic	aerobic infections	Reactive arthritis	Fixed drug eruption	balanitis xerotica obliterans	Zoon balanitis	Carcinoma in situ
History and symptoms
Associated findings
Physical examination finding
Laboratory finding
medical therapy
Surgical therapy
Primary prevention
Secondary prevention