Infectious balanitis
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. When balanitis involves the foreskin and perpuce, it is termed as balanoposthitis. Studies have showed that Balanitis commonly occurs around 10% of the patient population visiting the STD clinic, 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. Organisms could be part of the normal flora or sexually transmitted or autoinoculation, or 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 clinical presentation 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 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 |
|
| |
| Anaerobic Infection |
. |
|
Anaerobic gram-negative rods produce various toxins, proteases, elastase, and other virulence factors |
| Aerobic |
|
|
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 | 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 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], and 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
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]
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:[28]
- Phimosis
- Paraphimosis
- Painful erection
- Reduced urinary flow
- Urinary retention
Prognosis
Prognosis is good with treatment.
Diagnosis
History and symptoms
Patients may be asymptomatic or symptomatic presenting with itch, 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 |
|
| Aerobic | 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 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 candidiasis/candidal superinfection to be done in all cases Investigation for HIV or other causes of immunosuppression should be performed |
| Anaerobic Infection |
|
| Aerobic | Sub-preputial culture
Streptococci spp. and S. aureus have both been reported as causing balanitis |
| Trichomonas vaginalis | Wet preparation from the subpreputial sac demonstrates the organism |
| Treponema pallidum | Dark field microscopy, TP NAAT and DFA-TP will confirm the diagnosis. This should ideally be done every case.
TPHA coupled with non-treponemal 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 | Clotrimazole cream 1% | 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 | 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/clavulanic acid 375 mg 3 times daily for 1 week |
Alternative regimens depend on the sensitivities of the organisms isolated |
| Trichomonas vaginalis | Metronidazole 2 g orally single dose
Secnidazole 2 g orally single dose |
Metronidazole 400 mg orally twice a day for 7 days |
| Treponema pallidum | 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:[25]
- Safe sex practices.
- Maintaining proper penile hygiene.
Secondary prevention
There are no specific secondary preventive measures for Infective balanitis.
References
- ↑ Taylor PK, Rodin P (1975). "Herpes genitalis and circumcision". Br J Vener Dis. 51 (4): 274–7. PMC 1046564. PMID 1156848.
- ↑ 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.
- ↑ GENITOURINARY MEDICINE, Volume 72, Number 3: Pages 155-9,
- ↑ 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.
- ↑ 5.0 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.
- ↑ 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.
- ↑ Sobel JD (1985). "Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis". Am. J. Obstet. Gynecol. 152 (7 Pt 2): 924–35. PMID 3895958.
- ↑ 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.
- ↑ 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.
- ↑ Hook EW, Peeling RW (2004). "Syphilis control--a continuing challenge". N Engl J Med. 351 (2): 122–4. doi:10.1056/NEJMp048126. PMID 15247352.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 15.0 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.
- ↑ 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.
- ↑ 17.0 17.1 Koutsky L (1997). "Epidemiology of genital human papillomavirus infection". Am. J. Med. 102 (5A): 3–8. PMID 9217656.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ GENITOURINARY MEDICINE, Volume 72, Number 3: Pages 155-9, June 1996.
- ↑ International Journal of Research in Health Sciences. Jan–Mar 2014 Volume-2, Issue-1
- ↑ 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.
- ↑ Edwards S (1996). "Balanitis and balanoposthitis: a review". Genitourin Med. 72 (3): 155–9. PMC 1195642. PMID 8707315.
- ↑ Dockerty WG, Sonnex C (1995). "Candidal balano-posthitis: a study of diagnostic methods". Genitourin Med. 71 (6): 407–9. PMC 1196117. PMID 8566986.
- ↑ 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.