Balanoposthitis 

  • Author: Vladimir O Osipov, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jan 25, 2012
 

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.

Next

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.

Mayser has proposed that candidal balanitis/balanoposthitis is the most frequent mycotic infection of the penis,[5] 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).[6]

Rare causes include Streptococcus pyogenes,[7, 8] Prevotella melaninogenica, Cordylobia anthropophaga,[9] Providencia stuartii, and Pseudomonas aeruginosa,[10] 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.[11, 12, 13] Associations with ulcerative colitis[14] and Crohn disease[15] have also been noted. A case of granulomatous balanoposthitis after intravesical BCG vaccine instillation therapy has been published.[16]

Previous
Next

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.[17] In a study by Hsieh et al, only 1 in 2149 elementary schoolchildren in Hong Kong had balanoposthitis.[18] Dockerty and Sonnex diagnosed Candida species as the cause of balanoposthitis in 35% of 450 men examined in Great Britain.[19] 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.[20]

Mortality/Morbidity

  • Aside from the associated irritant symptoms, morbidity is limited.
  • Mortality is only present in patients who are immunocompromised and often develop balanoposthitis secondary to fungal septicemia.
  • Mondor phlebitis of penis following recurrent candidal balanoposthitis has been reported.[21]

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.

Previous
Proceed to Clinical Presentation
 
 
Contributor Information and Disclosures
Author

Vladimir O Osipov, MD  Staff Pathologist, Department of Anatomical Pathology, Labtests Auckland, New Zealand

Vladimir O Osipov, MD is a member of the following medical societies: American Society for Clinical Pathology, College of American Pathologists, Royal College of Pathologists of Australasia, and United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.

Coauthor(s)

Scott M Acker, MD  Associate Professor, Director of Dermatopathology, Departments of Dermatology and Pathology, University of Alabama at Birmingham

Scott M Acker, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society for Clinical Pathology, and Southern Medical Association

Disclosure: Nothing to disclose.

Peter Langenstroer, MD  Associate Professor, Department of Urology, Medical College of Wisconsin

Peter Langenstroer, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Milton W Datta, MD  Assistant Professor, Departments of Pathology, Urology, and Hematology-Oncology, Emory University School of Medicine

Milton W Datta, MD is a member of the following medical societies: College of American Pathologists and United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.

Specialty Editor Board

Abdul-Ghani Kibbi, MD  Professor and Chair, Department of Dermatology, American University of Beirut Medical Center, Lebanon

Disclosure: Nothing to disclose.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Jeffrey Meffert, MD  Assistant Clinical Professor of Dermatology, University of Texas School of Medicine at San Antonio

Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society

Disclosure: Nothing to disclose.

Joel M Gelfand, MD, MSCE  Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania

Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology

Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

  1. Fornasa CV, Calabro A, Miglietta A, Tarantello M, Biasinutto C, Peserico A. Mild balanoposthitis. Genitourin Med. Oct 1994;70(5):345-6. [Medline].

  2. Chen J, Zhou YX, Jin XD, Chen SW. Expression of interleukin-2 in Candidal balanoposthitis and its clinical significance. Chin Med J (Engl). Sep 2011;124(17):2776-8. [Medline].

  3. Burdge DR, Bowie WR, Chow AW. Gardnerella vaginalis-associated balanoposthitis. Sex Transm Dis. Jul-Sep 1986;13(3):159-62. [Medline].

  4. Kinghorn GR, Jones BM, Chowdhury FH, Geary I. Balanoposthitis associated with Gardnerella vaginalis infection in men. Br J Vener Dis. Apr 1982;58(2):127-9. [Medline].

  5. Mayser P. Mycotic infections of the penis. Andrologia. 1999;31 Suppl 1:13-6. [Medline].

  6. Wakatsuki A. [Clinical experience of streptococcal balanoposthitis in 47 healthy adult males]. Hinyokika Kiyo. Nov 2005;51(11):737-40. [Medline].

  7. Fuzi M, Csizik E, Gubacs G. [Balanoposthitis caused by Streptococcus pyogenes following sexual intercourse]. Orv Hetil. Jan 22 1984;125(4):217-9. [Medline].

  8. Minami M, Wakimoto Y, Matsumoto M, Matsui H, Kubota Y, Okada A, et al. Characterization of Streptococcus pyogenes isolated from balanoposthitis patients presumably transmitted by penile-oral sexual intercourse. Curr Microbiol. Aug 2010;61(2):101-5. [Medline].

  9. Petersen CS, Zachariae C. Acute balanoposthitis caused by infestation with Cordylobia anthropophaga. Acta Derm Venereol. Mar 1999;79(2):170. [Medline].

  10. Lincopan N, Neves P, Mamizuka EM, Levy CE. Balanoposthitis caused by Pseudomonas aeruginosa co-producing metallo-beta-lactamase and 16S rRNA methylase in children with hematological malignancies. Int J Infect Dis. Apr 2010;14(4):e344-7. [Medline].

  11. Birley HD, Luzzi GA, Walker MM, Ryait B, Taylor-Robinson D, Renton AM. The association of human papillomavirus infection with balanoposthitis: a description of five cases with proposals for treatment. Int J STD AIDS. Mar-Apr 1994;5(2):139-41. [Medline].

  12. Petersen CS, Larsen J, Albrectsen JM. [Human papillomavirus--(HPV)/balanoposthitis--a new disease?]. Ugeskr Laeger. Apr 1 1991;153(14):1000-1. [Medline].

  13. Wikstrom A, von Krogh G, Hedblad MA, Syrjanen S. Papillomavirus-associated balanoposthitis. Genitourin Med. Jun 1994;70(3):175-81. [Medline].

  14. Lyttle PH. Ulcerative colitis and balanoposthitis. Int J STD AIDS. Jan-Feb 1994;5(1):72-3. [Medline].

  15. Wijesurendra CS, Singh G, Manuel AR, Morris JA. Balanoposthitis--an unusual feature of Crohn's disease?. Int J STD AIDS. May-Jun 1993;4(3):184. [Medline].

  16. Yusuke H, Yoshinori H, Kenichi M, Akio H. Granulomatous balanoposthitis after intravesical Bacillus-Calmette-Guerin instillation therapy. Int J Urol. Oct 2006;13(10):1361-3. [Medline].

  17. Kayaba H, Tamura H, Kitajima S, Fujiwara Y, Kato T, Kato T. Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol. Nov 1996;156(5):1813-5. [Medline].

  18. Hsieh TF, Chang CH, Chang SS. Foreskin development before adolescence in 2149 schoolboys. Int J Urol. Jul 2006;13(7):968-70. [Medline].

  19. Dockerty WG, Sonnex C. Candidal balano-posthitis: a study of diagnostic methods. Genitourin Med. Dec 1995;71(6):407-9. [Medline].

  20. Kato S, Ohnishi S, Saka T, Nakajima H, Tanda H. [Clinical statistics on outpatients during the 5 years period (from 1978 Nov. 1st to 1983 Dec. 31st) after the opening of the Urological Clinic of East Sapporo Sanjukai Hospital (II)]. Hinyokika Kiyo. Nov 1984;30(11):1677-84. [Medline].

  21. Agrawal SK, Singal A, Pandhi D. Mondor's phlebitis of penis following recurrent candidal balanoposthitis. Int J Dermatol. Jan 2005;44(1):83-4. [Medline].

  22. Duerden BI. Black-pigmented gram-negative anaerobes in genito-urinary tract and pelvic infections. FEMS Immunol Med Microbiol. Mar 1993;6(2-3):223-7. [Medline].

  23. Alsterholm M, Flytstrom I, Leifsdottir R, Faergemann J, Bergbrant IM. Frequency of bacteria, Candida and malassezia species in balanoposthitis. Acta Derm Venereol. 2008;88(4):331-6. [Medline].

  24. Mallon E, Hawkins D, Dinneen M, et al. Circumcision and genital dermatoses. Arch Dermatol. Mar 2000;136(3):350-4. [Medline].

  25. Sonnex C, Croucher PE, Dockerty WG. Balanoposthitis associated with the presence of subpreputial "smegma stones". Genitourin Med. Dec 1997;73(6):567. [Medline].

  26. Wollina U. Ablative erbium:YAG laser treatment of idiopathic chronic inflammatory non-cicatricial balanoposthitis (Zoon's disease)--a series of 20 patients with long-term outcome. J Cosmet Laser Ther. Jun 2010;12(3):120-3. [Medline].

  27. Arumainayagam JT, Sumathipala AH, Smallman LA, Shahmanesh M. Flat condylomata of the penis presenting as patchy balanoposthitis. Genitourin Med. Aug 1990;66(4):251-3. [Medline].

  28. Hejase MJ, Bihrle R, Castillo G, Coogan CL. Amebiasis of the penis. Urology. Jul 1996;48(1):151-4. [Medline].

  29. Val-Bernal JF, Azcarretazábal T, Garijo MF. Pilonidal sinus of the penis. A report of two cases, one of them associated with actinomycosis. J Cutan Pathol. Mar 1999;26(3):155-8. [Medline].

  30. Cree GE, Willis AT, Phillips KD, Brazier JS. Anaerobic balanoposthitis. Br Med J (Clin Res Ed). Mar 20 1982;284(6319):859-60. [Medline].

  31. Waugh MA, Evans EG, Nayyar KC, Fong R. Clotrimazole (Canesten) in the treatment of candidal balanitis in men. With incidental observations on diabetic candidal balanoposthitis. Br J Vener Dis. Jun 1978;54(3):184-6. [Medline].

  32. Steinbach F, Essbach U, Florschütz A, Gruss A, Allhoff EP. Ulcerative balanoposthitis as the initial manifestation of acute promyelocytic leukemia. J Urol. Oct 1998;160(4):1430-1. [Medline].

  33. Abdullah AN, Drake SM, Wade AA, Walzman M. Balanitis (balanoposthitis) in patients attending a department of genitourinary medicine. Int J STD AIDS. Mar-Apr 1992;3(2):128-9. [Medline].

  34. Edwards S. Balanitis and balanoposthitis: a review. Genitourin Med. Jun 1996;72(3):155-9. [Medline].

  35. Farina LA, Alonso MV, Horjales M, Zungri ER. [Contact-derived allergic balanoposthitis and paraphimosis through topical application of celandine juice]. Actas Urol Esp. Jun 1999;23(6):554-5. [Medline].

  36. Manian FA, Alford RH. Nosocomial infectious balanoposthitis in neutropenic patients. South Med J. Jul 1987;80(7):909-11. [Medline].

  37. Masfari AN, Kinghorn GR, Duerden BI. Anaerobes in genitourinary infections in men. Br J Vener Dis. Aug 1983;59(4):255-9. [Medline].

  38. Moss S. Isolation and identification of anaerobic organisms from the male and female urogenital tracts. Br J Vener Dis. Jun 1983;59(3):182-5. [Medline].

  39. Patrizi A, Costa AM, Fiorillo L, Neri I. Perianal streptococcal dermatitis associated with guttate psoriasis and/or balanoposthitis: a study of five cases. Pediatr Dermatol. Jun 1994;11(2):168-71. [Medline].

 
Previous
Next
 
Dermis with lymphoplasmacytic infiltrates and dilated blood vessels.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.