Balanitis

CLINICAL

• Definition: a descriptive term for inflamed glans penis +/- prepuce (which is termed prosthitis, both = balanoposthitis).
• Causes/associations: infection, diabetes mellitus (check serum or urine glucose as may be initial presentation), poor hygiene (uncircumcised), chemical irritants (soap, petroleum jelly), anasarca, drugs, morbid obesity, penile CA.
  • Uncommon in circumcised men.
• Hx: tender glans, discharge, difficult to retract prepuce +/- impotence/difficult urination.
  • Take sexual history.
  • Poor hygiene is often a predisposing factor.
• PE: penile erythema/edema/ulcers/plaques +/- discharge +/- phimosis.
  • Signs and symptoms vary according to etiology.
• Various types:
  • Infection:
    • Candida: KOH prep and fungal culture.
    • Aerobic: cx for streptococci/staphylococci/Gardnerella (r/o syphilis/trichomonas/HSV).
    • Anaerobic: foul-smelling discharge, edema + lymphadenopathy. Gram stain will show mixed flora, polymicrobial cx.
    • HPV: typical pathology with warts possible.
    • Trichomonas vaginalis
    • Herpes simplex virus
    • Mycoplasma genitalium
  • Inflammatory dermatoses:
    • Circinate: a manifestation of reactive arthritis (formerly Reiter’s syndrome).
      • Bx - spongiform pustules, maybe chlamydia probe positive.
    • Psoriasis
    • Irritant/allergic/eczematous: secondary to condoms? diaphragms, lubricants/spermicides, etc. Hx atopy is common.
      • Patch testing.
      • A biopsy is nonspecific.
    • Fixed drug eruptions: medication hx (tetracycline, sulfa, PCN, salicylates, phenacetin, phenolphthalein, some hypnotics), + oral/ocular mucosa lesions.
      • Rechallenge to confirm dx.
    • Lichen sclerosus (balanitis xerotica obliterans):
      • Dx by biopsy. Associated with squamous cell CA in 4-6% of patients. 1% risk of malignant transformation. Annual f/u needed.
    • Lichen planus
    • Zoon’s (plasma cell): pinpoint red spots, "cayenne pepper spots" (typical appearance) or bright red or shiny brown patches with red specks.
      • It may resemble the erythroplasia of Queyrat.
      • Dx by biopsy.
  • Premalignant conditions:
    • Erythroplasia of Queyrat:
      • Biopsy shows squamous cell carcinoma in situ.
    • Bowenoid papulosis
    • Bowen’s disease
      • Sometimes referred to as squamous cell carcinoma in situ.
• Ddx: leukoplakia, lichen planus, psoriasis, seborrheic dermatitis, pemphigus, dermatitis artefacta, Bowen’s disease, Bowenoid papulosis.
• If not responsive to initial therapy, involve dermatology or urology consultants for consideration of biopsy (rule-out penile CA, pre-malignant lesion).