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==Overview==
==Overview==
Balanitis is [[inflammation]] of [[glans penis]]. When inflammation involves the [[foreskin]] and [[prepuce]], it is termed as [[balanoposthitis]]. Based on the etiology, balanitis can be mainly categorized into [[Infectious balanitis|infectious]], [[inflammatory dermatoses]], and [[penile carcinoma in situ]]. Patients with balanitis may present with asymptomatic or symptomatic lesions with [[itch]] or [[pain]] in the genital region. [[Risk factors]], [[pathogenesis]], clinical presentation, [[diagnosis]] and management varies depending on etiology.
Balanitis is [[inflammation]] of [[glans penis]]. When inflammation involves the [[foreskin]] and [[prepuce]], it is termed as [[balanoposthitis]]. Based on the etiology, balanitis can be mainly categorized into [[Infectious balanitis|infectious]], [[inflammatory dermatoses]], and [[penile carcinoma in situ]]. Patients with balanitis may present with asymptomatic or symptomatic lesions with [[itch]] or [[pain]] in the genital region. [[Risk factors]], [[pathogenesis]], clinical presentation, [[diagnosis]] and management varies depending on etiology.
==Overview==
Balanitis is inflammation of glans penis. When inflammation involves the foreskin and prepuce, it is termed as balanoposthitis. Based on the etiology, balanitis can be mainly categorized into infectious, inflammatory dermatoses, and penile carcinoma in situ. Patients with balanitis may present with asymptomatic or symptomatic lesions with itch or pain in the genital region. Risk factors, pathogenesis, clinical presentation, diagnosis and management varies depending on etiology.
==[[Balanitis historical perspective|Historical Perspective]]==
==[[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.
Line 19: Line 17:
*[[Penile carcinoma in situ]]
*[[Penile carcinoma in situ]]
==[[Balanitis pathophysiology|Pathophysiology]]==
==[[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="pmid2482855322">{{cite journal| author=Edwards SK, Bunker CB, Ziller F, van der Meijden WI| title=2013 European guideline for the management of balanoposthitis. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 9 | pages= 615-26 | pmid=24828553 | doi=10.1177/0956462414533099 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24828553  }}</ref><ref>{{cite journal| author=Hernandez BY, Wilkens LR, Zhu X, Thompson P, McDuffie K, Shvetsov YB et al.| title=Transmission of human papillomavirus in heterosexual couples. | journal=Emerg Infect Dis | year= 2008 | volume= 14 | issue= 6 | pages= 888-94 | pmid=18507898 | doi=10.3201/eid1406.070616 | pmc=2600292 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18507898  }}</ref><ref>Sobel JD (1985). "Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis". Am. J. Obstet. Gynecol. 152 (7 Pt 2): 924–35. <nowiki>PMID 3895958</nowiki>.</ref>
{| class="wikitable"
!Pathogen
!Route of transmission
!Risk factors
!Virulence factors
|-
|[[Candidiasis|Candidal Balanitis]]
|
*[[Sexual transmitted infection|Sexual transmitted]]
*[[Opportunistic infection]]
|
*[[Diabetes]]
*[[Immunocompromised]] conditions
*Age>40 yrs
|
*All strains of ''[[C. albicans]]'' possess a [[yeast]] surface mannoprotein. This allows the various strains to adhere to both the exfoliated and [[epithelial cells]].
*Other [[virulence factors]]   inclu:de [[Proteolytic enzyme|proteolytic enzymes]], [[toxins]] and [[phospholipase]]. [[Proteolytic enzyme|Proteolytic enzymes]] destroy the [[proteins]] that normally impair [[fungal]] invasion
|-
|[[Anaerobic organism|Anaerobic Infection]]
|
*[[Sexually transmitted disease|Sexually transmitted]]
*Extension from peri-rectal area
*Oro-genital [[Sex (activity)|sex]]-[[Saliva|(saliva]] as a lubricant during [[coitus]])
.
|
*Tight [[foreskin]]
*sub-optimal penile hygienic maintenance
|[[Anaerobic]] [[Gram-negative bacilli|gram-negative rods]] produce various [[toxins]], [[proteases]], and [[elastase]]
|-
|[[Aerobic organism|Aerobic]]
[[Aerobic organism|Infections]]
|
*[[Sexually transmitted]]
*[[Autoinoculation]] from other sites
|
*Uncircumcised penis
*[[Diabetes]]
*[[Immunocompromised|Immunocompromise]] conditions
|Adherence to [[epithelial cells]], [[Biofilm|biofilm production]], surface hydrophobicity, [[phospholipase C]] and [[protease]] activity
|-
|[[Trichomonas vaginalis]]
|[[Sexually transmitted]]
|
*Multiple sexual partners
*Unprotected sexual activity
*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
|-
|[[Treponema pallidum|Treponema]]
[[Treponema pallidum|pallidum]]
|Transmitted via direct contact with the infected lesion (sexual contact)
|[[Risk factors]] include:<ref name="pmid2356911">{{cite journal| author=Rolfs RT, Goldberg M, Sharrar RG| title=Risk factors for syphilis: cocaine use and prostitution. | journal=Am J Public Health | year= 1990 | volume= 80 | issue= 7 | pages= 853-7 | pmid=2356911 | doi= | pmc=1404975 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2356911  }}</ref><ref name="pmid17675391">{{cite journal| author=Zhou H, Chen XS, Hong FC, Pan P, Yang F, Cai YM et al.| title=Risk factors for syphilis infection among pregnant women: results of a case-control study in Shenzhen, China. | journal=Sex Transm Infect | year= 2007 | volume= 83 | issue= 6 | pages= 476-80 | pmid=17675391 | doi=10.1136/sti.2007.026187 | pmc=2598725 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17675391  }}</ref><ref name="pmid15247352">{{cite journal| author=Hook EW, Peeling RW| title=Syphilis control--a continuing challenge. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 2 | pages= 122-4 | pmid=15247352 | doi=10.1056/NEJMp048126 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15247352  }}</ref><ref name="pmid16205297">{{cite journal| author=Buchacz K, Greenberg A, Onorato I, Janssen R| title=Syphilis epidemics and human immunodeficiency virus (HIV) incidence among men who have sex with men in the United States: implications for HIV prevention. | journal=Sex Transm Dis | year= 2005 | volume= 32 | issue= 10 Suppl | pages= S73-9 | pmid=16205297 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16205297  }}</ref><ref name="pmid25514173">{{cite journal| author=Solomon MM, Mayer KH| title=Evolution of the syphilis epidemic among men who have sex with men. | journal=Sex Health | year= 2015 | volume= 12 | issue= 2 | pages= 96-102 | pmid=25514173 | doi=10.1071/SH14173 | pmc=4470884 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25514173  }}</ref><ref name="pmid24927712">{{cite journal| author=Hakre S, Arteaga GB, Núñez AE, Arambu N, Aumakhan B, Liu M et al.| title=Prevalence of HIV, syphilis, and other sexually transmitted infections among MSM from three cities in Panama. | journal=J Urban Health | year= 2014 | volume= 91 | issue= 4 | pages= 793-808 | pmid=24927712 | doi=10.1007/s11524-014-9885-4 | pmc=4134449 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24927712  }}</ref><ref name="newell">Newell, J., et al. "A population-based study of syphilis and sexually transmitted disease syndromes in north-western Tanzania. 2. Risk factors and health seeking behaviour." Genitourinary medicine 69.6 (1993): 421-426.</ref>Multiple sexual partners, prostitution, illicit drug use, unprotected sex
men who have sex with men, residence in highly prevalent areas, [[Human Immunodeficiency Virus (HIV)|HIV]] infection, presence of other [[STI]]<nowiki/>s, previous history of STIs, [[intravenous drug]] use, health care professionals who are predisposed to occupational risk, and low socioeconomic status
|[[Treponema Pallidum]] uses [[fibronectin]] molecules to attach to the [[endothelial]] surface of the [[vessels]] in organs resulting in [[inflammation]] and obliteration of the small blood vessels causing [[vasculitis]] ([[endarteritis obliterans]])
|-
|[[Herpes simplex]]
|Often transmitted sexually or direct contact with droplet or infected secretions entering thorough [[skin]] or [[Mucous membrane|mucous membranes]]
|
*Multiple sexual partners
*Low [[socio-economic status]]
|
*Inhibition of [[MHC class I|MHC Class I]]
*Impairing function of [[Dendritic cell|dendritric cells]]
|-
|[[Human papilloma virus]]
|Usually transmitted via [[Sexual|sexual route]] to the human host
|[[Risk factors]] responsible for sexual transmission of [[Human papillomavirus|HPV]] include:
Number of sex partners<ref name="pmid21414655">{{cite journal |vauthors=Bell MC, Schmidt-Grimminger D, Jacobsen C, Chauhan SC, Maher DM, Buchwald DS |title=Risk factors for HPV infection among American Indian and white women in the Northern Plains |journal=Gynecol. Oncol. |volume=121 |issue=3 |pages=532–6 |year=2011 |pmid=21414655 |pmc=4498572 |doi=10.1016/j.ygyno.2011.02.032 |url=}}</ref><ref name="pmid14702152">{{cite journal |vauthors=Tarkowski TA, Koumans EH, Sawyer M, Pierce A, Black CM, Papp JR, Markowitz L, Unger ER |title=Epidemiology of human papillomavirus infection and abnormal cytologic test results in an urban adolescent population |journal=J. Infect. Dis. |volume=189 |issue=1 |pages=46–50 |year=2004 |pmid=14702152 |doi=10.1086/380466 |url=}}</ref>, acqusition of new partner<ref name="pmid21414655" />


, having non monogamous sex partner<ref name="pmid9217656">{{cite journal |vauthors=Koutsky L |title=Epidemiology of genital human papillomavirus infection |journal=Am. J. Med. |volume=102 |issue=5A |pages=3–8 |year=1997 |pmid=9217656 |doi= |url=}}</ref><ref name="pmid12543621">{{cite journal |vauthors=Winer RL, Lee SK, Hughes JP, Adam DE, Kiviat NB, Koutsky LA |title=Genital human papillomavirus infection: incidence and risk factors in a cohort of female university students |journal=Am. J. Epidemiol. |volume=157 |issue=3 |pages=218–26 |year=2003 |pmid=12543621 |doi= |url=}}</ref>, starting sexual activity in young age<ref name="pmid9217656" />, vaginal delivery and multiple deliveries<ref name="pmid9464728">{{cite journal |vauthors=Tseng CJ, Liang CC, Soong YK, Pao CC |title=Perinatal transmission of human papillomavirus in infants: relationship between infection rate and mode of delivery |journal=Obstet Gynecol |volume=91 |issue=1 |pages=92–6 |year=1998 |pmid=9464728 |doi= |url=}}</ref>, age over 40 for women<ref name="pmid21495248">{{cite journal |vauthors=Ting J, Kruzikas DT, Smith JS |title=A global review of age-specific and overall prevalence of cervical lesions |journal=Int. J. Gynecol. Cancer |volume=20 |issue=7 |pages=1244–9 |year=2010 |pmid=21495248 |doi= |url=}}</ref>, history of [[Chlamydia infection|Chlamydia]] infection<ref name="pmid9332762">{{cite journal |vauthors=Kjaer SK, van den Brule AJ, Bock JE, Poll PA, Engholm G, Sherman ME, Walboomers JM, Meijer CJ |title=Determinants for genital human papillomavirus (HPV) infection in 1000 randomly chosen young Danish women with normal Pap smear: are there different risk profiles for oncogenic and nononcogenic HPV types? |journal=Cancer Epidemiol. Biomarkers Prev. |volume=6 |issue=10 |pages=799–805 |year=1997 |pmid=9332762 |doi= |url=}}</ref>,  and long term [[Oral contraceptive|OCP]] use<ref name="pmid1649312">{{cite journal |vauthors=Ley C, Bauer HM, Reingold A, Schiffman MH, Chambers JC, Tashiro CJ, Manos MM |title=Determinants of genital human papillomavirus infection in young women |journal=J. Natl. Cancer Inst. |volume=83 |issue=14 |pages=997–1003 |year=1991 |pmid=1649312 |doi= |url=}}</ref>
==Causes ==
|Linked to [[epithelial]] [[differentiation]] and maturation of host [[keratinocytes]], with [[transcription]] of specific [[Gene|gene products]] at every level.
|}
==[[Balanitis causes|Causes]]==
Causes of balanitis are:{{familytree/start}}
Causes of balanitis are:{{familytree/start}}
{{familytree | | | | | | | | | | | | | | | | | A01 |A01='''Balanitis'''}}  
{{familytree | | | | | | | | | | | | | | | | | A01 |A01='''Balanitis'''}}  
Line 249: Line 174:
*[[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>
==[[Balanitis risk factors|Risk Factors]]==
==[[Balanitis risk factors|Risk Factors]]==
Pathophysiology of Infectious balanitis varies from pathogen to pathogen:<ref name="pmid1156848" /><ref name="pmid6121604" /><ref>GENITOURINARY MEDICINE, Volume 72, Number 3: Pages 155-9,</ref><ref name="pmid20002652" /><ref name="pmid2482855322" /><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="pmid2482855322">{{cite journal| author=Edwards SK, Bunker CB, Ziller F, van der Meijden WI| title=2013 European guideline for the management of balanoposthitis. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 9 | pages= 615-26 | pmid=24828553 | doi=10.1177/0956462414533099 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24828553  }}</ref><ref>{{cite journal| author=Hernandez BY, Wilkens LR, Zhu X, Thompson P, McDuffie K, Shvetsov YB et al.| title=Transmission of human papillomavirus in heterosexual couples. | journal=Emerg Infect Dis | year= 2008 | volume= 14 | issue= 6 | pages= 888-94 | pmid=18507898 | doi=10.3201/eid1406.070616 | pmc=2600292 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18507898  }}</ref><ref>Sobel JD (1985). "Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis". Am. J. Obstet. Gynecol. 152 (7 Pt 2): 924–35. <nowiki>PMID 3895958</nowiki>.</ref>
{| class="wikitable"
{| class="wikitable"
!Pathogen
!Pathogen
Line 281: Line 206:
|[[Treponema pallidum|Treponema]]
|[[Treponema pallidum|Treponema]]
[[Treponema pallidum|pallidum]]
[[Treponema pallidum|pallidum]]
|[[Risk factors]] include:<ref name="pmid2356911" /><ref name="pmid17675391" /><ref name="pmid15247352" /><ref name="pmid16205297" /><ref name="pmid25514173" /><ref name="newell" />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="newell">Newell, J., et al. "A population-based study of syphilis and sexually transmitted disease syndromes in north-western Tanzania. 2. Risk factors and health seeking behaviour." Genitourinary medicine 69.6 (1993): 421-426.</ref>Multiple sexual partners, prostitution, illicit drug use, unprotected sex
men who have sex with men, residence in highly prevalent areas, [[Human Immunodeficiency Virus (HIV)|HIV]] infection, presence of other [[STI]]<nowiki/>s, previous history of STIs, [[intravenous drug]] use, health care professionals who are predisposed to occupational risk, and low socioeconomic status
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
|-
|-
Line 291: Line 216:
|[[Human papilloma virus]]
|[[Human papilloma virus]]
|[[Risk factors]] responsible for sexual transmission of [[Human papillomavirus|HPV]] include:
|[[Risk factors]] responsible for sexual transmission of [[Human papillomavirus|HPV]] include:
Number of sex partners<ref name="pmid21414655" /><ref name="pmid14702152" />, 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" /><ref name="pmid12543621" />, starting sexual activity in young age<ref name="pmid9217656" />, vaginal delivery and multiple deliveries<ref name="pmid9464728" />, age over 40 for women<ref name="pmid21495248" />, history of [[Chlamydia infection|Chlamydia]] infection<ref name="pmid9332762" />,  and long term [[Oral contraceptive|OCP]] use<ref name="pmid1649312" />
, 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>
|}
|}
==[[Balanitis screening|Screening]]==
==[[Balanitis screening|Screening]]==

Revision as of 18:08, 1 March 2017

Balanitis Microchapters

Patient Information

Overview

Classification

Infectious balanitis
Non-infectious balanitits
Zoon's balanitis
Balanitis xerotica obliterans

Causes

Differential Diagnosis

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

Synonyms and keywords: Balanoposthitis

Overview

Balanitis is inflammation of glans penis. When inflammation involves the foreskin and prepuce, it is termed as balanoposthitis. Based on the etiology, balanitis can be mainly categorized into infectious, inflammatory dermatoses, and penile carcinoma in situ. Patients with balanitis may present with asymptomatic or symptomatic lesions with itch or pain in the genital region. Risk factors, pathogenesis, clinical presentation, diagnosis and management varies depending on etiology.

Historical Perspective

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

Classification

There is no established classification system for Balantis. Based on the etiologies, Balanitis can be classified into:[1]

Pathophysiology

Causes

Causes of balanitis are:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Balanitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Infectious
 
 
 
 
 
 
 
 
 
 
Inflammatory dermatoses
 
 
 
 
 
 
 
 
Premalignant (penile carcinoma in situ)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Candida (albicans, krusei)
Streptococci
Anaerobes
Staphylococci
Trichomonas vaginalis
Herpes simplex virus
Human papillomavirus
Mycoplasma genitalium
 
 
 
 
 
 
 
 
 
 
Lichen sclerosus
Lichen planus
Psoriasis
Circinate balanitis
Zoon's balanitis
Eczema
Allergic reactions
 
 
 
 
 
 
 
 
Bowen's disease
Bowenoid papulosis
Erythroplasia of Queyrat

Causes of Infectious balanitis include:[2][3][4]

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

Differentiating diagnosis

Symptoms Signs
Malaise Pruritus Skin lesions Regional lymphadenopathy Erythema Swelling
Candida balanitis ✖ ✔ Erythematous rash with soreness and/or itch ✔ ✔ ✖
Trichomonas vaginalis ✖ ✔ Superficial erosive balanitis ✖ ✔ ✖
Treponema pallidum ✖ ✖ Multiple circinate lesions ✔ ✖ ✖
Herpes simplex ✔ ✔ Grouped vesicles on erythematous base ✔ ✔ ✖
Human papilloma virus ✖ ✔ Warts ✖ ✖ ✖
Lichen sclerosus ✖ ✔ White patches on glans ✖ ✖ ✖
Lichen planus ✖ ✔ Purplish lesions on the penis ✖ ✖ ✖
Psoriasis ✖ ✔ Red scaly plaques ✖ ✔ ✖
Circinate ✔ ✔ Greyish white areas on the glans ✖ ✖ ✖
Zoon's balanitis ✖ ✔ Well-circumscribed orange-red glazed areas ✖ ✖ ✖
Eczema ✖ ✔ Mild non-specific erythema to wide spread edema of penis. ✖ ✔ ✔
Fixed drug eruption ✖ ✔ Well demarcated and erythematous lesions ✖ ✔ ✖
Bowen's disease ✖ ✔ Multiple, small, well-demarcated papillomatous papules ✖ ✖ ✖
Bowenoid papulosis ✖ ✔ Single or multiple, sharply demarcated associated with scaling and crusting ✖ ✖ ✖
Erythroplasia of Queyrat ✖ ✔ Velvety patches and plaques of keratinization on penis. ✔ ✖ ✖

Epidemiology and Demographics

  • There are no comprehensive studies studying the incidence and prevalence in general population. A recent study has shown that balanitis commonly occurs in around 10% of the patient population visiting the STD clinic, with infectious etiology responsible for around 50% of the cases.[5]
  • Candida is the most common cause being responsible for 30-35% cases with infectious etiology.[6]

Risk Factors

Pathophysiology of Infectious balanitis varies from pathogen to pathogen:[7][8][9][10][11][12][13]

Pathogen Risk factors
Candidal Balanitis
Anaerobic Infection
  • Tight foreskin
  • sub-optimal penile hygienic maintenance
Aerobic

Infections

  • Uncircumcised penis
Trichomonas vaginalis
Treponema

pallidum

Risk factors include:[14][15][16][17][18][19]Multiple sexual partners, prostitution, illicit drug use, unprotected sex

men who have sex with men, residence in highly prevalent areas, HIV infection, presence of other STIs, previous history of STIs, intravenous drug use, health care professionals who are predisposed to occupational risk, and low socioeconomic status

Herpes simplex
Human papilloma virus Risk factors responsible for sexual transmission of HPV include:

Number of sex partners[20][21], acqusition of new partner[20]

, having non monogamous sex partner[22][23], starting sexual activity in young age[22], vaginal delivery and multiple deliveries[24], age over 40 for women[25], history of Chlamydia infection[26], and long term OCP use[27]

Screening

There is no established clinical guidelines for screening patients for balanitis.

Natural History, Complications and Prognosis

Natural history

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

Complications

Complication of Infectious balanitis include:[1]

Prognosis

Prognosis is usually good with treatment.

Natural history

Bowenoid papulosis

If left untreated, papules may increase, or decrease, or disappear with time, or progress into squamous cell carcinoma(Studies have reported risk of progression of bowenoid papulosis to squamous cell carcinoma at 2.6%).[28]

Erythroplasia of Queyrat

If left untreated, Erythroplasia of Queyrat may progress into invasive Squamous cell carcinoma, with an incidence ranging from 10% to 33%.[28]

Bowen's Disease

If left untreated, Bowen's disease may progress into invasive Squamous cell carcinoma(Incidence of Bowen's disease to develop into invasive squamous cell carcinoma is 3% to 5% for cutaneous and 10% for genital lesions). The malignant potential of Bowen's disease is increased when its existence is compounded by concomitant disease such as HPV infection, Lichen sclerosis or Lichen planus, or in patients with poor genital hygiene and smokers.[28]

Complications

Complication of penile carcinoma in situ include:[28]

Prognosis

The prognosis is usually good with treatment.

Diagnosis

Diagnostic Criteria | History and Symptoms | Physical Examination | Laboratory Findings | X-ray|CT-Scan| MRI| Other Diagnostic Studies

Treatment

Medical Therapy | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

Classification

There is no established classification system for Balantis. Based on the etiologies, Balanitis can be classified into:[29]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Balanitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Infectious
 
 
 
 
 
 
 
 
 
 
Inflammatory dermatoses
 
 
 
 
 
 
 
 
Premalignant (penile carcinoma in situ)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Candida (albicans, krusei)
Streptococci
Anaerobes
Staphylococci
Trichomonas vaginalis
Herpes simplex virus
Human papillomavirus
Mycoplasma genitalium
 
 
 
 
 
 
 
 
 
 
Lichen sclerosus
Lichen planus
Psoriasis
Circinate balanitis
Zoon's balanitis
Eczema
Allergic reactions
 
 
 
 
 
 
 
 
Bowen's disease
Bowenoid papulosis
Erythroplasia of Queyrat

Diagnosis and management

Adopted from National Guideline on the Management of Balanoposthitis UK 2008

 
 
 
 
 
 
 
 
 
 
Balanitis/balanoposthitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Take history and examine
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perpuce retracts
 
 
 
 
 
 
 
 
 
 
 
 
 
Perpuce does not retract
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ulceration present
 
 
 
 
Erythema,subpreputial discharge
 
 
 
 
 
Prepuce scarred
 
 
 
Prepuce swollen
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Follow genital ulcer protocol
 
Fowl smelling
 
 
No odour
 
 
 
Refer to surgical opinion
 
 
 
Treat as genital ulcer disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Metronidazole 400 mg bd
 
 
Antifungal+1% Hydrocortisone cream apply bd
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Review
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If better discharge
 
If not better 1) Reassess-try alternative pathway 2) Erythromycin 500 bd 3) Potent steroid cream
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Synopsis

Symptoms Signs
Malaise Pruritus Skin lesions Regional lymphadenopathy Erythema Swelling
Candida balanitis ✖ ✔ Erythematous rash with soreness and/or itch ✔ ✔ ✖
Trichomonas vaginalis ✖ ✔ Superficial erosive balanitis  ✖ ✔ ✖
Treponema pallidum ✖ ✖ Multiple circinate lesions ✔ ✖ ✖
Herpes simplex ✔ ✔ Grouped vesicles on erythematous base ✔ ✔ ✖
Human papilloma virus ✖ ✔ Warts ✖ ✖ ✖
Lichen sclerosus ✖ ✔ White patches on glans ✖ ✖ ✖
Lichen planus ✖ ✔ Purplish lesions on the penis ✖ ✖ ✖
Psoriasis ✖ ✔ Red scaly plaques ✖ ✔ ✖
Circinate ✔ ✔ Greyish white areas on the glans ✖ ✖ ✖
Zoon's balanitis ✖ ✔ Well-circumscribed orange-red glazed areas ✖ ✖ ✖
Eczema ✖ ✔ Mild non-specific erythema to wide spread edema of penis. ✖ ✔ ✔
Fixed drug eruption ✖ ✔ Well demarcated and erythematous lesions ✖ ✔ ✖
Bowen's disease ✖ ✔ Multiple, small, well-demarcated papillomatous papules ✖ ✖ ✖
Bowenoid papulosis ✖ ✔ Single or multiple, sharply demarcated associated with scaling and crusting ✖ ✖ ✖
Erythroplasia of Queyrat ✖ ✔ Velvety patches and plaques of keratinization on penis. ✔ ✖ ✖

References

  1. ↑ 1.0 1.1 Edwards SK, Bunker CB, Ziller F, van der Meijden WI (2014). "2013 European guideline for the management of balanoposthitis". Int J STD AIDS. 25 (9): 615–26. doi:10.1177/0956462414533099. PMID 24828553.
  2. ↑ GENITOURINARY MEDICINE, Volume 72, Number 3: Pages 155-9, June 1996.
  3. ↑ International Journal of Research in Health Sciences. Jan–Mar 2014 Volume-2, Issue-1
  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.
  5. ↑ Edwards S (1996). "Balanitis and balanoposthitis: a review". Genitourin Med. 72 (3): 155–9. PMC 1195642. PMID 8707315.
  6. ↑ Dockerty WG, Sonnex C (1995). "Candidal balano-posthitis: a study of diagnostic methods". Genitourin Med. 71 (6): 407–9. PMC 1196117. PMID 8566986.
  7. ↑ Taylor PK, Rodin P (1975). "Herpes genitalis and circumcision". Br J Vener Dis. 51 (4): 274–7. PMC 1046564. PMID 1156848.
  8. ↑ 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.
  9. ↑ GENITOURINARY MEDICINE, Volume 72, Number 3: Pages 155-9,
  10. ↑ 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.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ Sobel JD (1985). "Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis". Am. J. Obstet. Gynecol. 152 (7 Pt 2): 924–35. PMID 3895958.
  14. ↑ 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.
  15. ↑ 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.
  16. ↑ Hook EW, Peeling RW (2004). "Syphilis control--a continuing challenge". N Engl J Med. 351 (2): 122–4. doi:10.1056/NEJMp048126. PMID 15247352.
  17. ↑ 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.
  18. ↑ 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.
  19. ↑ 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.
  20. ↑ 20.0 20.1 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.
  21. ↑ 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.
  22. ↑ 22.0 22.1 Koutsky L (1997). "Epidemiology of genital human papillomavirus infection". Am. J. Med. 102 (5A): 3–8. PMID 9217656.
  23. ↑ 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.
  24. ↑ 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.
  25. ↑ 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.
  26. ↑ 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.
  27. ↑ 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.
  28. ↑ 28.0 28.1 28.2 28.3 Kutlubay Z, Engin B, Zara T, Tüzün Y (2013). "Anogenital malignancies and premalignancies: facts and controversies". Clin Dermatol. 31 (4): 362–73. doi:10.1016/j.clindermatol.2013.01.003. PMID 23806153.
  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.

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