Balanitis is defined as inflammation of the glans penis which often i - PDF document

Abstract Balanitis is defined as inflammation of the glans penis, which often involves the prepuce (Balanoposthitis ). In the present scenario, where there is a decline in the tropical Sexually Transmitted Diseases ( STD’s), balanoposthitis is the common condition in uncircumcised male patients attending the STD clinic. Candidal balanoposthitis is a known feature of di abetes mellitus especially in Indian males who are predominantly uncircumcised as the crude prevalence rate of type II diabetes mellitus in India is 9%. In our hospital, 31% of the newly diagnosed diabetic patients were presented only with balanoposthitis. T he common etiology for balanoposthitis is candida albicans, but it may be due to a variety of infective and non infective causes. The management of balanoposthitis is given in a simple and step by step approach for specific and non specific causes. Keywords : Balanoposthitis; Candidiasis; Circumcision; Diabetes mellitus; Phimosis; Prepuce; STD’s Introduction Balanitis is defined as inflammation of the glans penis, which often involves the prepuce (Balanoposthitis) [1]. In the present scenario, where there is a decline in the tropical Sexually Transmitted D iseases ( STD’s) balanoposthitis is the common condition in unci rcumcised male patients attending Balanitis and B alanoposthitis - R eview article S. Arunkumar 1 , S. Murugan 2 , B. Sowdhamani 3 , R. Sureshkumar 4 Review article Department of STD, Chengalpattu Medical College, Chengalpattu, Tamil Nadu, India. 1 - Professor & HOD , 2 - Assistant Professor, 3&4 – Junior Residents . www. ijrhs.com ISSN (o ): 2321 – 7251 Submission Date: 18 - 1 1 - 2013 , Acceptance Date: 2 4 - 11 - 2013 , Publication Date: 31 - 01 - 201 4 How to cite this article: Vancouver/ICMJE Style AS, MS, SB, SR . Balanitis and Balanoposthitis - Review article . Int J Res Health Sci [Internet] . 201 4 Jan31 ; 2 ( 1 ): 375 - 92 . Available from http://www.ijrhs.com/issues.php?val=Volume2&iss=Issue1 Harvard style A , S . , M , S . , S , B . , S , R . Balanitis and Balanoposthitis - Review article . Int J Res Health Sci . [Online] 2(1). p. 375 - 92 Available from: http://www.ijrhs.com/issues.php?val=Volume2&iss=Issue1 Corresponding Author: Dr. S. Arunkumar, Professor & HOD, Department of STD, Chengalpattu Medical College, Chengalpattu, Tamil Nad u, India . Email: arunssshc@gmail.com International Journal of Research in Health Sciences. Jan – Mar 201 4 Volume - 2 , Issue - 1 3

75 the STD clinic, which is around 11% [2]. Candidal balanoposthitis is a known feature of diabetes mellitus especially in Indian males who are predominantly uncircumcised as the crude prevalence rate of type II diabetes mel litus in India is 9%. In our hospital, 31% of the newly diagnosed diabetic patients were presented only with balanoposthitis. Risk factors for balanoposthitis are i) uncircumcised, ii) congenital and acquired phimosis [3], iii) poor genital hygiene, iv) la ck of safe sex practices, v) diabetes mellitus and vi) urinary incontinence . Apart from the common etiology candida albicans, it is due to a variety of infective and non infective causes [4 - 6]. Management of balanoposthitis remains a clinical challenge because the c ause is frequently undiagnosed as the clinical features are not specific. Hence we decided to do a review on this topic. Prepuce: Prepuce or foreskin is an integral part of external genitalia that covers the glans penis and clitoris of male and female genitalia respectively. It is a specialised mucosal tissue that marks the boundary between mucosa and skin [7]. It gives adequate protection to the genitalia and also functions as an erogenous tissue. Prepuce is composed of squamosal mucous epithelium, lamina propria, dartos muscle, dermis, outer g labrous skin. The outer epithelium of prepuce internalises glans penis / clitoris, urethral meatus (male). The inner epithelium decreases external irritation. The mucosal epithelium contains langerhans cells which are an important local defense mechanism. Tyson’s glands in lamina propria are often the source of smegma. Langerhans cells are also found in the outer epithelium of prepuce. The preputial sac provides lubrication for atraumatic vaginal sex. This is aided by the secretion in preputial sac. The secretions contributed by prostate, seminal vesicles and urethral glands (Littre’s) moistens male preputial sac. Aerobic organism like group B streptococci, coliforms, corynebacterium, coagulase positive staph. aureus, gonococci, enterococci are seen in s ubpreputial area normally. Group B streptococci causes balanitis in heterosexuals through sexual transmission is unimportant. The preputial sac is also colonised by Gram negative anaerobes (especially bacteroides melaninogenicus). Mycobacterium smegmatis i s a benign commensal organism in the genitalia. This organism causes non genital soft tissue infections post surgery/ trauma. The langerhans cells or dentritic cells are important for local mucosal immunity of prepuce. Langerhans cells [8] and squamous ep ithelial cells [9

] of prepuce secrete cytokines that stimulate the T helper system. Etio pathogenesis The causes of balanoposthitis is both infective and noninfective [4]. Infective balanoposthitis is more common in uncircumcised male, as a result of poor genital hygiene, lack of aeration, irritation by smegma, diabetes mellitus and immune suppression. The causes are broadly classified as: Infective Non Infective Non i nfective Arunkumar et al – Balanitis and Balanoposthitis www.ijrhs.com International Journal of Research in Health Sciences. Jan – Mar 201 4 Volume - 2 , Issue - 1 376 A. Fungal : Most common cause A. Skin Disorders (i) Candida (albicans, krusei ) (i) Circinate balanitis (Reiter’s syndrome) (ii) Dermatophytosis (ii) Lichen sclerosus et atrophicans (iii) Pityriasis versicolor (iii) Balanitis xerotica obliterans (BXO) (iv) Histoplasma capsulatum (iv) Lichen planus/ Lichen nitidus (v) Blastomyces dermatitidis (v) Zoon’s bal anitis (vi) Cryptococcus neoformans (vi) Psoriasis (vii) Penicillium marneffi (vii) Seborrhoeic dermatitis (viii) Pityriasis rosea (ix) Crohn’s disea se, Ulcerative colitis (x) Necrobiosis lipoidica B. Bacterial (2 nd Most common ) (xi) Hypereosinophilic syndrome (xii) Xanthom atosis ( i) Haemolytic Streptococci(Group B Streptococci) – Most Common (xiii) Histiocytosis X (ii) Staphylococci epidermidis / aureus (xiv) Sarcoidosis (iii) E.coli (xv) Porokeratosis (iv) Pseudomonas (v) Treponema pallidum (xvi) Apthous ulcers (vi) Neisseria gonorrhoea (xvii) Pyoderma gangrenosum vii) Haemophilus ducreyi (xviii) Bullous disorders vii) Mycoplasma genitalium (xix) Behcet’s disease ix) Chlamydia (xx) Premalignant Conditions x) Ureaplasma Erythroplasia of Queyrat, xi) Gardnerella vaginalis Bowen’s disease

xii) Non specific spirochaetal infection Bowenoid papulosis xiii) Citrobacter Extra mammary Paget’s disease xiv) Enterobacter (xxi) Malignant conditions xv) My cobacterium tuberculosis Squamous cell carcinoma, xvi) Anaerobes ( Bacteroides) Basal cell carcinoma, Melanoma, xvii) Haemophilus parainfluenzae infection CLL, Metastasis xvii i) Klebsi ella pneumonia B. Miscellaneous xix) Leprosy (i) Trauma C. Viral (ii) Poor hygiene i) Herpes simplex virus (HSV) (iii) Irritant & Allergic contact dermatitis ii) Varicella zoster virus (VZV) (iv) Fixed d rug eruption iii) Human papilloma virus (HPV) (v) Extra long foreskin D.Protozoal (vi) Phimosis i) Entamoeba histolytica (vii) Incontinence ii) Trichomonas vaginalis (viii) Granulomatous balanoposthitis iii) Leishmania species C. Non specific balanoposthitis E. Parasitic D. Balanoposthitis simplex i) Sarcoptes scabiei var hominis ii) Pediculosis iii) Ankylostoma species iv) Creeping eruptions Arunkumar et al – Balanitis and Balanoposthitis www.ijrhs.com International Journal of Research in Health Scie nces. Jan – Mar 201 4 Volume - 2 , Issue - 1 377 Among the infective causes, candida albicans is the most common etiology. It is one of the presenting features of diabetes mellitus. Apart from candida albicans, other important agents are staphylococcus, streptococcus, anaerobes and various other organisms may also cause balanoposthitis. Among the non infective causes irritant balanoposthitis, fixed drug eruption, plasma cell balanitis, circinate balanitis are the important ones. Type Symptoms Signs Diagnosis Treatment Remarks I. Infective A) Fungal Infections i) Candida albicans ( Also called as Balanoposthitis Candidomycetica). Pruritus, burning sensation, redness of glans and prepuce, whitish subpreputial discharge. Dry, raised excoriation small irregular papules and dispersed vesicles with plaques of white cheesy matter. Erythema of glans and fissuring of prepuce. Transient urethritis may be seen. Acute inflammatory edematous balanoposthitis associated with diabetes mellitus. 1) Subpreputial discharge swab – Gram stain, KOH preparation and Culture. 2) Urine culture. 3) FBS/ PPBS/ HbA1 C.

4) Germ tube test. 1) Topical [10] : Clotrimazole cream or Econazole cream or Sertaconazole cream or Miconazole (2%) cream or Nystatin Cream for 10 - 14 days bd. 2) Tab. Fluconazole 150 mg Stat or T. Itraconazole 200mg bd for 1day. First described by Engman in 1920[11]. Normally carried on penis in 14 - 18%. 35% of all cases of infective balanitis. Predisposing factors: Uncircumcised men Antibiotics and steroid abuse. Immunocompromi sed Poorly controlled DM patients. Sexual contact of a partner with vulv ovaginal candidiosis. No significant difference between carriage rate in uncircumcised/circ umcised men. ii) Dermatophyte infection History and clinical evidence of dermatophyte infection in other sites. Scraping and microscopy. Culture. Topical antifungals. Oral antifungals. iii) Pityriasis versicolor Circinate, fine, scaly, hypopigmented areas in glans. Scrapping and microscopy. Woods lamp. Culture. Topical antifungals. Deep Fungal Infections iv) Histoplasma capsulatum Multiple non tender punched out ulcers with ` Surgical debridement. Systemic antifungals Arunkumar et al – Balanitis and Balanoposthitis www.ijrhs.com International Journal of Research in Health Sciences. Jan – Mar 201 4 Volume - 2 , Issue - 1 378 indurated margins. like Amphotericin B, Ketoconazole. v) Cryptococcus neoformans Necrotizing ulcer over the glans. Same. vi) Penicillium marneffi Ulcers over the glans. Same. vii) Blastomyces dermatitidis Ulcers over the glans. Same. B. Bacterial Infections i) Group B Streptococci ii) Group A Beta haemolytic streptococci iii) Staph. aureus Nonspecific erythema without discharge, rarely penile edema (cellulitis). Penicillins. Cephalosporins. Caused asymptomatically in adult genital mucosa. Increased carriage in heterosexuals. Sexual transmission is unclear. Commonly involves children. Infrequently occurs. Toxic Shock syndrome is a rare complication. iv) Treponema pallidum ( Also known as syphilitic balanitis of Follman) Pri mary syphilis: Multiple circinate lesions eroded to form irregular ulcers at the glans penis and prepuce. Secondary syphilis: Swollen glans covered with partially coalescent white flat papules, plaques over glans penis. i) Demonstration of organism by dark field microscope. ii) Demonstration of T. pallidum by polymerase chain reaction. iii) Serology for syphilis. iv)Eliminate the presence[12] of other organism

like Candida, Group B Streptococci, Anaerobes, HSV etc. Benzathine Penicillin 24 lakh units IM aft er test dose. (v) Neisseria gonorrhoea Pain, burning sensation, urgency and frequency of micturition. Urethral Tender ulcers / pustules on prepuce and shaft. Thick creamy, greenish yellow purulent i) Grams stain: Intracellular Gram negative diplococcic. ii) Culture Single dose Ceftriaxone or Cefixime. Simultaneous treatment with Doxycycline or Hypopigmentation of glans penis is a rare complication. Arunkumar et al – Balanitis and Balanoposthitis www.ijrhs.com International Journal of Research in Health Sciences. Jan – Mar 201 4 Volume - 2 , Issue - 1 379 discharge. discharge. Lymphadenopathy is seen. Azithromycin for Chlamydial infection (vi) Haemophilus ducreyi Painful shallow ulcers with ragged and undermined edges . Systemic Antibiotics. Erythromycin or Ceftriaxone or Azithromycin or Ciprofloxacin. Phimosis and phagedenic ulcer are the complications. (vii) Mycoplasma genitalium Simple erythema. Circinate lesions over the glans penis and prepuce. Tendency for bleeding. Tetracyclines. Mycoplasma causes urethritis independent of balanitis. Increased risk of HIV transmission and susceptibility[13]. (viii) Chlamydia Irritant balanitis. Tetracyclines. D - K serotypes cause balanitis. (ix) Gardnerella vaginalis and other aerobes Mild symptoms Pruritus and irritation over Glans penis and prepuce Diffuse erythema and mild irritation over glans penis and prepuce. Increased offensive , fishy odour in sub preputial discharge (SPD)[14]. Subpreputial culture Group A streptocooci, staph aureus and Gardnerella vaginalis. As per guidelines and depending on the sensitivity of the organism. Erythromycin 500mg bd, 2% fusidic acid cream. Symptoms occur within 7 days of sexual contact. Most common in uncircumcised men. Congen ital phimosis and acquired phimosis. Poor hygiene. Normally this organism is present in glans penis and prepuce. Concomitant anaerobic infection is common. Sexually acquired. (x) Non specific spirochaetal infection ( Borrelia infection) Large, serpiginous, superficial, foul smelling tender. Dark field microscopy. Spirochaetes demonstrated. Penicillin and Metronidazole[15]. Coexists with other infections. Aetiology: Commonly Treponema refringens, Treponema phagedenis, Treponema balanitidis, Borrelia vincenti. (xi) Mycobacterim Ulcers with Biopsy ( HPE) MDT.

Common in Arunkumar et al – Balanitis and Balanoposthitis www.ijrhs.com International Journal of Research in Health Sciences. Jan – Mar 201 4 Volume - 2 , Issue - 1 38 0 leprae and (xii) Mycobacterim tuberculosis undermined edges over glans penis. Involement of glans penis and Phimosis[16]. Chronic papular eruption of glans penis which may be ulcerated, and heals with scarring[17] . shows tuberculoid granuloma formation. Anti tuberculous treatment. countries with increased prevalence of tuberculosis. Associated with positive Mantoux test. (xiii) Anaerobes ( Bacteroides, nonclostridial anaerobes). Also known as erosive bacterial balanitis. Foul smelling discharge. Swelling of glans penis. Superficial erosion of glans penis, coronal sulcus. Preputial edema. Tender lymphadenitis. Diagnosed clinically and treated early. Transmitted by Anogenital contact. Predisposing factor: Contact by mouth or finger, poor genital h ygiene, phimosis, uncircumcised. Causative agents:[18] Fusobacterium, Bacteroides, Anaerobic cocci etc., Complication: Gangrenous balanitis. C. Viral (i) Herpetic balanitis (HSV) Prodromal symtoms common. Pain in penis and inguinal region. Dysuria and ure thral discharge Multiple tender papulo vesicles over the glans penis and or prepuce. Multiple necrotic ulcers over glans Serology, culture in chick embryo, baby hamster kidney, Hep 2 cells. Biopsy. Light and Electron microscopy Acyclovir tablets. 5% Idoxuridine [19] solution in DMSO. Due to HSV1,2. Predisposing factors: Uncircumcised men, poor genital hygiene, orogenital contact. (ii) Human papilloma virus (HPV) Redness, itching, burning sensation, pain and fissuring of glans penis. Diffuse or patchy erythematous macules or maculo papules on the inner aspect of prepuce. 1) 5% Acetic acid test - on application the lesions become white - aceto white. 2) H PE: Hyperkeratosis and parakeratosis. 3) Detection of types. 1) 5 Fluorouracil (5FU) cream application once/ twice weekly. 2) 0.5% podophyllotoxin self application. 3) 25% Podophyllin once a week (under super vision). 4) 5% Imiquimod cream twice weekly for 16 weeks. Screening for other STDs is recommended. Screen the partner and Inform the partner about the risk of transmission. Advise barrier protection. Advise for follow up. Arunkumar et al – Balanitis and Balanoposthitis www.ijrhs.com International Journal of Research in Health Sciences. Ja

n – Mar 201 4 Volume - 2 , Issue - 1 381 D. Protozoal (i) Amoebic balanitis ( Caused by Entamoeba histolytica) Pain, dysuria. Ulcers and erosions over glans penis, edema of prepuce. Phimosis, discharge. Biopsy. Culture, smear, wet mount preparation. Metronidazole Circumcision. Described first by Straub in 1924. Seen in uncircumcised men with poor hygiene. Auto inoculation and intercourse with infected partner[20] are the main modes of transmission. (ii) Trichomonas vaginalis Copious frothy discharge. Superficial erosions present over the glans penis. Phimosis. Mucopurulent greenish frothy discharge with fishy odour. Wet Mount: from subpreputial discharge - demonstration of the organism. Culture: HPE: Dense lymphocytic infiltrate in upper dermis [21]. Metronidazole. Sexually acquired. Associated with other infections. 15 - 50% of men with trichomonas infection are asymptomatic carriers. Long prepuce is an important predisposing factor. (iii) Leishmania donovani Ulcers over glans penis and prepuce. Demonstation of leishmania amastigotes in smear / biopsy. Systemic/ local pentavalent antimony compounds. E. Parasitic (i) Sarcoptes scabiei var hominis Pruritus Raised, slightly elongated, circumscribed tracts and nodules over glans penis and scrotum, shaft and penis. 5% permethrin cream application. Transmitted by close body contact. Emphasis on good local hygiene. Treatment of household contacts and sexual partners of patient is mandatory. (ii) Creeping eruptions ( Cutaneous larva migrans) Itching Erythematous itchy papules and linear serpiginous bizarre tracts. Albendazole 400 - 800mg daily for 3 days. II. Non infective A. Skin disorders (1) Circinate balanitis / Balanoposthitis ( Reiter’s di sease) Shallow, circinate irregular greyish white lesions with raised edges coalesce to form geographic patches with white margin[23]. HPE: Hyperkeratosis, parakeratosis, acanthosis, elongated rete ridges, spongiform pustule in upper dermis. Dermal Not required usually Some cases : 1% hydrocortisone cream twice daily application. P otent steroids. Common in Shigella associated disease[22]. Post infection syndrome. Overlap with Psoriasis, HIV infection. HLA B 27 plays a role. Arunkumar et al – Balanitis and Balanoposthitis www.ijrhs.com International Journal of Research in Health Sciences. Jan – Mar 201 4 Volume - 2 , Issue - 1 382 capillaries – enlarged, increased i

n number mononuclear cell infiltrate. Extravasation of RBCs. Screening for concurrent STIs especially Chlamydia trachomatis. Triad includes Conjunctivitis, Urethritis and Arthritis. Circinate balanitis and Keratoderma blennorrhagicum seen. 2) Lichen Sclerosis et atrophicans (LSA) Usually asymptomatic. Non retractable foreskin. Pain, irritation. Disturbance of sexual function. Urinary symptoms. Recurrent painful vesicles and ulcers over glans penis. White plaques on glans penis and prepuce. Thickened non retractable prepuce. Hemorrhagic vesicles over plaques. Cicatricial shrinkage, urethral stricture, phimotic prepuce. HPE: Epidermis : ( Early) Thickened (Late) – Atrop hy, follicular hyperkeratosis. Dermis: Oedematous area with loss of elastic fibres and alteration in collagen. Perivascular band of lymphocytic infiltrate. Circumcision – Treatment of Choice[24] . Meatotomy for meatal stenosis. Topical potent steroids until remission then intermittently once a week ( for remission). Other treatment : photodynamic therapy, laser, testosterone ointment, calcipotriol ointment, topical Calcineurin inhibitors. Commonly seen in middle aged men uncircum cised men. Predisposing factors: Idiopathic, trauma, autoimmune disease, genetic factors, hormonal factors. Follow up is mandatory annually. 3) Balanitis Xerotica Obliterans ( BXO) Neonatal circumcision. Chronic scarring balanitis. Most commonly caused by LSA, Chronic non - specific balanitis. Associated with phimosis and squamous cell carcinoma. 4) Zoon’s balanitis ( Balanitis circumscript a plasma cellularis/ Plasma cell balanitis Usually indolent and asymptomatic mild pruritis. Irritation, pain, SPD, staining of under Raised, solitary, smooth, well circumcised, red - orange shiny[25] plaques on glans and prepuce with pinpoint purpuric “ Cayenne pepper” surface Biopsy : HPE: Epidermis : Atrophy, complete effacement of rete ridges. D iamond shaped or Circumcision ( Curative). Topical steroids. Topical tacrolimus, Pimecrolimus. Topical fusidic acid[26] cream. CO2 laser/ intra Described by Zoon in 1952. Common in middle aged and elderly uncircumcised men. It is an idiopathic Arunkumar et al – Balanitis and Balanoposthitis www.ijrhs.com International Journal of Research in Health Sciences. Jan – Mar 201 4 Volume - 2 , Issue - 1 383 garments with blood. Cosmetic concern. Anxiety. spotting with yellowish hue. lozenge shaped ke

ratinocytes in basal layer. Watery spongiosis, sparse dyskeratotic cells. lesional interferon α . Oral griseofulvin. chronic, reactive, rare penile dermatosis. Etiology: Unclear Predispoing factor: heat, friction, chronic irritation due to Mycobacteriu m smegmatis, poor genital hygiene, trauma, hypospadias, HSV infection. 5) Psoriasis Soreness, itching, change in appearance. Crusted, scaly plaques over glans penis (circumcised) red glazed patches (uncircumcised). HPE: Hyperkeratosis, parakeratosis , regional acanthosis, elongated rete ridges, Munro’s micro abscesses, spongiform pustule of Kogoj. 6) Lichen planus (LP) Itching, soreness and dyspareunia. Well demarcated, purple colored, plaques over glans, prepuce and shaft of penis. Erosions on muc osal surface LP lesions over other sites. HPE: Hyperkeratosis, irregular acanthosis, focal wedge shaped hypergranulosis, liquefactive degeneration of basal cell layer. Band like lymphocytic infiltrate in dermo epidermal Junction. Topical steroids, topical /oral Cyclosporine, topical Calcineurin inhibitors. Circumcision for persons with LP at glans. Inflammatory disorder of unknown etiology with immunological basis with lesions in skin, genitals and mucous membrane. 7) Seberrhoeic dermatitis Itching Erythema Fine scaling at classical sites like nasolabial fold, scalp and ears. Antifungal cream with mild – moderate steroids, oral steroids. Due to Pityriosporum ovale. 8) Eczema Dry, red glazed Slightly scaling, itching. 9) Porokeratosis Centrifugally spreading patches Cryotherapy, CO 2 laser, topical - 5 Arunkumar et al – Balanitis and Balanoposthitis www.ijrhs.com International Journal of Research in Health Sciences. Jan – Mar 201 4 Volume - 2 , Issue - 1 384 surrounded by ridge like border with central atrophy. fluro uracil, imiquimod. 10) Bullous disorders Pemphigus vulgaris Bullous pemphigoid Linear Ig A disease Cicatricial pemphigoid Pemphigus vegetans Erosions resembling balanitis. Topical and oral steroids. Immunosuppression. 11) Dermatitis artefacta Clobetasone butyrate 0.05% ( Moderately potent steroid cream). 12) Crohn’s disease and Ulcerative colitis 13) Behcet’s disease Chronic relapsing disease, unknown etiology, oral ulcers, arthritis, genital ulcers and eye lesions. Premalignant Conditions a) Erythroplasia of queyrat Well defined red shiny velvety plaques, patches with sharp margins and

granular surface. If indurated / keratotic plaques Rule out malignancy. HPE: Confirmatory and mand atory SCC in long term. 5% 5 FU cream, Cryotherapy, Laser, Excision ( Recommended) Circumcision. It is a premalignant condition described by Queyrat in 1911[27]. Common in uncircumcised men. Aetiology: exactly unknown, smegma, poor genital hygiene, trauma, friction, heat, maceration. b) Pseudo epitheliomatous micaceous and keratotic balanitis Phimosis Thick, dry, white, yellow mica like sheets and keratotic masses adherent to glans penis and coronal sulcus. HPE: Massive hyperkeratosis, acanthosis, pseudo epitheliomatous hyperplasia, sparse cellular infiltrate. Topical 5% 5FU cream for 6 weeks. Local surgical excision. Others: Cryotherapy, X ray ir radiation, Shave biopsy, Electrocautery, CO 2 laser. Acquired disease in elderly. Predisposing Factor: Smoking and tobacco chewing . Premalignant. Locally invasive low grade malignant lesion. Associated with verrucous carcinoma of penis. Arunkumar et al – Balanitis and Balanoposthitis www.ijrhs.com International Journal of Research in Health Sciences. Jan – Mar 201 4 Volume - 2 , Issue - 1 385 c) Bowen’s disease Well defined, red, discrete, scaly, erythematous plaque present over penile shaft / prepuce. Biopsy. Simple excision, 5% 5FU cream, Laser, Topical imiquimod. Etiology unknown. Carcinoma in situ, 20% will go for Squamous Cell Carcinoma. Follow up is important. d) Bowenoid papulosis Papules and plaques over glans penis. Local excision and Laser. Spontaneous resolution. Due to HPV infection. Carcinoma in situ. Malignant Conditions a) Squamous cell Carcinoma b) Basal Cell carcinoma c) Melanoma d) Metastasis e) Leukemia, CLL Ulcer over glans penis and Prepuce[28]. B.Miscellaneous 1) Trauma Pinpoint abrasions. Erythema over glans penis. Vigorous sexual activity, sharp pubic hair piercing of frenulum, zip fastening injury, teeth bites, beads, pin prick, self mutilation. 2) Contact Dermatitis ( irritant and allergic) i) Allergic Erythema, edema of penis. Patch test. Avoidance of precipita ting factors. Washing with soaps. Emollients. Etiology: Balsum of peru, kathon CG, perfume, rubber, spermicidal agents, smegma, condoms. ii) Irritant Erythematous, Oozing, crusted lesions ( Early) lichenoid plaques ( Late). Biopsy: Non specific, inflammation. Topical steroids like 1% hydrocortisone cream once or twice dai

ly. Systemic steroids. Etiology: Topical antifungals, soaps, antiseptics, podophyllotoxin. 3) Drug reactions Fixed drug eruptions (FDE) SJS/ TEN Itching, burning sensation. Edema of prepuce. Predilection for glans penis. Well demarcated, bullous, edematous and ulcerated lesions. Target lesions. Erosions. Rechallenge with the drug to confirm the diagnosis. Hydropic degeneration of basal cell layer. Spongiosis. Spontaneous fading without treatment. Residual hyperpigmentation. Rarely topical 1% hydrocortisone cream bd until resolution. Systemic steroids for severe lesio ns. Etiology: Tetracyclines, NSAIDS, Sulfonamides, Dapsone, Warfarin, Griseofulvin, Phenophthalein, Erythromycin, Phenacetin, Metronidazole, Anti convulsants, Hypnotics. Arunkumar et al – Balanitis and Balanoposthitis www.ijrhs.com International Journal of Research in Health Sciences. Jan – Mar 201 4 Volume - 2 , Issue - 1 386 Follow up n ot required. Avoid precipitating agents. 4) Phimosis Common in young boys 5) Granulomatous balanoposthitis Multiple painless firm papules (glans penis), edema of prepuce. After intra vesical BCG instillation therapy[29] for Carcinoma of bladder. Titanium. Low grade fever. 6) Nonspecific balanoposthitis Chronic symptomatic presentation. Failure to respond to conventional topical treatment. Biopsy : Non specific histology. Circumcision is curative. Etiology : Unknown associated with atopy. 7) Balanoposthitis Simplex Itching. Burning sensation while urinating. Redness, swelling. Etiology: Bacterial infections, mechanical irritants, chemicals. 8) Mild balanoposthitis It is balanoposthitis of a localised, inflammatory, nature with few non specific symptoms and a tendency to become chronic or recurrent[30]. Candidal balanoposthitis Accounts for 35% of cases of balanoposthitis. Mostly it is acquired sexually. It is commonly seen in pa tients with diabetes mellitus. Diabetes mellitus interferes with both cellular and humoral immunity a nd suppress the host defence against infections. Acquired balanoposthiti s can be the first sign of diabetes mellitus in uncircumcised males. In healthy males, candidal balanoposthitis may be a cutaneous marke r of diabetes mellitus. Various studies have shown that 55% of known diabetic patients have candidal balanoposthi tis . The pr esentation of candidal balanoposthitis varies according to the age group and the sexual activity of the pati ent.

In young, sexually active males, the symptoms include itching, burning sensation, increased fissuring of the inner part of prepuc e and subpreputial discharge. In elderly males, Arunkumar et al – Balanitis and Balanoposthitis www.ijrhs.com International Journal of Research in Health Sciences. Jan – Mar 201 4 Volume - 2 , Issue - 1 387 who are sexually inactive, itching and moist erythema of inner aspect of prepuce and glans penis is more prominent, whereas fissuring is not that much marked [31] . Though Indian muslim males are usually circu mcised, and Hindu males are usually uncircumcised, there is no scientific data available that demonstrates the advantage of circumcision in prevalence of candidal balanoposthitis. Candidal posthitis can occur without balanitis. The smegma and the enzymes i n prostatic secretion normally control and eliminate candidal growth. An acute fulminating oedematous type of balanoposthits may occur with ulceration of penis and a swollen fissured prepuce in undiagnosed diabetics. The appearance of prepuce may be call ed “volcano like” [32] . Diabetics with balanopo sthitis presenting as acquired phimosis was first reported in 1971 [33]. It is seen in one third of men with acquired phimosis and it is found that 26% of patients with acquired phimosis had history of type II DM [34]. Clinicians and urologists thus should check the fasting blood sugar of patients with volcano like appearance of prepuce. The pathogenesis for fissuring in candidal ba lanop ostitis is due to the following factors [35]. 1) In uncontrolled diabetics with poor glycemic control, there is accumulation of advanced glycation end products (AGE) in foreskin which results in impaired production of collagen and extra cellular m atrix, which further causes decreased hydroxy proline content of collagen and alteration of skin elasticity. 2) Impairment of sebaceous gland function leads to l oss of skin surface lipids which leads to loss of elasticity and hydration. 3) Decreased hydr ation in stratum corneum. 4) During urination and sexual intercourse, the retraction of foreskin produces biomechanical stress which causes vertical preputial fissures which leads to fibrosis and subsequent phimosis. Balanoposthitis in Children: Balanitis in children affects 4% of boys [36]. It commonly affects preschool children (2 - 5 years) and it is associated with nonretractable prepuce. It is uncommon in infants and among boys in napkins. The exact aetiology is not known. It is postulated that it may b e due to poor personal hygiene. Organi

sms like group A haemolytic streptococci (commonest), E.coli, Pseudomonas, Klebsiella, Serratia are implicated in causing this condition. Autoinoculation from other sites is usually the mode of infection. Symptoms include redness, swelling, ulcer over glans penis, itching, pain, subpreputial discharge (SPD), dysuria, bleeding, low grade fever and weakness. Physical examination reveals phimosis, erythematous appearance of glans penis, foul smelling subpreputial discharge and partially or completely non retractable prepuce. Ammonia dermatitis, foreskin fiddling are the common differential diagnosis. Though this conditi on is usually self limiting in nature, penicillins or cephalosporins may be useful in some children. In children with recurrent balanit is and causing severe distress circumcision is advised. Above all, investigation for diabetes mellitus is important, bec ause balanoposthitis is commonly seen in children with type I diabetes mellitus. Smegma and Balanoposthitis Smegma is the result of desquamated epithelial debris collected in the sub preputial space & not formed due to glandular secretions [37]. It contains squalene, beta cholesterol, long fatty acids, which produces calcium soaps ( Calcium phosphate and Magnesium phosphate). In chronic inflammation this leads to subpreputial smegma stones formation. Smegma stones are seen in uncircumcised men. Such stones are formed due to poor genital hygiene, lack of retracting and washing the prepuce, accumulation of smegma beneath the foreskin [38]. Patients complain of penile irritation, discharge, pain during and after coitus. Signs include inflammation, partially ret ractable prepuce and purulent SPD. Circumcision and Balanoposthitis : Balanitis is uncommon in circumcised men. Balanitis patients usually have increased risk of carcinoma of penis. Circumcision thus helps in preventing carcinoma of penis. Good genital hyg iene and safe sex will definitely help to prevent balanoposthitis. The aim of treating balanoposthitis is to relieve the symptoms, to decrease the complications and to restore sexual function. Treating the associated sexually transmitted diseases and preve nting the route of entry of HIV infection is also important. Algorithm I is useful for management o f balanitis / balanoposthitis ( European guidelines ) [39] Complications: Phimosis / Paraphimosis Meatal stenosis / stricture Recurrence, relapse and reinfection Scarring, Depigmentation and hyperpigmentation Preputial adhesion and perforation Gangrene Lymphangitis and lymphedema Carcinoma of penis Arunkumar et al – Balanitis and Balano

posthitis www.ijrhs.com International Journal of Research in Health Sciences. Jan – Mar 201 4 Volume - 2 , Issue - 1 388 Management of non - specific balanitis [40] (Algorithm II ) Conclusion Balanoposthitis is thus a treatable condition in most of the patients. Persistent recurrent balanposthitis needs extensive search for the cause and circumcision may be a best option in some of the cases. Since prepuce is an immunologically important tissue as well as an erogenous tissue it should be removed only when mandatory in certain conditions like BXO. Good genital hygiene and safe sex will def initely help to prevent balanoposthitis. The aim of treating balanoposthitis is to relieve the symptoms, to decrease complications and to restore sexual function. Treating associated sexually transmitted diseases and preventing the entry of HIV infection i s also important. Prevention and precautions for balanoposthitis : The following instructions and general advice will help the patients to prevent recurrence of balanoposthitis. General advice: 1) Avoid frequent washing of genitalia with soaps. 2) Maintaining th e genital hygiene by using weak salt solution or potassium permanganate soaks (1:8000) or soap free wash. 3) Using lukewarm water to clean penis and prepuce. 4) Drying the foreskin of the penis after washing and before putting on undergarments. 5) During washing and bathing the foreskin should be pulled back to expose the glans fully. 6) During urination pulling the foreskin back so that urine does not collect under the prepuce. 7) After urination dry the penis and prepuce should be replaced. 8) Washing and drying penis after having sex. Specific advic e : 1) Safe sex practices. 2) Appropriate hygiene. 3) Explain the about the condition and its long term complications. 4) Advice regarding the effect of condoms if creams are applied [41]. 5) Frequent changing of diapers in children. 6) Examination and treatment of sexual partners wherever necessary. References 1. P.M. Abdul Gaffoor, P.A. Nabil. Balanitis and Balanoposthitis.. The Gulf Journal of Dermatology.Volume 7, No 2, October 2000. 2. Birley HD, Walker MM, Luzzi GA, Bell R, Taylor Robinson D, Byrne M, et al. Clinical features and management of recurrent balanitis; association with atopy and genital washing. Genitourin Med 1993; 69: 400 - 3. 3. P.N. Arora, S.Arora. Balanoposthitis. A Textbook of Indian Association for the study of Sexually Transmitted Diseas and AIDS 2 nd edition. Pg: 446. 4. Lisboa C, Ferreire A, Resenda C,

Rodrigues AG .Infectious balanoposthitis; Manage ment, Clinical and laboratory features Int. J Dermatol. 2009 Feb; 48 (2): 121 - 4. 5. English JC III, Laws AR, Keough GC, et al. Dermatoses of the glans penis and prepuce. J AM Acad Dermatol 1997;37: 1 - 24. 6. Michael Waugh, Sunil dogra. Balanitis and Balanop osthitis. Textbook of Sexually Transmited Infections. 2 nd edition p. 696. 7. C.J. Cold, JR. Taylor. The Prepuce. British Journal of Urology volume 83, Supp. 1: Pages 34 - 44, January 1996. 8. Saunders DN, Dinarella CA, Morhernn VB, Langerhans cell product ion of Interleukin. 1. J. Invest. Dermatol 1984; 82: 605 - 7. 9. Kupper TS. Interleukin 1 and other human keratinocyte cytokines; Molecular and functional characterisation. Adv. Dermotol 1988; 3: 293 - 306. 10. M.A. Waugh, E.G.V Evans, K.C.Nayyar, R.Fong Clot rimazole (Canesten) in the treatment of candidal balanitis in men. British Journal of Venereal Diseases, 1978, 54, 184 - 186. 11. Engman MF.A Peculiar fungus infection of the skin. Arch Dermatol. Syphilol 1920; 1:730. 12. Abennader S, Casin I, Janier M, Zav aro A, Vendecil MO, Traore F, et al. Balanitis and Infectious agents. A Prospective study of 100 Patients. Ann.Dermatol.Venereol 1995; 122: 580 - 584. 13. Horner, Patrick J, Taylor - Robinson, David. The Association of Mycoplasma genitalium with Balanoposthit is in men with non - Gonococcal urethritis. Sexually Transmitted Infection 87, 1 (2010) 38. 14. GR Kinghorn, BM Jones, FH Chowdhury, I Geary, Balanoposthitis associated with Gardnerella vaginalis infection in men. Br J. Vener Dis 1982; 58:127 - 9. Arunkumar et al – Balanitis and Balanoposthitis www.ijrhs.com International Journal of Research in Health Sciences. Jan – Mar 201 4 Volume - 2 , Issue - 1 389 15. Cree GE , Willis AT, Philips KD, Brazier JS. Anaerobic Balanoposthitis. Br Med J 1982 ; 284: 859 - 60. 16. Chowdhury DS, Chaudhury M. A case report of gangrenous balanitis in progressive reaction in leprosy. Lepr Rev 1966; 37: 225 - 6. 17. Sarah Edwards. Balanitis and Balanoposthitis a review. Genitourin. Med 1996; 72: 155 - 159. 18. AN Masferi, GR Kinghorn, BI Duerden. Anaerobes in Genitourinary infection in men. Br. J vener Dis 1983 Aug 59(4): 255 - 9. 19. J.F. Peutherer, Isabel W. Smith, D.H.H Robertson. Necrotising balanitis due to generalised primary infection with Herpes simplex virus type 2. British Journal of Venereal Diseases. 1979, 55, 48 - 51. 20. Cook K.A., Rodrigue RB, Amoebic balanitis, Med. J . Austr. 1964.1: 114 - 6. 21. Michalowski R. Balanoposthitis in Trichomonas. A Proposed observa

tion. Ann Dermatol Venereol 1981; 108: 731 - 8. 22. Kanerva L, Kousa M, Niemik M, Larsus A, Juvalcoski T, Lauharanta J. Ultrahistopatho logy of Balanitis circinata. Br. J. Venereol Dis 1982; 58:188 - 95. 23. Rickwood AM, Hemalatha V. Batrya G, Salz L, Phimosis in boys Br. J. Urol 1980; 52:147 - 50. 24. Jorgeuson ET, Stevenson A. The treatment of phimosis in Boys with potent topical steroid (Cl obetasol propionate 0.05%) cream. Acta Derm Venereol (Stock) 1993; 931: 55 - 6. 25. P.V. Krishna Rao, Hari kishan Kumar Yadalla. Plasma cell balanitis (Zoon’s Balanitis): A clinicopathological study of 8 cases. Our dermatol online 2012; 3 (2): 109 - 111. 26. Peter CS, Thomson C, Fusidic acid cream in the treatment of plasma cell balanitis. J. Am. Acad. Dermatol. 1992; 27: 633 - 634. 27. Queyrat M. Erythroplasie du gland. Bull soc Fr De rmatol Syphiligr 1911; 22: 378 - 82. 28. Gatto – Weis C, Topolsky D, Sloane B, H on JS, Qu H, F yfe BS, Ulcerative Balanoposthitis of the fore skin as a manifestation of Chronic lymphocytic leukemia. Case report and review of the literature. Urology 2000 Oct1; 56 (4) : 669. 29. Yusuke H, Yoshinori H, Kenichi M, Akio H, Granulomatous balanoposthitis after Intravesical Bacillus - Calmette - Guerin instillation therapy. Int J. Urol 2006 Oct ; 13 (10) : 1361 - 3. 30. C. Veller Fernasa, A. Calabro, A Miglietto M. Tarantello, C. Biasinotto, A. Peserico. Mild Balanoposthitis. Genito Urin Med 1994 ; 70: 345 - 346.. 31. Shyam B Verma, UWC Wolina, Looking through the cracks of diabetic candidal balanoposthitis!. International Journal of General medicine. 2011; 4: 511 - 3. 32. Chih - Chun Ke, Chien Hua Chen, Jen - Jih Chon, Chung – Cheng Wong, Balanoposthiti s with a volcano appearance may the first clinical presentation of undiagnosed diabetes mellitus. Incont Pelvic Floor Dysfunct . 2011; 5 (4) : 120 - 21. 33. Skoglund RW ; Diabetes presenting with Phimosis. Lancet 1971; 2: 1431. 34. Bromage SJ, Cromp A, Pearc e I, Phimosis as a presenting feature of Diabetes .BJU Int 2008; 101: 338 - 340. 35. Lisboa C, Santos A, Dias C, Azoerdo F, Pina - Vaz C, Rodrigue A. Candida balanitis: risk factors, J. Eur. Acad Dermatol Venereol 2010. in press. 36. JM Escala, AMK Rickwood , Balanitis. British Journal of Urology, Volume 63, Page 196 - 197. 37. Parkash S, Jeyakumar S, Subramanyan K,Chaudhuri S. Human Subpreputial collection: its nature and formation. J. Urolog 1973; 110: 211 - 2. 38. C Sonnex, PE Croucher, WG Dockerty, Balanopost hitis associated with the presence of subpreputial “ Smegma Stones”. Genito Urin Med. 1997; 73: 567. 39. S.K. Edwards. Europea

n guidelines for the management of Balanoposthitis. International Journal of STD & AIDS. 2001; 12 (Suppl.3): 68 - 72. 40. Edwards SK Handfield - Jones S, on behalf of clinical effectiveness group, British Association for several health and HIV. 2008 UK National Guideline on the Management of Balanoposthitis, available from http : //www.bashh.org / guidelines. 41. Kingston Rajiah, Saj esh K. Veettil, Sureshkumar, Elizabeth M. Mathew. Study on various types of infections related to balanitis in circumcised or uncircumcised male and its causes, symptoms and management. African Journal of Pharmacy and Pharmacology. January 2012; 15 vol. 6(2): 74 - 83. Arunkumar et al – Balanitis and Balanoposthitis www.ijrhs.com International Journal of Research in Health Sciences. Jan – Mar 201 4 Volume - 2 , Issue - 1 39 0 Management of balanitis/ balanoposthitis ( European Guidelines) ( Algorithm I ) Prepuce retractable Prepuce not retractable Ulceration + Erythema / SPD+, No Ulcer Prepuce scarred Prepuce swollen Treat as genital ulcer Treat as Genital Ulcer Refer to Surgery Foul smell + No foul smelling Metronidazole 400mg bd for 1week Antifungal +1% Hydrocortisone cream application bd for 1 week Take history and examine Review after 1 week Better, Discharge and Follow up If no improvement, 1) Reassess or 2) Erythromycin 500mg qid for 1 week or 3) Potent steroid cream and follow up Balanitis / Balanoposthitis Arunkumar et al – Balanitis and Balanoposthitis www.ijrhs.com International Journal of Research in Health Sciences. Jan – Mar 201 4 Volume - 2 , Issue - 1 391 Management of Non specific Balanitis [40] (Algorithm II ) Balanitis Culture for pathogens Pathogens identified, treat appropriately No pathogens identified Improved No improvement, try empirical Metronidazole Good hygiene, Poor hygiene Improved No Improvement Improved Hydrocortisone 1% cream bd for 1 week No improvement and significant balanitis. Advice penile biopsy Treat as per specific diagnosis in biopsy Shows inflammatory dermatoses Consider Circumcision emollients / avoid potential irritants Advice to improve genital hygiene Arunkumar et al – Balanitis and Balanoposthitis www.ijrhs.com International Journal of Research in Health Sciences. Jan – Mar 201 4 Volume - 2 , Issue