Balanitis: Difference between revisions

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{{SK}} Balanoposthitis
{{SK}} Balanoposthitis
* '''Please [[Zoon's Balanitis|click here]] to know more about [[Zoon's Balanitis]]'''
 
* '''Please [[Balanitis xerotica obliterans|click here]] to know more about [[Balanitis xerotica obliterans]]'''


==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 from [[etiology]] to [[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.
== Classification ==
==[[Balanitis historical perspective|Historical Perspective]]==
 
Balanitis is an ancient disease,The term Balanitis is derived from a Greek term balanos or acorn.
There is no established classification system for Balantis. Based on the etiologies, Balanitis can be classified into:<ref name="pmid24828553">{{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>
==Classification==
* [[Infectious balanitis|Infectious]]  
There is no established classification system for Balantis. Based on the etiologies, Balanitis can be classified into:<ref name="pmid248285532">{{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>
* Non-infectious balanitis
*[[Infectious balanitis|Infectious]]
:*[[Zoon's balanitis]]
*[[Inflammatory dermatoses]]
:*[[Balanitis xerotica obliterans]]
*[[Penile carcinoma in situ]]
 
==[[Balanitis pathophysiology|Pathophysiology]]==
== Causes ==
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]]
=== '''Infectious balanitis''' ===
*[[Immunocompromised|Immunocompromise]] conditions
'''Common causes of infectious balanitis'''  
|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>
'''Fungal'''
|Linked to [[epithelial]] [[differentiation]] and maturation of host [[keratinocytes]], with [[transcription]] of specific [[Gene|gene products]] at every level.
* [[Candida]] (most common cause)
|}
'''Protozoal'''
==[[Balanitis causes|Causes]]==
* [[Trichomonas vaginalis]]  
Causes of balanitis are:{{familytree/start}}
'''spirochaetes'''
{{familytree | | | | | | | | | | | | | | | | | A01 |A01='''Balanitis'''}}
* [[Treponema pallidum]]
{{familytree | | | | |,|-|-|-|-|-|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|-|-|-|.| | | }}
'''Viral'''
{{familytree | | | | B01 | | | | | | | | | | | B02 | | | | | | | | | B03 |B01='''Infectious'''|B02='''Inflammatory dermatoses'''|B03='''Premalignant (penile carcinoma in situ)'''}}
* [[Herpes simplex]]
{{familytree | | | | |!| | | | | | | | | | | | |!| | | | | | | | | | |!| | | }}
* [[Human papillomavirus|Human papilloma virus]]  
{{familytree | | | | |!| | | | | | | | | | | | |!| | | | | | | | | | |!| | | }}
{{familytree | | | | C01 | | | | | | | | | | | C02 | | | | | | | | | C03 |C01=[[Candida]] (albicans, krusei)<br>[[Streptococci]]<br>Anaerobes<br>[[Staphylococci]]<br>[[Trichomonas vaginalis]]<br>[[Herpes simplex virus]]<br>[[Human papillomavirus]]<br>[[Mycoplasma genitalium]]|C02=[[Lichen sclerosus]]<br>[[Lichen planus]]<br>[[Psoriasis]]<br>[[Circinate balanitis]]<br>[[Zoon's balanitis]]<br>[[Eczema]]<br>[[Allergic reactions]]|C03= [[Bowen's disease]]<br>[[Bowenoid papulosis]]<br>[[Erythroplasia of Queyrat]]}}
{{familytree/end}}


Causes of Infectious balanitis include:<ref>GENITOURINARY MEDICINE, Volume 72, Number 3: Pages 155-9, June 1996.</ref><ref>International Journal of Research in Health Sciences. Jan–Mar 2014 Volume-2, Issue-1</ref><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>{{familytree/start}}
==== Less common causes of infectious balanitis ====
{{familytree | | | | | | | A01 | | | | | | | | | | | | | | | |A01=Balanitis}}
'''Fungal'''  
{{familytree | |,|-|-|-|v|-|^|-|v|-|-|-|-|-|-|.| | | | | | | | | | }}
* [[Dermatophytosis]] 
{{familytree | |!| | | |!| | | |!| | | | | | |!| | | | | | | | | | | | | }}
* [[Pityriasis versicolor]]
{{familytree | B01 | | B02 | | B03 | | | | | B04 | | | | |B01=Fungal|B02=Virus|B03=Parasite/Protozoal|B04=Bacteria}}                     
* [[Histoplasma capsulatum]]
{{familytree | |!| | | |!| | | |!| | |,|-|-|-|+|-|-|-|v|-|-|-|.|}}
* [[Blastomyces dermatitidis]]
{{familytree | |!| | | |!| | | |!| | |!| | | |!| | | |!| | | |!|}}
* [[Cryptococcus neoformans]]
{{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}}
==[[Balanitis differential diagnosis|Differentiating diagnosis]]==
{| class="wikitable"
! colspan="3" |Symptoms
! colspan="4" |Signs
|-
!
!Malaise
!Pruritus
!Skin lesions
!Regional lymphadenopathy
!Erythema
!Swelling
|-
|[[Candidiasis|Candida balanitis]]
|✖
|✔
|[[Erythematous]] [[Rash (patient information)|rash]] with soreness and/or [[itch]]
|✔
|✔
|✖
|-
|[[Trichomonas vaginalis]]
|✖
|✔
|Superficial erosive [[balanitis]]
|✖
|✔
|✖
|-
|[[Treponema pallidum]]
|✖
|✖
|Multiple circinate lesions
|✔
|✖
|✖
|-
|[[Herpes simplex]]
|✔
|✔
|Grouped [[vesicles]] on [[erythematous]] base
|✔
|✔
|✖
|-
|[[Human papillomavirus|Human papilloma virus]]
|✖
|✔
|[[Warts]]
|✖
|✖
|✖
|-
|[[Lichen sclerosus]]
|✖
|✔
|White patches on glans
|✖
|✖
|✖
|-
|[[Lichen planus]]
|✖
|✔
|Purplish lesions on the [[penis]]
|✖
|✖
|✖
|-
|[[Psoriasis]]
|✖
|✔
|Red scaly plaques
|✖
|✔
|✖
|-
|[[Reiter's Syndrome|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 [[Erythema|erythematous]] lesions
|✖
|✔
|✖
|-
|[[Bowen's disease]]
|✖
|✔
|Multiple, small, well-demarcated [[Papillomatosis|papillomatous]] [[papules]]
|✖
|✖
|✖
|-
|[[Bowenoid papulosis]]
|✖
|✔
|Single or multiple, sharply demarcated associated with [[Scaling skin|scaling]] and crusting
|✖
|✖
|✖
|-
|[[Erythroplasia of Queyrat]]
|✖
|✔
|Velvety patches and [[plaques]] of [[keratinization]] on [[penis]].
|✔
|✖
|✖
|}
==[[Balanitis epidemiology and demographics|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.<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>
*[[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]]==
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>
{| class="wikitable"
!Pathogen
!Risk factors
|-
|[[Candidiasis|Candidal Balanitis]]
|
*[[Diabetes]]
*[[Immunocompromised]] conditions
*Age>40 yrs
|-
|[[Anaerobic organism|Anaerobic Infection]]
|
*Tight [[foreskin]]
*sub-optimal penile hygienic maintenance
|-
|[[Aerobic organism|Aerobic]]
[[Aerobic organism|Infections]]
|
*Uncircumcised penis


*[[Diabetes]]
==== Viral ====
*[[Immunocompromised|Immunocompromise]] conditions
* [[Varicella zoster virus|Varicella zoster virus (VZV)]]
|-
|[[Trichomonas vaginalis]]
|
*Multiple sexual partners
*Unprotected sexual activity
*Co-existing [[venereal diseases]]
|-
|[[Treponema pallidum|Treponema]]
[[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
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
|-
|[[Herpes simplex]]
|
*Multiple sexual partners
*Low [[socio-economic status]]
|-
|[[Human papilloma virus]]
|[[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" />


, 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" />
==== Protozoal ====
|}
* [[Entamoeba histolytica]]
==[[Balanitis screening|Screening]]==
* [[Leishmania|Leishmania species]]
There is no established clinical guidelines for screening patients for balanitis.
==[[Balanitis natural history, complications and prognosis|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:<ref name="pmid248285532" />
*[[Pain]]
*Erosions
*[[Fissures]]


*[[Phimosis]]
==== Parasitic ====
*[[Paraphimosis]]
* [[Sarcoptes scabiei]]  
*Painful [[erection]]
* [[Pediculosis]]
*Reduced urinary flow
* [[Ancylostoma]]
*[[Urinary retention]]
===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%).<ref name="pmid23806153">{{cite journal| author=Kutlubay Z, Engin B, Zara T, Tüzün Y| title=Anogenital malignancies and premalignancies: facts and controversies. | journal=Clin Dermatol | year= 2013 | volume= 31 | issue= 4 | pages= 362-73 | pmid=23806153 | doi=10.1016/j.clindermatol.2013.01.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23806153  }}</ref>
==== Bacterial ====
====Erythroplasia of Queyrat====
'''Gram negative bacteria'''
If left untreated, Erythroplasia of Queyrat may progress into invasive [[Squamous cell carcinoma]], with an incidence ranging from 10% to 33%.<ref name="pmid23806153" />
* [[Escherichia coli|E.coli]]
====Bowen's Disease====
* [[Pseudomonas]]
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.<ref name="pmid23806153" />
* [[Haemophilus|Haemophilus parainfluenzae]]
===Complications===
* [[Klebsiella]]
Complication of penile carcinoma in situ include:<ref name="pmid23806153" />
* [[Neisseria gonorrhoeae|Neisseria gonorrhoea]]
*[[Pain]]
* [[Haemophilus ducreyi]]
*Transformation into invasive [[squamous cell carcinoma]]
* [[Mycoplasma genitalium]]
===Prognosis===
* [[Chlamydia]]
The [[prognosis]] is usually good with treatment.
* [[Ureaplasma]]
==Diagnosis==
* [[Gardnerella vaginalis]]
[[Balanitis diagnostic criteria| Diagnostic Criteria]] | [[Balanitis history and symptoms| History and Symptoms]] | [[Balanitis physical examination| Physical Examination]] | [[Balanitis laboratory findings| Laboratory Findings]] | [[Balanitis chest x ray|X-ray]]|[[CT-Scan]]| [[MRI]]|  [[Balanitis other diagnostic studies|Other Diagnostic Studies]]
* [[Citrobacter]]
==Treatment==
* [[Enterobacter]]
[[Balanitis medical therapy|Medical Therapy]] | [[Balanitis primary prevention|Primary Prevention]]  | [[Balanitis secondary prevention|Secondary Prevention]] | [[Balanitis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Balanitis future or investigational therapies|Future or Investigational Therapies]]


== Classification  ==
==== Spirochaetes ====
* Non-specific [[spirochaetal]] [[infection]]
'''Gram positive organism'''
* [[Streptococci|Haemolytic Streptococci(Group B Streptococci)]]
* [[Staphylococci|Staphylococci epidermidis/aureus]]
'''Acid fast bacilli'''
* [[Mycobacterium tuberculosis]]
* [[Mycobacterium leprae]]


There is no established classification system for Balantis. Based on the etiologies, Balanitis can be classified into:<ref name="pmid24828553">{{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>
==== Anaerobes ====
* [[Infectious balanitis|Infectious]]
* [[Bacteroides]]  
* [[Inflammatory dermatoses]]
* [[Penile carcinoma in situ]]  


{{familytree/start}}
=== '''Non-infectious balanitis''' ===
{{familytree | | | | | | | | | | | | | | | | | A01 |A01='''Balanitis'''}}
{{familytree | | | | |,|-|-|-|-|-|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|-|-|-|.| | | }}
{{familytree | | | | B01 | | | | | | | | | | | B02 | | | | | | | | | B03 |B01='''Infectious'''|B02='''Inflammatory dermatoses'''|B03='''Premalignant (penile carcinoma in situ)'''}}
{{familytree | | | | |!| | | | | | | | | | | | |!| | | | | | | | | | |!| | | }}
{{familytree | | | | |!| | | | | | | | | | | | |!| | | | | | | | | | |!| | | }}
{{familytree | | | | C01 | | | | | | | | | | | C02 | | | | | | | | | C03 |C01=[[Candida]] (albicans, krusei)<br>[[Streptococci]]<br>Anaerobes<br>[[Staphylococci]]<br>[[Trichomonas vaginalis]]<br>[[Herpes simplex virus]]<br>[[Human papillomavirus]]<br>[[Mycoplasma genitalium]]|C02=[[Lichen sclerosus]]<br>[[Lichen planus]]<br>[[Psoriasis]]<br>[[Circinate balanitis]]<br>[[Zoon's balanitis]]<br>[[Eczema]]<br>[[Allergic reactions]]|C03= [[Bowen's disease]]<br>[[Bowenoid papulosis]]<br>[[Erythroplasia of Queyrat]]}}
{{familytree/end}}


==Diagnosis and management==
==== Inflammatory dermatoses conditions causing balanitis ====
<small><small>Adopted from National Guideline on the Management of Balanoposthitis UK 2008</small></small><br>
* [[Lichen sclerosus]]
{| align=center
* [[Lichen planus]]
|-
* [[Zoon's balanitis]]
|
* [[Psoriasis]]
{{familytree/start |summary=Diagnostic and Management approach of balanitis and balanoposthitis}}
* [[Reiter's Disease|Circinate balanitis]]
{{familytree | | | | | | | | | | | A01 | | A01=Balanitis/balanoposthitis}} 
* [[Eczema]]
{{familytree | | | | | | | | | | | |!| | |}}
* [[Seborrhoeic dermatitis]]
{{familytree | | | | | | | | | | | B01 | | B01=Take history and examine}}
* [[Fixed drug eruption]]
{{familytree | | | |,|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | | }}
* Non-specific [[balanoposthitis]]
{{familytree | | | C01 | | | | | | | | | | | | | | C02 | |C01=Perpuce retracts|C02=Perpuce does not retract}}
'''Penile carcinoma in situ causing balanitis'''
{{familytree | |,|-|^|-|-|-|-|.| | | | | | |,|-|-|-|^|-|-|.| |}}
* [[Bowenoid papulosis]]
{{familytree | D01 | | | | | D02 | | | | | | D03 | | | | D04 |D01=Ulceration present|D02=Erythema,subpreputial discharge|D03=Prepuce scarred|D04=Prepuce swollen}}
* [[Erythroplasia of Queyrat]]
{{familytree | |!| | | |,|-|-|^|-|.| | | | | |!| | | | | |!|}}
* [[Bowen's disease]]
{{familytree | E01 | | E02 | | | E03 | | | | E04 | | | | E05 |E01=Follow genital ulcer protocol|E02=Fowl smelling|E03=No odour|E04=Refer to surgical opinion|E05=Treat as genital ulcer disease}}
{{familytree | |!| | | |!| | | | |!| | | | | |!| | | | | |!| | | |}}
{{familytree | |!| | | F01 | | | F02 | | | | |!| | | | | |!| | | | |F01=Metronidazole 400 mg bd|F02=Antifungal+1% Hydrocortisone cream apply bd}}
{{familytree | |!| | | |!| | | | |!| | | | | |!| | | | | |!|}}
{{familytree | |`|-|-|-|^|-|-| G01 |-|-|-|-|-|^|-|-|-|-|-|'| | | | | | |G01=Review}}
{{familytree | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | |}}
{{familytree | | | | | | | H01 | | H02 | | | | | | | | | | | | | | | |H01=If better discharge|H02=If not better 1) Reassess-try alternative pathway 2) Erythromycin 500 bd 3) Potent steroid cream}}
{{familytree/end}}
|}


==Synopsis==
= Differential Diagnosis =
{| class="wikitable"
{| class="wikitable"
! colspan="3" |Symptoms
! colspan="3" |Symptoms
Line 386: Line 110:
|-
|-
|[[Candidiasis|Candida balanitis]]
|[[Candidiasis|Candida balanitis]]
|✖
| -
|✔
| +
|[[Erythematous]] [[Rash (patient information)|rash]] with soreness and/or [[itch]]
|[[Erythematous]] [[Rash (patient information)|rash]] with soreness and/or [[itch]]
|✔
| +
|✔
| +
|✖
| -
|-
|-
|[[Trichomonas vaginalis]]
|[[Trichomonas vaginalis]]
|✖
| -
|✔
| +
|Superficial erosive [[balanitis]] 
|Superficial erosive [[balanitis]] 
|✖
| -
|✔
| +
|✖
| -
|-
|-
|[[Treponema pallidum]]
|[[Treponema pallidum]]
|✖
| -
|✖
| -
|Multiple circinate lesions
|Multiple circinate lesions
|✔
| +
|✖
| -
|✖
| -
|-
|-
|[[Herpes simplex]]
|[[Herpes simplex]]
|✔
| +
|✔
| +
|Grouped [[vesicles]] on [[erythematous]] base
|Grouped [[vesicles]] on [[erythematous]] base
|✔
| +
|✔
| +
|✖
| -
|-
|-
|[[Human papillomavirus|Human papilloma virus]]
|[[Human papillomavirus|Human papilloma virus]]
|✖
| -
|✔
| +
|[[Warts]]  
|[[Warts]]  
|✖
| -
|✖
| -
|✖
| -
|-
|-
|[[Lichen sclerosus]]
|[[Lichen sclerosus]]
|✖
| -
|✔
| +
|White patches on glans
|White patches on [[glans]]
|✖
| -
|✖
| -
|✖
| -
|-
|-
|[[Lichen planus]]
|[[Lichen planus]]
|✖
| -
|✔
| +
|Purplish lesions on the [[penis]]
|Purplish [[lesions]] on the [[penis]]
|✖
| -
|✖
| -
|✖
| -
|-
|-
|[[Psoriasis]]
|[[Psoriasis]]
|✖
| -
|✔
| +
|Red scaly plaques
|Red scaly [[plaques]]
|✖
| -
|✔
| +
|✖
| -
|-
|-
|[[Reiter's Syndrome|Circinate]]
|[[Reiter's Syndrome|Circinate]]
|✔
| +
|✔
| +
|Greyish white areas on the [[glans]]
|Greyish white areas on the [[glans]]
|✖
| -
|✖
| -
|✖
| -
|-
|-
|[[Zoon's balanitis]]
|[[Zoon's balanitis]]
|✖
| -
|✔
| +
|Well-circumscribed orange-red glazed areas
|Well-circumscribed orange-red glazed areas
|✖
| -
|✖
| -
|✖
| -
|-
|-
|[[Eczema]]
|[[Eczema]]
|✖
| -
|✔
| +
|Mild non-specific [[erythema]] to wide spread [[edema]] of [[penis]].
|Mild non-specific [[erythema]] to wide spread [[edema]] of [[penis]].
|✖
| -
|✔
| +
|✔
| +
|-
|-
|[[Fixed drug eruption]]
|[[Fixed drug eruption]]
|✖
| -
|✔
| +
|Well demarcated and [[Erythema|erythematous]] lesions
|Well demarcated and [[Erythema|erythematous]] lesions
|✖
| -
|✔
| +
|✖
| -
|-
|-
|[[Bowen's disease]]
|[[Bowen's disease]]
|✖
| -
|✔
| +
|Multiple, small, well-demarcated [[Papillomatosis|papillomatous]] [[papules]]  
|Multiple, small, well-demarcated [[Papillomatosis|papillomatous]] [[papules]]  
|✖
| -
|✖
| -
|✖
| -
|-
|-
|[[Bowenoid papulosis]]
|[[Bowenoid papulosis]]
|✖
| -
|✔
| +
|Single or multiple, sharply demarcated associated with [[Scaling skin|scaling]] and crusting
|Single or multiple, sharply demarcated associated with [[Scaling skin|scaling]] and crusting
|✖
| -
|✖
| -
|✖
| -
|-
|-
|[[Erythroplasia of Queyrat]]
|[[Erythroplasia of Queyrat]]
|✖
| -
|✔
| +
|Velvety patches and [[plaques]] of [[keratinization]] on [[penis]].
|Velvety patches and [[plaques]] of [[keratinization]] on [[penis]].
|✔
| +
|✖
| -
|✖
| -
|}
|}
== References ==
== References ==
{{Reflist|2}}
{{Reflist|2}}
[[Category:Balanitis]]
[[Category:Infectious diseases]]
{{WikiDoc Help Menu}}
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{{WikiDoc Sources}}
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[[Category:Emergency medicine]]

Latest revision as of 20:35, 29 July 2020

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 from etiology to etiology.

Classification

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

Causes

Infectious balanitis

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

Non-infectious balanitis

Inflammatory dermatoses conditions causing balanitis

Penile carcinoma in situ causing balanitis

Differential 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. + - -

References

  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.

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