Introduction
Inflammation of the non-keratinized epithelium of the glans penis (i.e. balanitis) and prepuce (i.e. posthitis) together comprise the term balanoposthitis.[1] It affects 3–12% of male genitourinary clinic attendees.[2–5] Etiological factors are infective, inflammatory, pre-malignant, neoplastic, drugs, chemicals, and mechanical trauma. Different etiological conditions can have similar clinical presentations.[6] Predisposing factors are extra-long foreskin, phimosis, poor hygiene, trauma, diabetes mellitus, use of strong soaps/cleansers, and so on.[2]
Although balanoposthitis is commonly encountered in dermatology and sexually transmitted disease (STD) clinics across the globe, published studies describing various morphological patterns of balanoposthitis are still scarce. Therefore, we planned this study to ascertain the correlation of various morphological patterns with final diagnosis as well as disease burden and common etiological factors of balanoposthitis in our clinical setting.
Materials and Methods
An observational cross-sectional study was conducted over a period of 8 months, and all males presenting to the out-patient department of dermatology and STD clinic with complaints related to prepuce and/or glans were included in the study after obtaining written informed consent. The study was approved by the institutional ethics committee (approval number RNT/Stat/IEC/2015/1245, dated 03.11.2015). Apart from demographic details, present, past, personal, travel, drug, sexual contact, proper penile hygiene, and transfusion histories were recorded. The presenting episode was labeled as primary, recurrent (≥2 episodes), or persistent (lesions which had not completely remitted even once in the last 6 weeks). Thorough general, dermatological, and systemic examinations were performed. Proper penile hygiene was defined as cleaning of glans and prepuce regularly with clean water without using any soap or irritant, retracting the prepuce before urination, and cleaning genitals after sexual activity or nocturnal emission. Unsafe sexual exposure refers to sexual contact without use of any barrier contraceptives.
Investigations such as Gram-staining, Tzanck smear, potassium hydroxide (KOH) mount, pus culture and sensitivity, urine routine/microscopy and culture/sensitivity, venereal disease research laboratory test (VDRL), enzyme-linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV), fasting and post prandial blood sugar, HbA1C, and biopsy were performed as and when required for establishing the diagnosis.
Data were collected and tabulated in MS-excel version 16.0. Continuous data were presented as mean and standard deviation, and discrete data were in the form of frequencies and percentages. The test applied for continuous data was Student’s t-test, and Chi-square test was applied for discrete data. The test of significance applied for each morphological pattern was Chi-square test for 11 × 2 table at degree of freedom = 10. A P value of <0.05 was considered statistically significant.
Results
A total of 7200 males attended the dermatology and STD clinic during the study period, out of which 1.8% (129) had balanoposthitis. The mean age was 39.35 ± 15.15 years (range 2–72 years). The majority of patients belonged to the age group of 21–40 years (51.2%). Most of the patients (87.6%) were married, and 30.2% reported unsafe sexual exposure during the past 6 months. All patients were uncircumcised and heterosexual. More than half (65.1%) patients presented within 2 weeks of symptoms. The presenting episode was the first episode in 43.4%, recurrent in 41.9%, and persistent in 14.7% patients. Proper penile hygiene was practiced by 63.6% patients, and all patients with persistent balanoposthitis had improper penile hygiene.
The most common symptom was itching (68.2%), followed by difficult retraction of foreskin, fissuring, burning sensation, pain, redness, and discharge [Table 1]. The most common presentations were erosion/confluent wet erythema with sub-preputial discharge (24.81%), fissure with superficial pustules (15.5%), fissure alone (13.18%), patchy dry erythema (11.63%), and superficial pustules (intact or exfoliated) with or without underlying erythema (10.85%) [Table 2].
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Table 1: Symptoms associated with balanoposthitis
Table 2: Table showing level of significance between morphological patterns and final etiological diagnosis
KOH mount was positive in 38.9% (35/90) cases, and Tzanck smear showed multi-nucleated giant cells in 15.78% (12/76) patients. Gram’s stain was positive in 32.6% (15/46) patients; thirteen samples showed Gram-positive cocci, and the rest two smears showed Gram-negative bacilli. Bacterial culture was performed in 46 patients who presented with erosions/confluent wet erythema with sub-preputial discharge and superficial pustule (intact or exfoliated) but were KOH-negative for Candida. It was positive with the presence of aerobic pyogenic organisms in 39.1% (18/46) patients. Organisms grown on culture were coagulase negative Staphylococci 44.44% (8/18), Staphylococcus aureus 22.22% (4/18), group B Streptococci 16.67% (3/18), Klebsiella 11.11% (2), and Pseudomonas 5.56% (1/18). Four (3.2%) patients were found positive for HIV-ELISA, and two (1.6%) were reactive for VDRL test in serial dilution. Diabetes mellitus (DM) was found in 24 (18.6%) patients, and 13 (10.1%) patients were pre-diabetics. Out of 24 diabetics, eight were newly diagnosed (seven candidal balanitis and one bacterial balanitis).
Laboratory confirmation of the final diagnosis could be performed in 105 patients (81.39%) [Table 3]. The rest of the cases were managed empirically with a combination of drugs as laboratory results were inconclusive and were excluded from further analysis. Candidal balanoposthitis was the most common final diagnosis (33.3%, 35/105), and almost half (48.57%, 17/35) had recurrent episodes. Out of the 14 cases of irritant balanitis, 10 (71.43%) had a history of atopy. Most of the cases with unsafe sexual exposure had infective balanitis (32/39; 82%) [Figures 1-10]. Correlation of morphological patterns with laboratory diagnosis is depicted in Table 2. Erosion/confluent wet erythema with sub-preputial discharge was most commonly seen with herpes genitalis and bacterial balanitis compared to any other etiological diagnosis, and the difference was statistically significant (P value 0.0004). Patchy dry erythema was statistically significantly the most common presentation of irritant balanitis (P value 0.049). Papule/plaque was the most common presentation of genital lichen sclerosus et atrophicus (LSA) (P value 0.0402). For other morphological presentations, no statistically significant correlation was found with any etiological diagnoses.
Table 3: Final laboratory diagnosis of balanoposthitis
Figure 1: (a) Superficial exfoliated pustules over glans with underlying erythema in a case of candidal balanitis. (b) Fissuring over prepuce with phimosis in a case of candidal balanoposthitis
Figure 2: (a) Confluent erosions over glans and prepuce with sub-preputial discharge in a case of bacterial balanoposthitis. (b) Larger superficial pustules in a case of bacterial balanitis
Figure 3: Superficial irregular erosions over prepuce in a case of herpetic balanitis
Figure 4: Irregular confluent erosions over glans extending toward prepuce associated with whitish discharge in a case of syphilitic balanitis
Figure 5: Dry erythematous patch over glans near coronal sulcus in a 4-years-old atopic child with irritant balanitis
Figure 6: Whitish plaque of genital LSA involving entire prepuce with associated phimosis and fissures
Figure 7: Sharply demarcated hyper-pigmented patch over prepuce extending up to glans in a case of genital FDE
Figure 8: Shiny, glazed well-defned erythematous macules involving both glans and prepuce in a case of Zoon’s balanitis
Figure 9: Well-defined violaceous plaque of lichen planus over glans penis
Figure 10: Well-defined erythematous plaque with mild scaling over glans in a case of genital psoriasis
Discussion
Balanoposthitis is a common genital problem for which patients seek consultation in dermatology, urology, and STD clinics. Birley et al.[2] reported 11% incidence of balanitis in genitourinary medicine clinic attendees. In our study, incidence of balanoposthitis was 1.8% among male patients attending the dermatology out-patient department and STD clinic.
The mean age of our patients was 39.35 ± 15.15 years (range 2–72 years). In two other studies, these were 37 years (range 13–68 years)[7] and 42.2 years (range 20–83 years).[8] The maximum number (51.2%) of patients belonged to the age group of 21–40 years, similar to other studies.[1,7] It is expected as this age group is the most sexually active.
The maximum number of patients (87.6%) in our study were married, whereas in other two studies, a lesser number of patients (67% and 68.87%) were married.[7,8] Unsafe sexual exposure predisposes a person to balanoposthitis besides increasing risk of other conventional STDs. In our study, unsafe sexual practices were followed by 30.2% patients; most of these had infective balanoposthitis. Out of 82 patients of infective balanoposthitis, 18.29% had a history of unsafe extra/pre-marital contact in the study by Jegadish et al.[7] In the same study,[7] 41.51% had poor, 20.75% had moderate, and 37.74% had good genital hygiene, whereas 63.6% patients of our study followed proper penile hygiene.
All our patients were uncircumcised, similar to the study by Lisboa et al.[8] In two other studies, 92% and 95.28% patients were uncircumcised.[1,7] Uncircumcised penis predisposes a person to increased risk of balanitis because of a larger surface area for transmission, more opportunities for epithelial microtrauma, and warm and moist niche under the prepuce favoring the persistence of fastidious organisms. The prevalence of balanitis was 68% lower in circumcised versus uncircumcised males.[9] However, balanoposthitis is not confined to uncircumcised men. Birley et al.[2] reported six circumcised patients out of 18 patients with recurrent balanitis.
The most common morphological pattern observed in our study was erosion/confluent wet erythema with sub-preputial discharge (24.81%), similar to the study by Jegadish et al.,[7] but it was seen in a higher (47.17%) percentage of cases.
Infectious etiology was found in 62.86% of our laboratory-confirmed cases – 33.3% candidal, 17.1% bacterial, 12% herpetic, and 0.95% syphilis. However, Jegadish et al.[7] reported a higher percentage (77.36%) of infective balanopothitis – 59.76% candidal, 19.51% herpetic, 4.88% syphilitic, and other infections. Raju et al.[1] reported 64% cases of infective balanoposthitis – 47.9% candida, 37% bacterial, 4.16% herpetic, and other infections.
Among the non-infectious etiologies, Jegadish et al.[7] reported 4.72% fixed drug eruption (FDE), 3.77% lichen planus, 3.77% psoriasis, 0.94% irritant, and 0.94% Zoon’s balanitis. In our study, 13.3% had irritant balanitis, 8.6% had FDE, 6.7% had lichen sclerosus et atrophicus (LSA), 3.8% had Zoon’s, 2.9% had lichen planus, and 1.9% had psoriasis. Raju et al.[1] reported 36% cases of non-infectious etiology, which is similar (37.14%) to our study.
In our study, Candida was a causative agent in 33.33% (35/105) cases. Previous studies have reported a wide range of candida infections among balanoposthitis patients such as 11.87%,[8] 18%,[10] and 50.67%.[1] Some of our cases in whom we strongly suspected a clinical diagnosis of candidal balanitis but who were KOH-negative responded to oral anti-candidal therapy. Isolation of candida can vary depending upon the sampling methods such as cotton-tipped swab or adhesive tape method and diagnostic modality like culture versus microscopy. A higher rate of isolation of candida in our study and Raju et al. study[1] can be attributed to more prevalence of infections in developing countries. Among the morphological patterns, fissuring with superficial pustules was the most common (51.43%) presentation of candidal balanoposthitis in our study, as in a south Indian study (53.06%).[7]
Diabetics are predisposed to candidal balanoposthitis, especially uncircumcised and immunocompromised males.[9] In our study, 40% of patients with candidal balanoposthitis were diabetics, 20% had impaired glucose tolerance (pre-diabetics), and 20% were newly diagnosed. Lisboa et al.[8] reported 76.92% of patients with candidal balanitis to have diabetes and 30.77% patients to be newly diagnosed. Jegadish et al.[7] found 61.22% cases of candidal balanoposthitis to be diabetes, whereas 24.49% were newly diagnosed. Raju et al.[1] found DM in 35% of candidal balanoposthitis patients.
We found aerobic bacterial culture positivity in 17.1% (18/105) patients. Coagulase negative Staphylococcus and Staphylococcus aureus were the most common. Lisboa et al.[8] found positive bacterial culture in 10.04% (22/219) cases; Staphylococcus species and group B and D Streptococci were the most frequently isolated bacteria. Alsterholm et al.[11] isolated Staphylococcus aureus in 19% balanoposthitis patients. We made the final diagnosis of bacterial balanoposthitis on the basis of isolation of organisms on aerobic culture. However, mere isolation of bacteria on culture does not necessarily mean that they are causative of balanitis as some such organisms are common members of normal mucosal microflora. Some of the isolated organisms in our study such as coagulase negative Staphylococci may not be true causative pathogens. However, our patients of bacterial balanitis had favorable response to anti-bacterial treatment.
Herpetic balanitis was considered as the final diagnosis in cases where multi-nucleated giant cells were present on Tzanck smear. This was seen in 11.4% cases. Herpes contributed to 4.16% and 19.51% cases of balanoposthitis in previous studies.[1,7] Birley et al.[2] isolated herpes simplex virus in 1 out of 43 cases of recurrent balanitis. The morphological pattern that correlated best with herpetic and bacterial balanitis was erosion/confluent wet erythema with sub-preputial discharge (P value 0.0004). Some balanitis patients with clinical suspicion of herpes, who had negative Tzanck smear examination, responded well to oral acyclovir therapy. Our belief is that many patients with recurrent superficial erosive balanitis may have herpetic etiology. However, confirmation in these cases is always very difficult. With better methods for investigating herpes simplex virus, some cases of recurrent balanitis with minimal vesiculation can be identified as herpetic.
Non-infective balanoposthitis was diagnosed in 37.1% cases. Irritant contact dermatitis (13.33%) was the most common cause of such balanitis. The morphological pattern of patchy dry erythema was statistically significantly (P value 0.049) related to irritant balanitis. Irritant contact dermatitis is also a frequent cause of recurrent or persistent balanitis. It can result from exposure to medications such as antibiotics, allergens such as latex in condoms, propylene glycol in lubricants, some spermicides, and corticosteroids. Ammonia, released from urine by bacterial hydrolysis of urea, can induce inflammation of the glans and prepuce.[9] Genital hygiene practices used by patients have a strong bearing on the presence and persistence of irritant balanitis. In our study, 50% patients with irritant balanitis gave a history of frequent washing of genitals with soap and other irritants. Fornasa et al.[12] reported that 9 out of 51 patients developed mild balanoposthitis because of contact irritation, whereas a south Indian study[7] reported only a single case (0.94%) of balanoposthitis because of irritant contact. Alsterholm et al.[11] proposed a possible role of increased susceptibility to irritants causing dermatitis and subsequent colonization or infection with microbes over glans penis and prepuce. Ten out of 14 (71.5%) patients of irritant balanitis had a history of atopy. Birley et al.[2] reported a history of atopy in 67% of their cases of recurrent balanitis.
We made a clinical diagnosis of LSA on morphological grounds which was present in 6.7% (7/105) of patients. Six (6/75, 8%)[8] and nine (9/86, 10.4%)[10] cases of two Portugal studies from the same center had lichen sclerosus. All seven patients of LSA had white plaques over glans and/or prepuce, and five patients had associated phimosis with difficulty in performing sexual activity. Phimosis was seen in 23.58% cases in one report,[7] while 39.5% had painful/non-retraction of foreskin in our study.
The morphological pattern of Zoon’s balanitis is characteristic with appearance of shiny, glazed macular erythematous lesion with cayenne-pepper spots on glans and/or prepuce. We found the typical morphological presentation of Zoon’s balanitis in four cases. Other two studies have reported a single case and two cases of Zoon’s balanitis.[7,10]
Fixed drug eruption on genitals is a common occurrence. We found 8.6% cases of FDE among patients of balanoposthitis. Jegadish et al.[7] reported 4.72% and Raju et al.[1] reported 8% cases of balanoposthitis because of FDE.
One of the principal aims of our study was to categorize the clinical presentation of patients into various morphological patterns and to find the correlation between these patterns with final etiological diagnosis. To a large extent, we succeeded in categorizing balanitis into specific morphological patterns, although there can be overlapping of these patterns in any given patient. More importantly, some of these morphological patterns correlated strongly with final etiological diagnosis.
Limitations
The limitation of our study was that we did not undertake an exhaustive laboratory workup such as fungal or viral culture, herpes serology, real-time polymerase chain reaction, and biopsy for histopathological analysis, which could have improved our final tally of etiological diagnosis.
Conclusion
Balanoposthitis is a commonly encountered entity with many etiological and predisposing factors. Prompt etiological diagnosis and treatment can be difficult because of overlapping clinical presentations, reluctance of patients for follow-ups and investigations, and unfeasibility of extensive workup in resource poor settings. Our study identifies that a morphological pattern can be strongly associated with certain diagnosis, such as fissuring with superficial pustules for candidal balanitis and erosion/confluent wet erythema with sub-preputial discharge for bacterial and herpetic balanitis. Our finding that improper penile hygiene and atopy predisposes the individual to irritant and persistent balanitis can be helpful in counseling and preventing recurrences.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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