Infectious balanitis

Template:BalanitisVEditor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Vishal Devarkonda, M.B.B.S[2]

Synonyms and keywords:Candida balanitis, Candidal balanitis, Infectious balanoposthitis

Overview

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

Historical Perspective

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

Classification

There is no established classification system for Infectious Balanitis.

Pathophysiology

Pathophysiology of Infectious balanitis varies from pathogen to pathogen:

Pathogen	Route of transmission	Risk factors	Virulence factors
Candidal Balanitis	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 enzymes, toxins and phospholipase. Proteolytic enzymes destroy the proteins that normally impair fungal invasion
Anaerobic Infection	Sexually transmitted Extension from peri-rectal area Oro-genital sex-(saliva as a lubricant during coitus) .	Tight foreskin sub-optimal penile hygienic maintenance	Anaerobic gram-negative rods produce various toxins, proteases, and elastase
Aerobic Infections	Sexually transmitted Autoinoculation from other sites	Uncircumcised penis Diabetes Immunocompromise conditions	Adherence to epithelial cells, 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	Transmitted via direct contact with the infected lesion (sexual contact)	Risk factors include: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	Multiple sexual partners Low socio-economic status	Inhibition of MHC Class I Impairing function of dendritric cells
Human papilloma virus	Usually transmitted via sexual route to the human host	Risk factors responsible for sexual transmission of HPV include: Number of sex partners, acqusition of new partner , having non monogamous sex partner, starting sexual activity in young age, vaginal delivery and multiple deliveries, age over 40 for women, history of Chlamydia infection, and long term OCP use	Linked to epithelial differentiation and maturation of host keratinocytes, with transcription of specific gene products at every level.

Causes

Causes of Infectious balanitis include:

Common causes of infectious balanitis

Fungal

• Candida(most common cause)

Protozoal

• Trichomonas vaginalis

spirochaetes

• Treponema pallidum

Viral

• Herpes simplex
• Human papilloma virus

Less common causes of infectious balanitis

Fungal

• Dermatophytosis 
• Pityriasis versicolor
• Histoplasma capsulatum
• Blastomyces dermatitidis
• Cryptococcus neoformans

Viral

• Varicella zoster virus (VZV)

Protozoal

• Entamoeba histolytica
• Leishmania species

Parasitic

• Sarcoptes scabiei
• Pediculosis
• Ancylostoma

Bacterial

Gram negative bacteria

• E.coli
• Pseudomonas
• Haemophilus parainfluenzae
• Klebsiella
• Neisseria gonorrhoea
• Haemophilus ducreyi
• Mycoplasma genitalium
• Chlamydia
• Ureaplasma
• Gardnerella vaginalis
• Citrobacter
• Enterobacter

Spirochaetes

• Non-specific spirochaetal infection

Gram positive organism

• Haemolytic Streptococci(Group B Streptococci)
• Staphylococci epidermidis/aureus

Acid fast bacilli

• Mycobacterium tuberculosis
• Mycobacterium leprae

Anaerobes

• Bacteroides

Epidemiology

Epidemiology

• 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.
• Candida is the most common cause being responsible for 30-35% cases with infectious etiology.

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.

Complications

Complication of Infectious balanitis include:

• Pain
• Erosions
• Fissures

• Phimosis
• Paraphimosis
• Painful erection
• Reduced urinary flow
• Urinary retention

Prognosis

Prognosis is usually good with treatment.

Diagnosis

History and symptoms

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

Physical examination

Patients with infectious balanitis are usually well appearing, with no systemic signs of examination. Local genital examination may show: Erythema of prepuce or glans penis Edema of prepuce or glans penis Discharge Lymphadenopathy Ulcers Phimosis vesicles

Clinical features of Infectious balanitis(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 discharge: in severe cases associated with swelling and inflamed inguinal lymph nodes Preputial edema, superficial erosion's: 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 pallidum	Multiple circinate lesions which erode to cause irregular ulcers have been described in the late primary or early secondary stage. A primary chancre may also be present.
Herpes simplex	Grouped vesicles on erythematous base over glans, prepuce and shaft which rupture to form shallow erosions. In rare cases primary herpes can cause a necrotic balanitis, with necrotic areas on the glans accompanied by vesicles elsewhere and associated with headache and malaise.
Human papilloma virus	Papilloma virus may be associated with patchy or chronic balanitis, which becomes acetowhite after application of 5% acetic acid

Laboratory findings

Laboratory findings(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	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
Trichomonas vaginalis	Wet preparation from the subpreputial sac demonstrates the organism Culture and NAAT can also be carried out
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 PCR-preferred HSV tests for persons who seek medical treatment for gential ulcers or other muco-cutaneous lesions
Human papilloma virus	Diagnosed clinically

Distinguishing clinical features, diagnosis, and management of balanitis due to inflammatory dermatoses, include:

Distinguishing clincal features, diagnosis, and management of balanitis due to inflammatory dermatosis
	Diagnosis
Lichen sclerosus	Biopsy of lesion Epidermis: Thickened epidermis which then becomes atrophic with follicular hyperkeratosis Dermis: Dermal hyalinization with loss of elastin fibers and underlying perivascular lymphocytic infiltrate
Lichen planus	Biopsy of lesion Epidermis Irregular saw-toothed acanthosis, increased granular layer and basal cell liquefaction Dermis: Band-like dermal infiltrate (mainly lymphocytic)
Zoon’s (plasma cell) balanitis	Biopsy of lesion Epidermis: Epidermis thickening which is followed by epidermal atrophy, at times with erosions Dermis: Plasma cell infiltrate with haemosiderin and extravasated red blood cells
Psoriasis	Biopsy of lesion Parakeratosis and acanthosis with elongation of rete ridges and collections of neutrophils in the epidermis may be present
Circinate balanitis	Biopsy of lesion Epidermis: Spongiform pustules in the upper epidermis
Eczema	Biopsy of lesion Eczematous with spongiosis and non-specific inflammation
Seborrhoeic dermatitis
Fixed drug eruption	Biopsy of lesion Hydropic degeneration of the basal layer Epidermal detachment and necrosis with pigmentary incontinence
Non-specific balanoposthitis	Failure to respond to maximal topical steroid and antifungal treatments. Non-specific histology on biopsy.

Treatment

Treatment of infectious balanitis is predominately antimicrobials.

Treatment(adopted from the Indian journal of sexually transmitted diseases and AIDS)
	Preferred regimen	Alternative regimen
Candidal Balanitis	Clotrimazole cream 1% or Miconazole cream 2%	Fluconazole 150 mg stat orally or Nystatin cream-if resistance suspected topical or 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	Co-amoxiclav(amoxycillin/clavulanic acid) 375 mg 3 times daily for 1 week or Clindamycin cream applied twice daily until resolved
Aerobic Infections	Usually topical Triple combination (clotrimazole 1%, beclometasone dipropionate 0.025%, gentamicin sulfate 0.3%) applied once daily Severe cases-systemic antibiotics Erythromycin 500 mg QDS for 1 week or 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 or 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 or 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% gel-twice daily for three consecutive days, but no more than 4 weeks or Imiquimod 5% cream-applied at bedtime 3 times/week for a maximum of 16 weeks, and must be left in place for 6-10 h following application. Provider-administered Podophyllin resin 20% in a compound tincture of benzoin-once a week for 6-8 week or Cryotherapy with liquid nitrogen cryoprobe. Repeat applications every 1-2 weeks or TCA/bichloroacetic acid-80-90% once per week for an average course of 6-10 weeks or Surgical removal either by tangential scissor excision, tangential shave excision, curettage, or electrosurgery.

Prevention

Primary Prevention

Primary prevention of Infectious balanitis include:

• Safe sex practices
• Maintaining proper penile hygiene

Secondary prevention

There are no specific secondary preventive measures for Infective balanitis