eMedicine Specialties > Dermatology > Reactive & Inflammatory Dermatoses

Balanoposthitis

Author: Vladimir O Osipov, MD, Assistant Professor, Department of Pathology, Section of Bone and Soft Tissue Pathology, Section of Gastrointestinal Pathology, Medical College of Wisconsin
Coauthor(s): Scott M Acker, MD, Associate Professor, Director of Dermatopathology, Departments of Dermatology and Pathology, University of Alabama at Birmingham; Peter Langenstroer, MD, Associate Professor, Department of Urology, Medical College of Wisconsin; Milton W Datta, MD, Assistant Professor, Departments of Pathology, Urology, and Hematology-Oncology, Emory University School of Medicine
Contributor Information and Disclosures

Updated: Mar 30, 2009

Introduction

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.

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. Older men often have other etiologies, including intertrigo, irritant dermatitides, or other fungal infections. Organisms that have been identified include Bacteroides, Gardnerella,2,3 and Candida species and beta-hemolytic streptococci.

Mayser has proposed that candidal balanitis/balanoposthitis is the most frequent mycotic infection of the penis,4 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).5

Rare causes include Streptococcus pyogenes,6 Prevotella melaninogenica, Cordylobia anthropophaga,7 Providencia stuartii, and Pseudomonas aeruginosa, 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.8,9,10 Associations with ulcerative colitis11 and Crohn disease12 have also been noted. A case of granulomatous balanoposthitis after intravesical BCG vaccine instillation therapy has been published.13

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.14 In a study by Hsieh et al, only 1 in 2149 elementary schoolchildren in Hong Kong had balanoposthitis.15 Dockerty and Sonnex diagnosed Candida species as the cause of balanoposthitis in 35% of 450 men examined in Great Britain.16 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.17

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.18

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.

Clinical

History

In adults, a detailed clinical history focusing on topical irritants and home remedies assists in making the correct diagnosis and in detecting possible contact dermatitides.

Physical

  • Examination of the glans and the prepuce often reveals a red, moist macular lesion.
  • Associated erythema is noted, and areas of yellow-to-black discoloration have been described.19
  • The presence of lichenification, irregular borders, or acetowhite changes with 5% acetic acid treatment suggest an HPV infection, which can be seen in association with balanoposthitis.
  • A superimposed balanoposthitis on a flat condyloma has been described. Such coexisting lesions may be diagnosed based on the clinical history and a culture of fungus or bacteria from the ulcer.
  • Ulceration and deep erosion have been seen in patients with advanced disease, often in association with fungal infections and in individuals who are immunocompromised.

Causes

In a study conducted by Alsterholm et al, patients with balanoposthitis had a significantly higher frequency of positive cultures than in the control group (59% and 35%, respectively, P <.05).20 In the balanoposthitis group, Staphylococcus aureus was found in 19%, group B streptococci in 9%, Candida albicans in 18%, and Malassezia in 23% of patients. In the control group, S aureus was not found at all, whereas C albicans was found in 7.7% and Malassezia in 23% of patients. Different microbes did not correspond with distinct clinical manifestations.

Although not shown to be a direct cause, an association exists between nonspecific balanoposthitis and the uncircumcised penis. Mallon et al have proposed that circumcision may protect against balanoposthitis and common penile infections.21 Rare causes include a contact-induced balanoposthitis from the application of celandine juice (from the plant Chelidonium majus). An association with preputial smegma stones has been described, a correlation that most likely reflects the hygiene of the affected population.22

More on Balanoposthitis

Overview: Balanoposthitis
Differential Diagnoses & Workup: Balanoposthitis
Treatment & Medication: Balanoposthitis
Follow-up: Balanoposthitis
Multimedia: Balanoposthitis
References
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References

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

  3. 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].

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

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

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

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

  8. 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].

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

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

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

  12. 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].

  13. 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].

  14. 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].

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

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

  17. 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].

  18. 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].

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  27. 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].

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  31. 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].

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

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

  34. 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].

  35. 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].

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Further Reading

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Keywords

balanoposthitis, inflammation of the foreskin and glans, glans penis inflammation, foreskin inflammation

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Contributor Information and Disclosures

Author

Vladimir O Osipov, MD, Assistant Professor, Department of Pathology, Section of Bone and Soft Tissue Pathology, Section of Gastrointestinal Pathology, Medical College of Wisconsin
Vladimir O Osipov, MD is a member of the following medical societies: American Society for Clinical Pathology, College of American Pathologists, 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.

Medical Editor

Abdul-Ghani Kibbi, MD, Chairman and Professor, Department of Dermatology, American University of Beirut Medical Center, Lebanon
Disclosure: none None None

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
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.

Managing Editor

Jeffrey Meffert, MD, Assistant Clinical Professor of Dermatology, University of Texas Health Science Center-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.

CME Editor

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 None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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