Sandbox:Infectious Balanitis: Difference between revisions

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June 1996.
June 1996.
</ref><ref name="pmid248285532" />
</ref><ref name="pmid248285532" /><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>


{| class="wikitable"
{| class="wikitable"
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|-
|-
|Candidal Balanitis
|Candidal Balanitis
|Sexual acquired
|Sexual transmitted 
|
|
* Diabetes
* Diabetes
Line 32: Line 32:
|-
|-
|Anaerobic Infection
|Anaerobic Infection
|Possible modes of transmission include contact with infected mucosal surfaces, such as during sexual intercourse, contamination by colonized saliva, or extension from the perirectal area.
|Sexually transmitted
orogenital sex
Extension from the perirectal area
saliva as a lubricant during coitus
 
Orogenital sex-saliva as a lubricant during coitus
 
.
 
|Tight foreskin 
|Tight foreskin 


sub-optimal hygienic mainta 
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
Infections
Infections
|Sexually acquired and partners of women with ''Gardnerella vaginalis'' have high isolation rates from the urethra<sup>24</sup> or urine.autoinoculation
|Sexually transmitted
Autoinoculation from other sites  
Autoinoculation from other sites  
|uncircumcised ch
|
* Uncircumcised penis
 
* Diabetes
* Diabetes
* Neutropenia
* Neutropenia
Line 50: Line 56:
|-
|-
|Trichomonas vaginalis
|Trichomonas vaginalis
|Sexually
|Sexually transmitted
|presence of other infections
|presence of other infections
|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
|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
Line 61: Line 67:
|-
|-
|Herpes simplex
|Herpes simplex
|often transmitted sexually
|Often transmitted sexually


direct contact with, or droplets from, infected secretions entering via skin or mucous membrane, where primary infection may become evident
Direct contact with, or droplets from, infected secretions entering via skin or mucous membrane
|Multiple sexual partners  
|Multiple sexual partners  


Line 70: Line 76:
|-
|-
|Human papilloma virus
|Human papilloma virus
|usually transmitted via the sexual route to the human host.<sup>[[Human papillomavirus pathophysiology|[1]]]</sup> 
|Usually transmitted via the sexual route to the human host. 
|
|Risk factors responsible for sexual transmission of 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">{{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>
 
,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">{{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>,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>, 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>
|linked to epithelial [[differentiation]] and maturation of host keratinocytes, with [[transcription]] of specific gene products at every level.<sup>[[Human papillomavirus pathophysiology|[2][3]]]</sup>
|linked to epithelial [[differentiation]] and maturation of host keratinocytes, with [[transcription]] of specific gene products at every level.<sup>[[Human papillomavirus pathophysiology|[2][3]]]</sup>
|}
|}
Line 91: Line 101:
Epidemiology
Epidemiology


There are no comprehensive studies  
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.<ref name="pmid8707315">{{cite journal| author=Edwards S| title=Balanitis and balanoposthitis: a review. | journal=Genitourin Med | year= 1996 | volume= 72 | issue= 3 | pages= 155-9 | pmid=8707315 | doi= | pmc=1195642 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8707315  }}</ref>
 
Candida being the most common cause responsible for 30-35% of cases.<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>


==Screening==
==Screening==

Revision as of 22:32, 25 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:Candida balanitis, Candidal balanitis, Infectious balanoposthitis

Overview

Historical Perspective

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]

Pathogen Route of transmission Risk factors virulence factors
Candidal Balanitis Sexual transmitted
  • Diabetes
  • Neutropenia
  • Age>60 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.[1][2]
  • 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 Sexually transmitted

Extension from the perirectal area

Orogenital sex-saliva as a lubricant during coitus

.

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
  • Neutropenia
Adherence to epithelial cells, biofilm production, surface hydrophobicity, phospholipase C and protease activity
Trichomonas vaginalis Sexually transmitted presence of other infections 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) Multiple sexual partners 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[6][7],Acqusition of new partner[6]

,Having non monogamous sex partner[8][9], Starting sexual activity in young age[8],Vaginal delivery and multiple deliveries[10], Age over 40 for women[11], History of Chlamydia infection[12], Long term OCP use[13]

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:[14][15][4][16]

 
 
 
 
 
 
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)
 
Entamoeba histolytica
Trichomonas vaginalis
Leishmania species
Parasties
Sarcoptes scabiei var hominis
Pediculosis
Ankylostoma species
 
Gram negative bacteriaE.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.[17]

Candida being the most common cause responsible for 30-35% of cases.[18]

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.[4]

Complications

Complication of Infectious balanitis include:[19]

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

Prognosis

Prognosis is good with treatment.

Diagnosis

Clinical features of Infectious balanitis[16]
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 inflmmatory changes including uniform erythema and edema
T. vaginalis Superficial erosive balanitis which may lead to phimosis
TP 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[16]
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[16]
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

Secondary prevention

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, June 1996.
  4. 4.0 4.1 4.2 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.
  5. 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.
  6. 6.0 6.1 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.
  7. 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.
  8. 8.0 8.1 Koutsky L (1997). "Epidemiology of genital human papillomavirus infection". Am. J. Med. 102 (5A): 3–8. PMID 9217656.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
  14. GENITOURINARY MEDICINE, Volume 72, Number 3: Pages 155-9, June 1996.
  15. International Journal of Research in Health Sciences. Jan–Mar 2014 Volume-2, Issue-1
  16. 16.0 16.1 16.2 16.3 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.
  17. Edwards S (1996). "Balanitis and balanoposthitis: a review". Genitourin Med. 72 (3): 155–9. PMC 1195642. PMID 8707315.
  18. Dockerty WG, Sonnex C (1995). "Candidal balano-posthitis: a study of diagnostic methods". Genitourin Med. 71 (6): 407–9. PMC 1196117. PMID 8566986.
  19. 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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