Balanoposthitis - Causes, Diagnosis, and Management

Introduction

Balanoposthitis causes inflammation of the head of the penis or the prepuce (foreskin of the penis). It is mainly caused due to infection, irritation, or trauma. Balanitis is the inflammation of the glans, and posthitis is the inflammation of the prepuce. The prepuce, or the foreskin of the penis, is adherent to the glans. This is usually due to non-pathological causes of phimosis which is physiological and decreased retraction of the foreskin. Balanoposthitis affects up to 12 % to 20 % of adults and pediatric patients. Balanoposthitis is commonly seen in uncircumcised males.

What Is the Etiology of Balanoposthitis?

Nonspecific balanoposthitis is common among the other types and is caused by poor hygiene. Other causes include infection, trauma, cancer, and inflammatory skin diseases. In pediatric cases, the cause can be associated with diaper rash or candidal infection, which is prevalent in children. Infections of aerobic and anaerobic bacteria, such as Staphylococcus aureus and group A Streptococcus, and viruses, such as human papillomavirus (HPV), are the infectious causes of balanoposthitis. In addition, contact dermatitis, lichen sclerosis, and reactive arthritis are inflammatory diseases that can cause balanoposthitis.

What Is the Epidemiology of Balanoposthitis?

The prevalence of balanoposthitis is 12% to 20% in all ages and affects children and adults equally. Balanoposthitis presents in children from the age of two to five years. In children, it is more likely physiological phimosis or nonspecific balanoposthitis. In adults, there is a 35 % prevalence rate among uncircumcised males with diabetes mellitus. Studies have shown that circumcision of the penis reduces the rate of balanoposthitis by 68%.

What Is the Pathophysiology of Balanoposthitis?

The pathophysiology of balanoposthitis depends on its etiology. The etiologies are infection, allergy, irritants secondary to trauma or malignancy, and autoimmune-mediated diseases. The inflammation begins due to moisture caused by urine, sweat, or smegma (physiologic sweats from genital sebaceous glands). This moisture is trapped in the preputial space, which is an aftermath of poor hygiene and adhesions, which provides a favorable environment for the growth of bacteria and fungi. In addition, irritants and allergens can cause inflammation leading to balanoposthitis.

How Does Balanoposthitis Present Itself?

Symptoms involve:

• Dry skin.

• Discolored shiny skin.

• Pain and tenderness.

• Irritation.

• Burning sensation.

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• Itching.

• Leathery, thick skin caused due to lichenification (caused due to constant scratching and rubbing).

• Abnormal discharge.

• Phimosis (a condition that affects both adults and children who have not undergone circumcision, it involves the foreskin on the head or glans of the penis and can not be retracted or pulled back).

• Skin erosions or lesions.

• Foul odor.

What Is the Evaluation of Balanoposthitis?

A history of the case and physical examination are necessary to diagnose balanoposthitis. Evaluation of symptoms based on their duration is advised, including infectious exposures, hygiene habits, sexual practices, and potential allergens.

The evaluation takes into consideration the following aspects:

• Urethral discharge.

• Urinary retention.

• Edema.

• Tenderness.

• Scarring.

• Inguinal lymphadenitis.

• Tenderness.

• Testicular edema.

Smegma is a physiological secretion of the genital sebaceous gland, which should not be confused with discharge. Discharge is associated with erythema and tenderness and appears foul-smelling and exudative. Penile ulcers, vesicles, and urethral discharge are symptoms of sexually transmitted infections.

Empirical therapy is suggested in children after ruling out the absence of lesion, discharge, or sexual abuse. A nucleic acid amplification test (NAAT) is performed in individuals suspected of sexually transmitted diseases such as gonorrhea and chlamydia to get a diagnosis. Culture for group A beta-hemolytic Streptococcus may be suspected in adults and children. In cases of recurrent balanoposthitis, even after treatment of four weeks, it may be suggested for biopsy for further investigation and treatment.

Balanoposthitis and Diabetes:

Studies have shown that individuals with type 2 diabetes are susceptible to developing balanoposthitis. The reason inadequate glucose control and obesity are the causes of diabetes, which provides a favorable environment for yeast and Candida growth.

Home Care for Children With Balanoposthitis:

• The physician usually prescribes medication that helps treat the infection and swelling. The medication course should be completed even after the child feels better.

• The caretaker should wash their hands before and after attending to the care of the child's penis. This prevents the further spread of infection. The child should be given instructions on personal hygiene, such as washing the hands before and after touching the penis.

• The penis can be soaked in clean water with one tablespoon of salt by making the child sit in a bathtub or using a container. This can be repeated two to three times a day as it helps in reducing inflammation.

• In babies, gently retract the foreskin and rinse it with clean water, and then use cotton to clean it. Soap, bubble bath oils, and talc powder should be avoided as it irritates.

• The child should be taught to retract the foreskin gently. By the age of 10, the foreskin can retract completely.

What Is the Treatment for Balanoposthitis?

Nonspecific Balanoposthitis:

It is commonly caused due to poor hygiene in children. The area is cleaned two to three times a day, and hygiene instructions should be given to the child.

Candidal Infection:

Candidal infection in children may present secondary to diaper dermatitis. Its symptoms involve an erythematous rash with satellite lesions. The lesion is tender on palpation. In adults, it is associated with immunosuppressive disorders, the use of broad-spectrum antibiotics, and diabetes mellitus. Topical treatment involves 0.25 % of Miconazole for each diaper change for seven days. In addition, Nystatin cream 100000 u/gram three times a day for two weeks can be used as an adjunct.

Irritant Balanoposthitis:

There is mild edema with or without pruritus and it is commonly seen in association with atopic dermatitis. It is caused due to frequent or aggressive washing using soap. This condition can be avoided by not using strong soaps and by the application of vaseline multiple times a day. It can be caused by allergic reactions from latex condom use, detergents used in washing the undergarment, and lubricants. 1% Hydrocortisone for two weeks is the treatment of choice.

Bacterial Balanoposthitis:

It is presented in association with erythema and transudative or exudative discharge. Common causative agents are Streptococcus pyogenes and Staphylococcus aureus. Treatment involves topical antibiotics such as Mupirocin 2 % for 14 days.

Sexually Transmitted Infections:

Commonly seen infections are chlamydia and gonorrhea. Treatment involves Ceftriaxozone 250 mg IM and a single dose of Azithromycin 1g PO. A syphilitic ulcer is treated with 50000 U/kg IM.

Anaerobic Bacterial Infection:

Mild cases are treated with topical Metronidazole, and severe cases are treated with oral antibiotics such as oral Metronidazole.

Circinate Balanitis:

It occurs in association with reactive arthritis and presents as pale macules with white margins. Treatment involves topical steroids such as 1 % Hydrocortisone.

Conclusion

Balanoposthitis is the inflammation of the foreskin of the glans or head of the penis. It is mainly caused due to infection, irritation, or trauma. It has infectious and noninfectious etiology. Treatment is mainly based on the cause. Balanoposthitis due to infectious causes is treated with antibiotics and steroids.