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Balanoposthitis

  • Author: Vladimir O Osipov, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Nov 20, 2015
 

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]  

Mayser has proposed that candidal balanitis/balanoposthitis is the most frequent mycotic infection of the penis,[6] 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).[7]

Rare causes include Streptococcus pyogenes,[8, 9] Prevotella melaninogenica, Cordylobia anthropophaga,[10] Providencia stuartii, and Pseudomonas aeruginosa,[11] 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.[12, 13, 14] Associations with ulcerative colitis[15] and Crohn disease[16] have also been noted. A case of granulomatous balanoposthitis after intravesical BCG vaccine instillation therapy has been published.[17]

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

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Contributor Information and Disclosures
Author

Vladimir O Osipov, MD Pathologist In Charge, QML Townsville

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

Disclosure: Nothing to disclose.

Coauthor(s)

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, United States and Canadian Academy of Pathology

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.

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, Southern Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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

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

Disclosure: Nothing to disclose.

Jeffrey Meffert, MD Associate 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, Texas Dermatological Society

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

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

Disclosure: Nothing to disclose.

Additional Contributors

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

Disclosure: Nothing to disclose.

References
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