Balanoposthitis

Updated: Aug 11, 2016
  • Author: Vladimir O Osipov, MD; Chief Editor: Dirk M Elston, MD  more...
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Overview

Background

Defined as the inflammation of the foreskin and glans in uncircumcised males, balanoposthitis occurs over a wide age range and may have any of multiple bacterial or fungal origins or be caused by contact dermatitides. Complex infections have been well documented, often from a poorly retractile foreskin and poor hygiene that leads to colonization and overgrowth. Treatment focuses on clearing the acute infection and preventing recurrent inflammation/infection through improved hygiene. Although not as necessary as in the past, circumcision may be considered for refractory or recurrent balanoposthitis. Balanoposthitis should not be confused with balanitis, which is inflammation of the glans penis or the clitoris.

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Pathophysiology

Although multiple organisms have been incriminated as causative agents, the patient is empirically treated without obtaining specific organism etiology in most cases. The multicausal origin of balanoposthitis has been emphasized by Fornasa et al, who identified infectious, mechanical/traumatic, or contact dermatitides in 67% of their patients with balanoposthitis. [1] In one third of the patients, a specific cause could not be established even after clinical examination and microbiologic and serologic tests had been performed. Candidal infection appears to be the most common cause of disease. [2] Older men often have other etiologies, including intertrigo, irritant dermatitides, or other fungal infections. Organisms that have been identified include Bacteroides, Gardnerella, [3, 4] and Candida species and beta-hemolytic streptococci. It may also occur as a manifestation of syphilis. [5, 6]

Mayser has proposed that candidal balanitis/balanoposthitis is the most frequent mycotic infection of the penis, [7] although, in general, fungal infections of the penis are rare. In one series, Candida species accounted for 30% of the causative organisms, and beta-hemolytic streptococci accounted for 13%. Wakatsuki detected the following infectious agents as a cause: Candida species in 50%, Streptococcus species in 25%, and no growth in 13% (12% were not tested). [8]

Rare causes include Streptococcus pyogenes, [9, 10] Prevotella melaninogenica, Cordylobia anthropophaga, [11] Providencia stuartii, and Pseudomonas aeruginosa, [12] the last 2 in individuals who are immunocompromised. Reports of an association between human papillomavirus (HPV) infection and long-standing balanoposthitis have been published, but they may reflect a noncausative association. [13, 14, 15] Associations with ulcerative colitis [16] and Crohn disease [17] have also been noted. A case of granulomatous balanoposthitis after intravesical BCG vaccine instillation therapy has been published. [18]

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Epidemiology

Frequency

United States

No studies of incidence have been performed in the United States.

International

In a Japanese study, balanoposthitis was found in 9 (1.5%) of 603 uncircumcised Japanese boys aged 0-15 years. [19] In a study by Hsieh et al, only 1 in 2149 elementary schoolchildren in Hong Kong had balanoposthitis. [20] Dockerty and Sonnex diagnosed Candida species as the cause of balanoposthitis in 35% of 450 men examined in Great Britain. [21] Italian studies have found balanoposthitis in 51 (16%) of 321 patients with genital dermatoses. A long-term Japanese study revealed an incidence of 3-7% per annum. [22]

Race

Breakdowns of race or ethnic background have not been performed, although balanoposthitis, because of its heterogenous etiology, has been described in many races and ethnic backgrounds.

Sex

Balanoposthitis only occurs in males.

Age

Although identified over a wide age range, most studies have centered on the juvenile population (0-5 y) or in sexually active adult males.

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Prognosis

The outcome is often favorable, with treatment failures often leading to further clinical examination and tailoring of the treatment to the particular offending agent. Aside from the associated irritant symptoms, morbidity is limited.

Failure of response in the setting of appropriate treatment should raise the suspicion of malignancy. This necessitates a biopsy to rule out both primary malignancies and secondary malignancies involving the penis. The most common malignancy that mimics balanoposthitis is erythroplasia of Queyrat, although Bowen disease may have some clinical overlap. A single case report has described the presentation of acute promyelocytic leukemia as an ulcerating balanoposthitis. [23]  

Mondor phlebitis of the penis following recurrent candidal balanoposthitis has been reported. [24]

In a patient who is immunocompromised, the presence of a systemic fungal infection can lead to involvement of the penis and often arises as a more deeply involved ulcerating lesion. Treatment of this disease, which can be caused by any number of fungal agents, involves clearing the systemic infection and immunodepression. Mortality is only present in patients who are immunocompromised and often develop balanoposthitis secondary to fungal septicemia.

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Patient Education

For patient education resources, see the Men's Health Center. Also, see the patient education articles Foreskin Problems and Circumcision.

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