Sandbox: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.


==Historical Perspective==
==Historical Perspective==
Balanitis is an ancient disease,The term Balanitis is derived from a Greek term balanos or acorn
==Classification==
==Classification==
There is no established classification system for Infectious Balanitis.  
There is no established classification system for Infectious Balanitis.  
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|-
|-
|Candidal Balanitis
|Candidal Balanitis
|Sexual transmitted
|
* Sexual transmitted
* Normal flora
|
|
* Diabetes
* Diabetes
* Immunocompromised  
* Immunocompromised
* Age>40 yrs
* Age>40 yrs
|
|
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* 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 enzymes, toxins and phospholipase. Proteolytic enzymes destroy the proteins that normally impair fungal invasion
|-
|-
|Anaerobic Infection
|[[Anaerobic organism|Anaerobic Infection]]
|Sexually transmitted
|
Extension from the perirectal area
* [[Sexually transmitted disease|Sexually transmitted]]
 
* Extension from the perirectal area
Orogenital sex-saliva as a lubricant during coitus
* Orogenital sex-saliva as a lubricant during [[coitus]]
 
.
.


|
|
* Tight foreskin
* Tight foreskin
* sub-optimal hygienic maintenance  
* sub-optimal hygienic maintenance
|Anaerobic Gram-negative rods produce various toxins, proteases, elastase, and other virulence factors
|Anaerobic gram-negative rods produce various [[toxins]], [[proteases]], elastase, and other virulence factors
|-
|-
|Aerobic
|Aerobic
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{{familytree | |!| | | |!| | | |!| | |,|-|-|-|+|-|-|-|v|-|-|-|.|}}
{{familytree | |!| | | |!| | | |!| | |,|-|-|-|+|-|-|-|v|-|-|-|.|}}
{{familytree | |!| | | |!| | | |!| | |!| | | |!| | | |!| | | |!|}}
{{familytree | |!| | | |!| | | |!| | |!| | | |!| | | |!| | | |!|}}
{{familytree | C01 | | C02 | | C03 | |C04| | C05 | | C06 | | C07 | |C01=Candida (albicans, krusei)<br> Dermatophytosis <br>Pityriasis versicolor<br>Histoplasma capsulatum<br>Blastomyces dermatitidis<br>Cryptococcus neoformans|C02=Herpes simplex virus<br>Varicella zoster virus (VZV)<br>Human papilloma virus (HPV)|C03=Entamoeba histolytica<br>Trichomonas vaginalis<br>Leishmania species<br>'''Parasties'''<br>Sarcoptes scabiei var hominis<br>Pediculosis<br>Ankylostoma species|C04='''Gram negative bacteria'''E.coli, Pseudomonas, Haemophilus parainfluenzae, Klebsiella, Neisseria gonorrhoea, Haemophilus ducreyi, Mycoplasma genitalium, Chlamydia, Ureaplasma, Gardnerella vaginalis, Citrobacter, Enterobacter<br>|C05='''Spirochaetes'''<br>Treponema pallidum, Non specific spirochaetal infection<br>|C06='''Gram positive organism'''<br> Haemolytic Streptococci(Group B Streptococci), Staphylococci epidermidis/aureus|C07='''Acid fast bacilli'''<br> Mycobacterium tuberculosis, Leprosy<br>'''Anaerobes'''<br>(Bacteroides)}}
{{familytree | C01 | | C02 | | C03 | |C04| | C05 | | C06 | | C07 | |C01=Candida (albicans, krusei)<br> Dermatophytosis <br>Pityriasis versicolor<br>Histoplasma capsulatum<br>Blastomyces dermatitidis<br>Cryptococcus neoformans|C02=Herpes simplex virus<br>Varicella zoster virus (VZV)<br>Human papilloma virus (HPV)|C03='''Protozoal'''<br>Entamoeba histolytica<br>Trichomonas vaginalis<br>Leishmania species<br>'''Parastic'''<br>Sarcoptes scabiei var hominis<br>Pediculosis<br>Ankylostoma species|C04='''Gram negative bacteria'''<br>E.coli, Pseudomonas, Haemophilus parainfluenzae, Klebsiella, Neisseria gonorrhoea, Haemophilus ducreyi, Mycoplasma genitalium, Chlamydia, Ureaplasma, Gardnerella vaginalis, Citrobacter, Enterobacter<br>|C05='''Spirochaetes'''<br>Treponema pallidum, Non specific spirochaetal infection<br>|C06='''Gram positive organism'''<br> Haemolytic Streptococci(Group B Streptococci), Staphylococci epidermidis/aureus|C07='''Acid fast bacilli'''<br> Mycobacterium tuberculosis, Leprosy<br>'''Anaerobes'''<br>(Bacteroides)}}
{{familytree/end}}
{{familytree/end}}
==Epidemiology and Demographics==
==Epidemiology and Demographics==


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==Diagnosis==
==Diagnosis==
==== History and symptoms ====
Patients may be asymptomatic or present with pruritic, or painful lesions in the genital region.
{| 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>
! 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)
|-
|-
|Candidal Balanitis
|Candidal Balanitis
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|Aerobic
|Aerobic
Infections
Infections
|Variable inflmmatory changes including uniform erythema and edema
|Variable inflammatory changes including uniform erythema and edema
|-
|-
|Trichomonas  vaginalis
|Trichomonas  vaginalis
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====Laboratory findings====
====Laboratory findings====
{| class="wikitable"
{| class="wikitable"
! colspan="2" |Laboratory findings<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>
! colspan="2" |Laboratory findings<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)
|-
|-
|Candidal Balanitis
|Candidal Balanitis
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==Treatment==
==Treatment==
{| class="wikitable"
{| class="wikitable"
! colspan="2" |Treatment<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>
! colspan="3" |Treatment<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)
!
|-
|-
!
!
Line 289: Line 297:


==References==
==References==
{{Reflist|2}}{{WikiDoc Help Menu}} {{WikiDoc Sources}}
{{Reflist|2}}

Latest revision as of 17:03, 8 February 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:Candida balanitis, Candidal balanitis, Infectious balanoposthitis

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 STD clinc, 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. Orgnaism could be part of the normal flora or transmitted by sexually, or autoinoculation, or via direct contact. Patients may be asymptomatic or present with pruritic, or painful lesions in the genital region. Specific infectious balanitis etiology is diagnosed based on clinical presentation supported with laboratory findings. Infectious balanitis is usually 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
  • Sexual transmitted
  • Normal flora
  • Diabetes
  • Immunocompromised
  • 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.
  • 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
Anaerobic Infection

.

  • Tight foreskin
  • sub-optimal hygienic maintenance
Anaerobic gram-negative rods produce various toxins, proteases, elastase, and other virulence factors
Aerobic

Infections

Sexually transmitted

Autoinoculation from other sites

  • Uncircumcised penis
  • Diabetes
  • Immunocompromised
Adherence to epithelial cells, biofilm production, surface hydrophobicity, phospholipase C and protease activity
Trichomonas vaginalis Sexually transmitted 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
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

Direct contact with, or droplets from, infected secretions entering via skin or mucous membrane

Multiple sexual partners

Low socio-economic status

Inhibition of MHC Class I, Impairing funtion of dentric cells
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], 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 and Demographics

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]

Demographics

Screening

There is no established screening guidelines for Infectious Balanitis

Natural History, Complications, and Prognosis

Natural history

If left untreated, Infection balanitis may result in complications.[5]

Complications

Complication of Infectious balanitis include:[28]

  • Pain
  • Erosions
  • Fissures
  • Phimosis
  • Paraphimosis
  • Painful erection
  • Reduced urinary flow
  • Urinary retention

Prognosis

Prognosis is good with treatment.

Diagnosis

History and symptoms

Patients may be asymptomatic or present with pruritic, or painful lesions in the genital region.

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 Foul smelling sub-preputial inflammation and discharg: in severe cases associated with swelling and inflamed inguinal lymph nodes

Preputial edema, superficial erosions: milder forms also occur

Aerobic

Infections

Variable inflammatory changes including uniform erythema and edema
Trichomonas vaginalis Superficial erosive balanitis which may lead to phimosis
Treponema paliidum 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 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.
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 candidasis/candidal superinfection-to be done in all cases

Investigation for HIV or other causes of immunosuppression

Anaerobic Infection
  • Gram stain may show fusiform/mixed bacterial picture
  • Sub-preputial culture wet prep or NAAt(to exclude other causes)
  • G. vaginalis is a facultative anaerobe which may be isolated
  • Swab for HSV infection if ulcerated
Aerobic

Infections

Sub-preputial culture

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

T. vaginalis Wet preparation from the subpreputial sac demonstrates the organism

Culture and NAAT can also be carried out

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

TPHA coupled with nontreponemal 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 Clotimazole 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/clvulanic acid 375 mg 3 times daily for 1 week

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

Secidazole 2 g orally single dose

Metronidazole 400 mg orally twice a day for 7 days
TP 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:

Safe sex practices.

Maintaining proper penile hygiene.

Secondary prevention

There ares 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.
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