Balanoposthitis 

Updated: Oct 05, 2020
Author: Vladimir O Osipov, MD; Chief Editor: Dirk M Elston, MD 

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.[1]

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.[2] 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.[3] Older men often have other etiologies, including intertrigo, irritant dermatitides, or other fungal infections. Organisms that have been identified include Bacteroides, Gardnerella,[4, 5] and Candida species and beta-hemolytic streptococci. It may also occur as a manifestation of syphilis.[6, 7, 8, 9]

Mayser has proposed that candidal balanitis/balanoposthitis is the most frequent mycotic infection of the penis,[10] 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).[11]

Rare causes include Streptococcus pyogenes,[12, 13] Prevotella melaninogenica, Cordylobia anthropophaga,[14] Providencia stuartii, and Pseudomonas aeruginosa,[15] 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.[16, 17, 18] Associations with ulcerative colitis[19] and Crohn disease[20] have also been noted. A case of granulomatous balanoposthitis after intravesical BCG vaccine instillation therapy has been published.[21]

Etiology

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).[22] 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. Several authors have proposed that circumcision may protect against balanoposthitis and common penile infections.[23, 24] 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.[25] Granulomatous balanoposthitis has occurred after intravesicle BCG treatment of urothelial cancer.[26]

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.[27] In a study by Hsieh et al, only 1 in 2149 elementary schoolchildren in Hong Kong had balanoposthitis.[28] Dockerty and Sonnex diagnosed Candida species as the cause of balanoposthitis in 35% of 450 men examined in Great Britain.[29] 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.[30]

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.

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.[31] 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.[32]  

Mondor phlebitis of the penis following recurrent candidal balanoposthitis has been reported.[33]

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.

Patient Education

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

 

Presentation

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

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.[34]  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.

 

DDx

Diagnostic Considerations

Also consider the following:

  • Candidal, viral, or fungal infections
  • Zoon balanitis (balanitis circumscripta plasma cellularis) [35]
  • Ulcerating lesions of the penis (may result from bites with subsequent infection by oral flora)
  • HPV infection, in particular flat condylomas [36]
  • Amebiasis (rare; usually in homosexual men; suspect in patients with poor response to antibiotics) [37]
  • Trophozoites (examination is confirmatory)
  • Pilonidal sinus of the penis (rare; presenting at the coronal sulcus) [38]

Differential Diagnoses

 

Workup

Laboratory Studies

Potassium hydroxide (KOH) slide preparation allows for the rapid visualization of the candidal hyphae and culture for Candida species often isolates candidal species and helps to direct proper treatment.

Imaging Studies

No imaging studies are indicated.

Other Tests

Rarely, serologic tests for candidal species may be indicated, particularly in unclear cases and for academic interest.

Procedures

Biopsy is performed in doubtful cases and if antifungal treatment fails to produce a favorable response. Biopsy is especially warranted if premalignant or malignant lesions, such as erythroplasia of Queyrat or Bowen disease, are suspected and need to be excluded.

Histologic Findings

The histologic findings are nonspecific and eczematous in nature. Dermis contains lymphoplasmacytic infiltrates. Special stains for fungi, such as the periodic acid-Schiff (PAS) stain, may exhibit fungal elements characteristic of candidal organisms.

See the image below.

Dermis with lymphoplasmacytic infiltrates and dila Dermis with lymphoplasmacytic infiltrates and dilated blood vessels.
 

Treatment

Medical Care

Topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams for contact dermatitides often lead to clearing of the lesion.[39, 40, 41]

Proper hygiene with frequent washing and drying of the prepuce is an essential preventive measure.

Topical applications of "water of the 3 sulfates" (copper sulfate, zinc sulfate, and alum) have been reported as effective.[42]

Consensus-based guidelines of care are available.[43]

Surgical Care

Circumcision or preputioplasty may be advocated in recurrent and recalcitrant cases.[44]

Prevention

Prevention has centered on improved hygiene of the prepuce. Although circumcision has been advocated for refractory or recurrent cases, this is now primarily used if improved drying and hygiene are not effective. Several authors have proposed that circumcision may protect against balanoposthitis and common penile infections.[23, 24]

 

Medication

Medication Summary

Topical medications are the treatment of choice in this condition. The primary goal is elimination of various pathogenic organisms and control of inflammation.

Antifungals

Class Summary

The mechanism of action usually involves inhibiting pathways (enzymes, substrates, transport) necessary for sterol/cell membrane synthesis or altering the permeability of the cell membrane (polyenes) of the fungal cell.

Clotrimazole (Lotrimin, Mycelex, Femizole-7, Gyne-Lotrimin)

Imidazoles have broad-spectrum antifungal action and are used to treat dermal infections caused by various species of pathogenic dermatophytes, yeasts, and Malassezia furfur. Clotrimazole inhibits yeast growth by altering cell membrane permeability, causing death of fungal cells. Reevaluate the diagnosis if no clinical improvement is seen after 4 weeks. Use 1% cream.

Antimicrobials

Class Summary

These agents tend to destroy microbes, to prevent their multiplication or growth, or to prevent their pathogenic action.

Metronidazole (1% Noritate cream, 0.75% MetroGel cream or lotion)

Metronidazole is an imidazole with the ability to inhibit fungi, protozoa, and anaerobic bacteria. Anti-inflammatory effects include modulation of leukocyte activity.

 

Questions & Answers