Infectious balanitis

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

Historical Perspective

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

Classification

There is no established classification system for Infectious Balanitis.

Pathophysiology

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

Pathogen Route of transmission Risk factors Virulence factors
Candidal Balanitis
Anaerobic Infection

.

  • Tight foreskin
  • sub-optimal penile hygienic maintenance
 Anaerobic gram-negative rods produce various toxins, proteases, and elastase
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 sexual route to the human host Risk factors responsible for sexual transmission of HPV include:

Number of sex partners[15][16], acqusition of new partner[15]

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

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

Causes

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

Common causes of infectious balanitis

Fungal

Protozoal

spirochaetes

Viral

Less common causes of infectious balanitis

Fungal

Viral

Protozoal

Parasitic

Bacterial

Gram negative bacteria

Spirochaetes

Gram positive organism

Acid fast bacilli

Anaerobes

Epidemiology and demographics

Epidemiology

  • There are no comprehensive studies studying the incidence and prevalence of balanoposthitis in general population. A recent study has shown that balanitis commonly occurs in around 10% of the patient population visiting the STD clinic, with infectious etiology responsible for around 50% of the cases.[26]
  • Candida is the most common cause being responsible for 30-35% cases with infectious etiology.[27]

Demographics

Age

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

Sex

Balanoposthitis occurs only in males.

Race

There is no racial predilection.

Screening

There is no established screening guidelines for Infectious Balanitis.

Natural History, Complications, and Prognosis

Natural history

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

Complications

Complication of Infectious balanitis include:[29]

Prognosis

Prognosis is usually good with treatment.

Diagnosis

History and symptoms

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

Physical examination

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

Examination of genitourinary system may show:[5]

  • Erythema of prepuce or glans penis
  • Edema of prepuce or glans penis
  • Discharge
  • Inguinal lymphadenopathy
  • Ulcers
  • Phimosis
  • Vesicles
Clinical features of Infectious balanitis[25](adopted from the Indian journal of sexually transmitted diseases and AIDS)
Candidal Balanitis Erythematous rash with soreness and/or itch, blotchy erythema with small papules which may be eroded, or dry dull red areas with a glazed appearance
Anaerobic Infection
Aerobic

Infections

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

Laboratory findings

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

Infections

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

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

Treatment

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

Candidal balanitis

Preferred regimen

Clotrimazole cream 1% or Miconazole cream 2%

Alternative regimen

Fluconazole 150 mg stat orally or Nystatin cream-if resistance suspected topical or clotrimazole/miconazole with 1% hydrocortisone-if marked inflammation

Anaerobic Infection

Preferred regimen

Alternative regimen

Aerobic Infections

Preferred regimen

Usually topical triple combination (clotrimazole 1%, beclometasone dipropionate 0.025%, gentamicin sulfate 0.3%) applied once daily

Severe cases-systemic antibiotics

Alternative regimen

  • Alternative regimens depend on the sensitivities of the organisms isolated

Trichomonas vaginalis

Preferred regimen

Alternative regimen

Treponema pallidum

Preferred regimen

Herpes simplex

Preferred regimen

  • 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

Preferred regimen

Patients applied

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

Provider-administered

  • Podophyllin resin 20% in a compound tincture of benzoin-once a week for 6-8 week or Cryotherapy with liquid nitrogen cryoprobe. Repeat applications every 1-2 weeks or
  • TCA/bichloroacetic acid-80-90% once per week for an average course of 6-10 weeks or
  • Surgical removal either by tangential scissor excision, tangential shave excision, curettage, or electrosurgery.

Prevention

Primary Prevention

Primary prevention of Infectious balanitis include:[25]

Secondary prevention

There are no specific secondary preventive measures for infectious balanitis.

References

  1. ↑ Taylor PK, Rodin P (1975). "Herpes genitalis and circumcision". Br J Vener Dis. 51 (4): 274–7. PMC 1046564. PMID 1156848.
  2. ↑ Cree GE, Willis AT, Phillips KD, Brazier JS (1982). "Anaerobic balanoposthitis". Br Med J (Clin Res Ed). 284 (6319): 859–60. PMC 1496281. PMID 6121604.
  3. ↑ GENITOURINARY MEDICINE, Volume 72, Number 3: Pages 155-9,
  4. ↑ Lisboa C, Santos A, Dias C, Azevedo F, Pina-Vaz C, Rodrigues A (2010). "Candida balanitis: risk factors". J Eur Acad Dermatol Venereol. 24 (7): 820–6. doi:10.1111/j.1468-3083.2009.03533.x. PMID 20002652.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Edwards SK, Bunker CB, Ziller F, van der Meijden WI (2014). "2013 European guideline for the management of balanoposthitis". Int J STD AIDS. 25 (9): 615–26. doi:10.1177/0956462414533099. PMID 24828553.
  6. ↑ Hernandez BY, Wilkens LR, Zhu X, Thompson P, McDuffie K, Shvetsov YB; et al. (2008). "Transmission of human papillomavirus in heterosexual couples". Emerg Infect Dis. 14 (6): 888–94. doi:10.3201/eid1406.070616. PMC 2600292. PMID 18507898.
  7. ↑ Sobel JD (1985). "Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis". Am. J. Obstet. Gynecol. 152 (7 Pt 2): 924–35. PMID 3895958.
  8. ↑ Rolfs RT, Goldberg M, Sharrar RG (1990). "Risk factors for syphilis: cocaine use and prostitution". Am J Public Health. 80 (7): 853–7. PMC 1404975. PMID 2356911.
  9. ↑ Zhou H, Chen XS, Hong FC, Pan P, Yang F, Cai YM; et al. (2007). "Risk factors for syphilis infection among pregnant women: results of a case-control study in Shenzhen, China". Sex Transm Infect. 83 (6): 476–80. doi:10.1136/sti.2007.026187. PMC 2598725. PMID 17675391.
  10. ↑ Hook EW, Peeling RW (2004). "Syphilis control--a continuing challenge". N Engl J Med. 351 (2): 122–4. doi:10.1056/NEJMp048126. PMID 15247352.
  11. ↑ Buchacz K, Greenberg A, Onorato I, Janssen R (2005). "Syphilis epidemics and human immunodeficiency virus (HIV) incidence among men who have sex with men in the United States: implications for HIV prevention". Sex Transm Dis. 32 (10 Suppl): S73–9. PMID 16205297.
  12. ↑ Solomon MM, Mayer KH (2015). "Evolution of the syphilis epidemic among men who have sex with men". Sex Health. 12 (2): 96–102. doi:10.1071/SH14173. PMC 4470884. PMID 25514173.
  13. ↑ Hakre S, Arteaga GB, Núñez AE, Arambu N, Aumakhan B, Liu M; et al. (2014). "Prevalence of HIV, syphilis, and other sexually transmitted infections among MSM from three cities in Panama". J Urban Health. 91 (4): 793–808. doi:10.1007/s11524-014-9885-4. PMC 4134449. PMID 24927712.
  14. ↑ Newell, J., et al. "A population-based study of syphilis and sexually transmitted disease syndromes in north-western Tanzania. 2. Risk factors and health seeking behaviour." Genitourinary medicine 69.6 (1993): 421-426.
  15. ↑ 15.0 15.1 Bell MC, Schmidt-Grimminger D, Jacobsen C, Chauhan SC, Maher DM, Buchwald DS (2011). "Risk factors for HPV infection among American Indian and white women in the Northern Plains". Gynecol. Oncol. 121 (3): 532–6. doi:10.1016/j.ygyno.2011.02.032. PMC 4498572. PMID 21414655.
  16. ↑ Tarkowski TA, Koumans EH, Sawyer M, Pierce A, Black CM, Papp JR, Markowitz L, Unger ER (2004). "Epidemiology of human papillomavirus infection and abnormal cytologic test results in an urban adolescent population". J. Infect. Dis. 189 (1): 46–50. doi:10.1086/380466. PMID 14702152.
  17. ↑ 17.0 17.1 Koutsky L (1997). "Epidemiology of genital human papillomavirus infection". Am. J. Med. 102 (5A): 3–8. PMID 9217656.
  18. ↑ Winer RL, Lee SK, Hughes JP, Adam DE, Kiviat NB, Koutsky LA (2003). "Genital human papillomavirus infection: incidence and risk factors in a cohort of female university students". Am. J. Epidemiol. 157 (3): 218–26. PMID 12543621.
  19. ↑ Tseng CJ, Liang CC, Soong YK, Pao CC (1998). "Perinatal transmission of human papillomavirus in infants: relationship between infection rate and mode of delivery". Obstet Gynecol. 91 (1): 92–6. PMID 9464728.
  20. ↑ Ting J, Kruzikas DT, Smith JS (2010). "A global review of age-specific and overall prevalence of cervical lesions". Int. J. Gynecol. Cancer. 20 (7): 1244–9. PMID 21495248.
  21. ↑ Kjaer SK, van den Brule AJ, Bock JE, Poll PA, Engholm G, Sherman ME, Walboomers JM, Meijer CJ (1997). "Determinants for genital human papillomavirus (HPV) infection in 1000 randomly chosen young Danish women with normal Pap smear: are there different risk profiles for oncogenic and nononcogenic HPV types?". Cancer Epidemiol. Biomarkers Prev. 6 (10): 799–805. PMID 9332762.
  22. ↑ Ley C, Bauer HM, Reingold A, Schiffman MH, Chambers JC, Tashiro CJ, Manos MM (1991). "Determinants of genital human papillomavirus infection in young women". J. Natl. Cancer Inst. 83 (14): 997–1003. PMID 1649312.
  23. ↑ GENITOURINARY MEDICINE, Volume 72, Number 3: Pages 155-9, June 1996.
  24. ↑ International Journal of Research in Health Sciences. Jan–Mar 2014 Volume-2, Issue-1
  25. ↑ 25.0 25.1 25.2 25.3 25.4 Pandya I, Shinojia M, Vadukul D, Marfatia YS (2014). "Approach to balanitis/balanoposthitis: Current guidelines". Indian J Sex Transm Dis. 35 (2): 155–7. doi:10.4103/0253-7184.142415. PMC 4553848. PMID 26396455.
  26. ↑ Edwards S (1996). "Balanitis and balanoposthitis: a review". Genitourin Med. 72 (3): 155–9. PMC 1195642. PMID 8707315.
  27. ↑ Dockerty WG, Sonnex C (1995). "Candidal balano-posthitis: a study of diagnostic methods". Genitourin Med. 71 (6): 407–9. PMC 1196117. PMID 8566986.
  28. ↑ Fergusson DM, Lawton JM, Shannon FT (1988). "Neonatal circumcision and penile problems: an 8-year longitudinal study". Pediatrics. 81 (4): 537–41. PMID 3353186.
  29. ↑ Edwards SK, Bunker CB, Ziller F, van der Meijden WI (2014). "2013 European guideline for the management of balanoposthitis". Int J STD AIDS. 25 (9): 615–26. doi:10.1177/0956462414533099. PMID 24828553.
  30. ↑ Edwards SK, Bunker CB, Ziller F, van der Meijden WI (2014). "2013 European guideline for the management of balanoposthitis". Int J STD AIDS. 25 (9): 615–26. doi:10.1177/0956462414533099. PMID 24828553.
  31. ↑ Kishimoto M, Lee MJ, Mor A, Abeles AM, Solomon G, Pillinger MH (2006). "Syphilis mimicking Reiter's syndrome in an HIV-positive patient". Am J Med Sci. 332 (2): 90–2. PMID 16909057.
  32. ↑ Neill SM, Lewis FM, Tatnall FM, Cox NH, British Association of Dermatologists (2010). "British Association of Dermatologists' guidelines for the management of lichen sclerosus 2010". Br J Dermatol. 163 (4): 672–82. doi:10.1111/j.1365-2133.2010.09997.x. PMID 20854400.
  33. ↑ Chi CC, Kirtschig G, Baldo M, Brackenbury F, Lewis F, Wojnarowska F (2011). "Topical interventions for genital lichen sclerosus". Cochrane Database Syst Rev (12): CD008240. doi:10.1002/14651858.CD008240.pub2. PMID 22161424.
  34. ↑ Porter WM, Francis N, Hawkins D, Dinneen M, Bunker CB (2002). "Penile intraepithelial neoplasia: clinical spectrum and treatment of 35 cases". Br J Dermatol. 147 (6): 1159–65. PMID 12452865.
  35. ↑ Weyers W, Ende Y, Schalla W, Diaz-Cascajo C (2002). "Balanitis of Zoon: a clinicopathologic study of 45 cases". Am J Dermatopathol. 24 (6): 459–67. PMID 12454596.
  36. ↑ Kumar B, Sharma R, Rajagopalan M, Radotra BD (1995). "Plasma cell balanitis: clinical and histopathological features--response to circumcision". Genitourin Med. 71 (1): 32–4. PMC 1195366. PMID 7750950.
  37. ↑ Nast A, Kopp I, Augustin M, Banditt KB, Boehncke WH, Follmann M; et al. (2007). "German evidence-based guidelines for the treatment of Psoriasis vulgaris (short version)". Arch Dermatol Res. 299 (3): 111–38. doi:10.1007/s00403-007-0744-y. PMC 1910890. PMID 17497162.
  38. ↑ Zawar V, Kirloskar M, Chuh A (2004). "Fixed drug eruption - a sexually inducible reaction?". Int J STD AIDS. 15 (8): 560–3. doi:10.1258/0956462041558285. PMID 15307969.
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