Objectives: To give an overview of the literature on balanitis, with a special emphasis on infective causes.
Method: A data search was performed using the OVID CD plus Medline 1967-1995, using balanitis and balanoposthitis as textword search strategy. Specific subjects such as anaerobic infection, Zoon's balanitis were sought separately and subgroups combined. Original articles and abstracts were referenced to illustrate each condition. These were mainly English language articles, but included appropriate non-English language papers.
Conclusions: Balanitis is a common condition among genitourinary medicine clinic attendees, the cause often remaining undiagnosed. Many cases are caused by infection, with candida being the most frequently diagnosed. However, gardnerella and anaerobic infections are common, and there are a wide variety of other rarer infective causes. In addition irritant balanitis is probably a contributing factor in many cases. Balanitis which persists and in which the cause remains unclear warrants biopsy.
Balanitis is defined as inflammation of the glans penis, which often involves the prepuce (balanoposthitis). It is a common condition affecting 11% of male genitourinary clinic attendees in one study and it can be a recurrent or persistent condition. There is a wide variety of causes and predisposing factors; balanitis is more common among uncircumcised men possibly as a result of poorer hygiene and aeration or because of irritation by smegma. Underlying medical conditions can also predispose to balanitis, which may be more severe. It has been reported as a source of fever and bacteraemia in neutropenic men, and candidal balanitis may be especially severe in patients with diabetes mellitus. In a series of 321 patients, the majority (185 patients had an infective cause, although a greater proportion with mild disease had irritant or mechanical reasons for the inflammation. Inflammation of the glans and prepuce may also provide a route for the acquisition of the human immunodeficiency virus (HIV) infection.
Candidal balanitis This is considered to be the most common cause of balanitis and is due to infection with candidal species, usually Candida albicans. It is generally sexually acquired although carriage of yeasts on the penis is common, being 14-18%[7,8] with no significant differences between carriage rate in circumcised and uncircumcised men. Symptomatic infection is more common in the uncircumcised male. Significantly more of the female partners of men carrying yeasts were found to have candidal infection. Diagnosis may be on clinical appearances alone, microscopy and/or culture. The sensitivity of microscopy varies with method of sampling, and an "adhesive tape" method has proven to be more accurate than swabbing. Infection may occur without sexual contact, usually in the presence of diabetes of which it may be the presenting symptom, or after the use of oral antibiotics. Symptoms are of burning and itching of the penis with generalized erythema of the glans and/or prepuce which may have a dry glazed appearance, with eroded white papules and white discharge.[10,11] In diabetic patients the presentation may be more severe with oedema and fissuring of the foreskin, which may become non-retractile. Treatment can be topical (for example clotrimazole), or oral (such as with fluconazole) but partners should be screened as they may have a high rate of infection.
Pityriasis versicolor This condition is caused by the yeast Malassezia furfur, and has an incidence of 0.5-1% of all skin disease in England, but up to 50% in tropical areas. Genital involvement is uncommon and presents as a discrete, circinate, finely scaling hypopigmented areas on the glans which fluoresce in Wood's light.[13-15] The lesions can be treated with topical antifungals.
The presence of anaerobes on the glans penis, particularly in the uncircumcised male has been associated with non specific urethritis (NSU) and balanitis. In this study anaerobes were isolated in only 21% of healthy controls, but in 76% with balanoposthitis and 67% with NSU, whilst in those with both NSU and balanitis 95% had anaerobic bacteria, bacteroides species being the most common. The predominance of bacteroides strains in anaerobic balanitis has been found by others, in a study of 104 patients with balanoposthitis, anaerobes were isolated in 29 cases. Most of these were mixed infections, but the commonest isolates were B. melaninogenicus (10 specimens) and other bacteroides species (27 specimens).
A severe erosive and gangrenous form of anaerobic balanitis (the fourth venereal disease of Corbus) has been recognised for many years with the presence of anaerobes and fusobacterium spp. Anaerobes do not appear to cause genital ulceration, but are found in genital ulcers of any aetiology, and in this situation the predominant strains are B. assacharolytica and B. ureolyticus.[19-21]
The features of anaerobic balanitis are superficial erosions, foul smelling subpreputial discharge, preputial oedema an inguinal adenitis. More minor forms also occur. Resolution is normally rapid with metronidazole treatment.
Gardnerella vaginalis In unselected men the prevalence of Gardnerella vaginalis isolation is 7.2-8.0%[22,23] with a significantly higher isolation rate in men with balanoposthitis (P < 0.001). The prevalence of Gardnerella vaginalis in non-candidal balanoposthitis is 31% and concomitant anaerobic infection is common (75% co-isolation of bacteroides spp by Kinghorn et al). It is likely to be sexually acquired and partners of women with Gardnerella vaginalis have high isolation rates from the urethra or urine. Subpreputial carriage in consorts of women with Gardnerella vaginalis have not been studied specifically.
The symptoms of pure Gardnerella vaginalis balanitis are milder than those in anaerobic infection with irritation of the prepuce and glans penis, macular erythema and a fishy sub-preputial discharge. As coinfection with anaerobes is common, this may represent the milder end of a spectrum of disease.
Streptococci Group B streptococci can be carried asymptomatically in the adult genital tract, but are strongly associated with balanitis.[26,27] Rate of carriage varies between homosexuals (16.6% in heterosexuals and 39.3% in homosexuals) although no balanitis occurred in the latter groups. Sexual transmission is unclear as there was no expected age differential in one study, and in another meatal carriage was not proportional to promiscuity. The clinical appearance is of nonspecific erythema with or without exudates,[26,27] but more rarely may extend to penile cellulitis if abrasions are present.
Group A haemolytic streptococci have also been reported as causing balanitis. Most reports are of uncircumcised children who presented with erythematous moist balanitis[30,31,32] where the mode of transmission seems to have been autoinoculation from other sites. Pyoderma of the penis following fellatio has been reported, and in this case group A haemolytic streptococci were isolated from the coronal sulcus. Penicillins or cephalosporins are effective in treatment.
Tuberculosis Scandinavian data suggest that genitourinary tuberculosis remains stable in western countries, despite a fall in the prevalence of pulmonary tuberculosis. However, balanitis remains an uncommon presentation in Europe and the United States, but is common in Japan and countries where there is a high prevalence of tuberculosis. It presents as a chronic popular eruption of the glans penis, which may be ulcerated, and heals with scarring. It is associated with a positive Mantoux test and histology shows tuberculoid granuloma formation with a characteristic absence of tubercle bacilli. Penis tuberculides are thought to be due to the haematogenous spread of infection, and respond well to antituberculous chemotherapy.Leprosy Involvement of the glans penis has been reported in leprosy alone and in association with penis tuberculides.
Trichomonas Tricomonas can cause a sexually acquired superficial erosive balanitis which may lead to phimosis. There is a strong association with the presence of other infections. Histology of the lesions shows dense lymphocytic infiltration in the upper dermis. The organism may be demonstrated in a wet preparation from the subpreputial sac. This condition responds well to treatment with metronidazole.
Entamoeba histolytica Cutaneous amoebiasis of the genitalia occurs occasionally, and amoebic balanitis has been reported among uncircumcised men in New Guinea. It causes oedema of the prepuce with phimosis and discharge and in those cases circumcision is helpful. despite rectal carriage of amoeba by homosexuals balanitis is rarely seen in Europe, but the high prevalence in New Guinea is thought to be due to sodomy.
Syphilitic balanitis Multiple circinate lesions which erode to cause irregular ulcers have been described in the late primary or early secondary stage. A primary chancre may also be present. Spirochaetes are easily identified from the lesions.
Non syphilitic spirochaetes Ulcerative balanitis has been associated with infection by non-syphilitic treponemes of the borrelia group, and spirochaetes have been observed on dark field microscopy. This often coexists with other genital infection, and has been reported from Africa and India. In a study by Brams et al fusiform bacteria and spirochaetes were seen in 51% of men and were associated with balanitis in the presence of pyogenic organisms.
Herpes simplex In rare cases primary herpes can cause a necrotising balanitis, with necrotic areas on the glans accompanied by vesicles elsewhere and associated with headacre and malaise. This has been reported with herpes simplex virus types 1 and 2.
Human papillomavirus (HPV) Papillomavirus may be associated with a patchy or chronic balanitis, which becomes acetowhite after the application of 5% acetic acid.[50,52] Acetowhite change has also been reported in non-HPV associated balanitis and has resolved on treatment. HPV was identified in two studiesâ€”in the first in 56% of patient samples (of which 54% were oncogenic types) but only 26% of controls, and the other revealed HPV6 in 4 out of 5 cases.
Balanitis xerotica obliterans
This is a descriptive term for a scarring balanitis which was first described by Stuhmer,54 and which is most commonly caused by lichen sclerosus et atrophicus. Other causes are rare and include pemphigus vulgaris and chronic nonspecific bacterial balanitis.
Lichen sclerosus et atrophicus The association between balanitis xerotica obliterans and lichen sclerosus et atrophicus was made by Laymon and Freeman who described five patients with skin lesions as well as genital involvement. The main symptoms are pain, irritation, disturbance of sexual function, or urinary symptoms (including obstruction). Rarely this can present as a recurrent bullous balanitis, with the development of painful blisters and ulceration which may be precipitated by local trauma. The clinical appearance is of white plaques on the glans, often with involvement of the prepuce which becomes thickened and non-retractile. In active disease haemorrhagic vesicles may be seen. The changes only affect squamous skin, leaving atrophic areas which cause cicatritial shrinkage leading to urethral stenosis and phimosis. The condition affects all ages and circumcision specimens from children with phimosis often show the characteristic histological appearances.[61,62] Histology initially shows a thickened epidermis, followed by atrophy and follicular hypekeratosis. This overlies an area of oedema with loss of the elastic fibres and alteration in the collagen, which in turn overlies a perivascular band of lymphocytic infiltration. Haemorrhagic vesicles occur when the oedema causes detachment of the epidermis with a capillary erosion and extravasation of blood.
The course is chronic and relapsing, and although it may sometimes arrest, the areas of atrophy do not regress. Development of squamous cell carcinoma has been reported in patients with balanitis xerotica obliterans, both in areas of active and quiescent disease,[64,65] but malignant change appears to be less common than in lichen sclerosus et atrophicus in the female.
Potent topical steroids usually control the symptoms, although occasionally intralesional steroids may be required.[61,66] Testosterone ointment has also been advocated. If phimosis is present, circumcision may be required or meatotomy for meatal stenosis.
Pamphigus This autoimmune bullous disorder may cause balanitis. Pemphigus vulgaris may cause the clinical picture of balanitis xerotica obliterans, and pemphigus vegetans, a rare varian, is manifest by vegetating plaques. These may occur in intertriginous areas but may affect the glans penis.
Zoon's (plasma cell) balanitis This was first described by Zoon in 1952 and is a main differential diagnosis with erythoplasia of Queyrat. The lesions are well circumscribed and orange-red in colour with a characteristic glazed appearance and multiple pinpont redder spotsâ€”"cayenne pepper spots." Symptoms of pain and irritation and dischange occur. Histological appearances are also characteristic with epidermal atrophy, loss of rete ridges, "lozenge keratinocytes" and spongiosis. A predominantly plasmacytic nature of the infiltrate is found subdermally, which helps to differentiate this condition from others in which there is a non specific plasma cell infiltrate. The aetiology is unknown although chronic infection with Mycobacterium smegmatis has ben proposed as a cause. The course is chronic and poorly responsive to topical treatment but it can resolve completely on circumcision.[73,74]
Erythroplasia of Queyrat This is a manifestation of carcinoma in situ which was described by Queyrat in 1911. It has a characteristic red, velvety appearance with sharp margins, and a granular surface, usually occurring in the uncircumcised male over 40 years of age. The lesions may be single or multiple, and if keratotic or indurated suggest the development of frank squamous cell carcinoma. There are various treatment options including 5 fluorouracil, cryotherapy, laser treatment, or surgical excision. Circumcision is recommended and close follow up advised.67
Pseudoepitheliomatous, micaceous and keratotic balanitis This rare condition of the glans penis was first described by Lortat-Jacob and Civate in 1961. The course is progressive initially causing phimosis, then the development of a tumour with a verrucous appearance, and a well demarcated white keratotic layer which covers the glans. Histologically the lesions show a hyperplastic, keratotic epidermis with a polymorphonuclear infiltrate. Although originally considered to be benign, case reports suggest that the lesion may be locally invasive, or synonymous with verrucous carcinoma.
Circinate balanitis The commonest mucocutaneous manifestation of sexually acquired Reiter's syndrome, circinate balanitis occurs in 20-40% of cases. The incidence in enteric Reiter's disease is lower, and has only been noted in shigella associated disease. It appears as grayish white areas on the glans which coalesce to form larger "geographic" areas with a white margin. The histology shows spongiform pustules in the upper epidermis with parakeratosis, acanthosis and elongation of rete ridges. Dermal capillaries are enlarged and increased numbers are present together with mononuclear cell infiltrate and some evidence of extravasation. These changes are similar to those of pustular psoriasis. Circinate balanitis may occur with or without other features of Reiter's syndromeâ€”in one series 9 out of 17 patients had balanitis alone, although the association with HLA 27 occurred in 15 of the 17 patients.
Fixed drug eruptions Fixed drug eruptions have a predilection for the glans penis, and are commonly related to therapy with antibioticsâ€”especially tetracyclines[86,87] and sulphonamides. Other causes include salicylclates, phenacetin, phenolphthalein and some hypnotics, although there are case reports of other less common causative agents, for example, Mandrax. However, tetracycline induced eruptions may not recur on challenge with doxycycline. Most lesions will fade spontaneously without treatment, but may leave an area of residual hyperpigmentation. Occasionally treatment with topical, or rarely systemic steroids may be required.
Irritant and allergic balanitides Many balantides are non-specific and no aetiological agent can be found. It has been suggested that these are often due to irritation, particularly if symptoms are persistent or recurrent. In one study of patients with persistent or recurrent problems 72% were diagnosed with irritant balanitis, and this was associated with a history of atopy and more frequent genital washing with soap. Other series have found higher rates of infective agents,[5,17,35] although a large proportion of cases in one study remained undiagnosed. It is likely that irritation plays some part in other balantides. More severe reactions have been seen with topical agents, some of which may have been used for treatment. Dequalinium is known to cause a necrotic balanitis, while titanium (that was previously thought to be biologically inert) may cause a necrotic balanitis. Balanitis as an allergic reaction is very uncommon; rubber and its constituents are the most frequently described allergens,[91,92] although allergy to spermicidal lubricants are also well described.[91,92,93] There is a wide spectrum of clinical manifestations varying from balanitis to oedema of the whole penis extending to the groins. Treatment will depend on the severity of the reaction but patch testing and avoidance of the precipitant is required.
Many dermatological conditions may also have a prediliction for the male genitalia. Psoriasis, lichen planus and sebhorroeic dermatitis are common and evidence of involvement at other sites should be sought. Dermatitis aretfacta of the genitals has also been reported. Balanitis may occur with both Crohn's disease and ulcerative colitis. Many balantides prove difficult to diagnose and any condition which persists warrants further investigation. Penile biopsy is easy to perform and is useful in these cases. In one series 60 patients with unresponsive penile dermatoses underwent biopsy, of whom 26% had a non specific dermatitis, 23% wart virus infection, and 15% lichen sclerosus. The original clinical diagnosis was confirmed in 33% of cases and the biopsy was not diagnostic in only 3% of cases.
- Birley HDL, Walker MM, Luzzi Ga, et al. Clinical features and management of recurrent balanitis; association with recurrent washing. Genitourin Med 1993;69:400-3.
- Vohra S, Badlani G. Balanitis and and balanoposthitis. Urol Clin North Am 1992;19:143-7.
- Manian FA, Alford RH. Nosocomial infectious balanins in neutropenic patients. South Med J 1987;80:909-11.
- Waugh MA, Evans EGV, Nayyar KE, Fong R. Clotrimazole (Castren) in the treatment of candidal balanitis in men. Br J Venereal Dis 1978;54:184-6.
- Veller Fornase C, Calabro A, Miglietta A, Tarantello M, Biasinutto C, Peserico A. Mild balanoposthitis. Genitourin Med 1994;70:345-6.
- de Vincenzi I, Mertens T. Male Circumcision: a role in HIV prevention? AIDS 1994;8:153-60.
- Davidson F. Yeasts and circumcision in the male. Br J Venereal Dis 1977;53:121-3.
- Rodin P, Kolantor B. Carriage of yeasts on the penis. BMJ 1976;1:1223-4.
- Dockerty WG, Sonnex C. Candidal balano-posthitis: a study of diagnostic methods. Genitourin Med 1995;71:107-9.
- Waugh MA. Clinical presentation of clinical balanitisâ€”its differential diagnosis and treatment. Chemotherapy 1982; 28 (suppl 1):56-60.
- Oates JK. Sexually transmitted skin diseases. Br J Sex Med 1976;3:8-10.
- Kinghorn GR, Wooley PD. Single-dose fluconazole in the treatment of Candida albicans balanitis. Int J STD AIDS 1990;1:366-7.
- Smith EL. Pityriasis versicolor of the penis. Br J Venereal Dis 1978;54:441.
- Karim Nia A, Smith EL Pityriasis versicolor of the glans penis. Br J Venereal Dis 1979;55:230.
- Charkraborty AK Clinicopathological study of balanoposthitis in male. Indian J Dermatol 1982;27:105-8.
- Masfari AN, Kinghorn GR, Duerden BI. Anaerobes in genitourinary infection in men. Br J Venereal Dis 1983;59:255-9.
- Emach Gcee F, Willis AT, Phillips KD, Brazier JS. Anaerobic balanoposthitis. BMJ 1982;284:859-60.
- Corbus BC, Harris FG. Erosive and gangrenous balanitis. The fourth venereal disease. JAMA 1909;52:1474-7.
- Chapel T, Brown WJ, Jeffries C, Stewart JA. The microbiological flora of penile ulcerations. J Infect Dis 1978;137:50-6.
- Masfari AN, Kinghorn GR, Hafix S, Barton IG, Duerden BI, Anaerobic bacteria and herpes simplex virus in genital ulceration. Genitourin Med 1985;61:109-13.
- Duerden BI. Black pigmented gram-negative araerobes in genitourinary tract and pelvic infections. FEMS Immuno Med Microbiol 1993;6:223-8.
- Kinghorn GR, Jones DM, Chowdhury FH, Geary I. Balanoposthitis associated with gardnerella vaginalis infection in men. Br J Venereal Dis 1982;58:127-9.
- Karpovaskaya O. The role of Haemophilus vaginalis infection of the female genitalia. Akush Ginekol (Mosk) 1971; 47:33.
- Pheifer TA, Forsyth PS, Durfee MA, Pollock HM, Holmes KK. Non specific dermatitis. Role of Haemophilus vaginalis and treatment with Methronidazole. N Engl J Med 1978;298:1439-33.
- Dunkelberg WE, Woolvin SC. Haemophilus vaginalis relative to gonorrhoea and male urethritis. Mil Med 1963;128:1098-101.
- Bhargava RK, Thin RNT, Subpreputial carriage of aerobic microorganisms and balanitis. Br J Venereal Dis 1983; 59:191-3.
- Brook I. Balanitis by Group B beta-hemolytic streptococci. STD 1980; 7: 195-6.
- Wallin J. Porsgren A. Group B streptococci in venereal disease patients. Br J Venereal Dis 1975;51:401-4.
- Lucks Da, Venezio FR, Lakin CM. Balanitis caused by group B Streptococcus. J Urol 1986;135:1015.
- Kynazi NC, Costerberger CL. Group A beta-hemolytic streptococcal balanitis: it may be more common than you think. Pediatrics 1991;88:154-6.
- Deliyanni VA, Boniatsi LS, Photinou AS. Balanitis caused by Group A streptococcus in an 8 year old boy. Pediatr Infect Dis J 1989;8:61-2.
- Guerrero-vazquez J, Sebastian-Planes M, Olmedo-Sanlaureano S. Group A streptococcal proctitis and balanitis. Pediatr Infect Dis J 1990;9:223.
- Drusin LM, Wilkes BM, Gringrich RD. Streptococal pyoderma of the penis following fellatio. Br J Venereal Dis 1975;51:61-2.
- Pattman RS. Two unusual manifestations of infection with Staphylococcus aureus presenting to a clinic for sexually transmitted diseases. Br J Clin Pract 1983;37:28-9.
- Abdullah An, Drake SM, Wade AAH. Walzman M. Balanitis (Balanoposthitis) in patients attending a department of genitourinary medicine. Int J STD AIDS 1992;3:128-9.
- Petersen L, Momsen S, Palligaard G. Male genitourinary tuberculosis. Report of 12 cases and review of the literature. Scand J Urol Nephrol 1993;27:425-8.
- Stevanic DV. Papulonecrotic tuberculids of glans penis. Arch Dermatol 1958;78:760-1.
- Nishigori C. Taniguchi S, Hawakawa M, Imamura S. Penis tubercilides: papulonecrotic tuberculides on glans penis. Dermatologica 1986;172:93-7.
- Jeyakumar W, Ganesh R, Mohanram MS, Shanmugasundararsi A. Papulonecrotic tuberculids on glans penis: case report. Genitourin Med 1988:64:130-2.
- Chaudhury DS, Chaudhury M. A case report of gangrenous balanitis in progressive reaction in leprosy. Lepr Rev 1966;37:225-6.
- Kumar B, Sharma VK. Papulonecrotic tuberculides on glans penis. Dermatologica 1987;174:151-3.
- Michalowski R. Balano-posthites a Trichomonas. A propos de 16 observations. Ann Dermatol Venereol 1981;108;731-8.
- Thomas JA, Anthony AJ. Amerbiasis of the penis. Br J Urol 1976;48:269.
- Cooke RA, Rodrique RB. Amoebic balanitis. Med J Aust 1964;1:114:-6.
- Lejman K, Starzyki Z. Syphilic balanitis of Follman developing after appearance of the primary chancre: a case report. Br J Venereal Dis 1975;51:138-40.
- Piot P, Duncan M, van Dyck B, Baillard RC. Ulcerative balanitis associated with non-syphilitic spirochaetal infection. Genitourin Med 1986;62:44-6.
- Brams J, Pilot I, Davis DJ. Studies of fusiform bacilli and spirochaeties. J Infect Dis 1923;32:159-66.
- Peutherer JF, Smith IW, Robertson DHH. Necrotising balanitis due to a generalized primary infection with Herpes simplex virus type 2. Br J Venereal Dis J 1979;55:48-51.
- Powers RD, Rein MF, Hayden FG. Necrotizing balanitis due to herpes simplex type 1. JAMA 1982;248:215-6.
- Arcrumainayagam JT, Sumathipala AH, Smallman LA, Shamanesh M. Flat condylomata of the penis presenting as patchy balanoposthitis. Genitourin Med 1990;66:251-3.
- Birley HD, Luzzi GA Walker MM, Ryait B, Taylor-Robinson D, Renton AM. The association of human papillomavirus infection with balanoposthitis: a description of five cases with proposals for treatment. Int J STD AIDS 1994;5:139-41.
- Wilkstrom A, von Krogh G, Hedblad MA, Syrjanen S. Papillomavirus-associated balanoposthitis: a description of five cases with proposals for treatment. Int J STD AIDS 1994;5:139-41.
- Griffiths M, Penna LK, Tovey SJ. Aceto-white change of the glans penis associated with balanitis not human papillomavirus infection. Int J STD AIDS 1991;2:211-2.
- Stuhmer A. Balanitis xerotica obliterans (post-operationem) und ihre beizhunger zur ";Kraurosis glandis et praeputii penis" Arch Dermatol Syph 1928;156:613-23.
- Coldiron BM, Jacobson C. Common penile lesions. Urol Clin North Am 1988;15:671-85.
- Laymon CW, Freeman C. Relationship of balanitis xerotica obliterans to lichen sclerosus et atrophicus. Arch Dermatol Syph 1944;70;175-181.
- Laymon CW. Lichen sclerosus et atrophicus and related disorders. Arch Dermatol Syph 1951;64:620-7.
- Catterall RD, Oates JK Treatment of balanitis xerotica obliterans with hydrocortisone injections. Br J Venereal Dis 1962;38:75-7.
- Bainbridge DR, Whittaker RH, Shepheard BGF. Balanitis xerotica obliterans and urinary obstruction. Br J Urol 1971;43:487.
- Hatcourt CS, Higgins SP, Goorney BP. Recurrent bullous balanitis: an unusual presentation of balanitis xerotica obliterans. Int J STD AIDS 1994;5:58-9.
- Chalmers RJ, Burton PA, Bennet RF, Goring CC, Smith PJ. Lichen sclerosus et atrophicus. A common and distinctive cause of phimosis in boys. Arch Dermatol 1984;120:1025-7.
- Rickwood AM, Hemalatha V, Tatoya G, Salz L. Phimosis in boys. Br J Urol 1980;52:147-50.
- Braun-Falco O, Plewig G, Wolff HH, Winkelman RK, eds. Dermatology. Berlin: Springer-Verlag, 1991.p553.
- Bart RS, Kopf AW. Squamous cell carcinoma arising in balanitis xerotica obliterans. J Dermatol Surg Oncol 1978;4:556-8.
- Bingham JS. Carcinoma of the penis developing in lichen sclerosus et atrophicus. Br J Venereal Dis 1978;54:350-1.
- Poynter JH, Levy J. Balanitis xerotica obliterans: Effective treatment with topical and sublesional steroids. Br J Urol 1967;39:420.
- Mikhail GR. Cancers, precancers, and pseudocancers on the male genitalia: a review of clinical appearances, histopathology, and management. J Dermatol Surg Oncol 1980;6:1027.
- Castle WN, Wentzell JM, Schwartz BK, Clendenning WE, Selikowitz SM. Chronic balanitis owing to pemphigus vegetans. J Urol 1987; 137:289-91.
- Zoon JJ. Balanoposthite chronique circonscrite benigne a plasmocytes. Dermatologica 1952;105:1.
- Souteyrand P, Wong G, MacDonald DM. Zoon's balanitis (balanitis circumscipta plasmacellularis). Br J Dermatol 1981;105:195-9.
- Murray JG, Fletcher MS, Yates-Bell AJ, Pryor JP, Darby AJ, Packham DA. Plasma cell balanitis of Zoon. Br J Urol 1986;58:689-91.
- Montgomery D, ed. Dermatopathology. London: Harper and Row, 1967. Vol. 2: p988.
- Sonnex TS, Dawber RPR, Ryan TJ, Ralfs IG. Zoon's (plasma cell) balanitis: treatment by circumcision. Br J Dermatol 1982;105:585-8.
- Kumar B, Sharma R, Ragopalan M, Radothra BD. Plasma cell balanitis: clinical and histopathological features--response to circumcision. Genitourin Med 1995;71:32-4.
- Queyrat M. Erythroplasie du gland. Bull Soc Fr Dermatol Syphilgr 1911;22:378-82.
- Goetre DK, Elgart M, De Villez RL. Erythroplasia of Queyrat: treatment with topically applied fluorouacil. JAMA 1975;232:934.
- Sonnex TS, Ralfs IG, Delanza MP, et al. Treatment of erythroplasia of Queyrat with liquid nitrogen cryosurgery. Br J Dermatol 1982;106:581-4.
- Boon TA. Sapphire probe laser surgery for localized carcinoma of the penis. Eur J Surg Oncol 1988;14:193.
- Berstein G, Forgaard DM, Miller JE. Carcinoma in situ of the glans penis and distal urethra. J Dermatol Surg Oncol 1986;12:450.
- Lortat-Jacob E, Civatte J. Balanite pseudo-epitheliomateuse keratosique et micacee. Bull Soc Fr Derm Syphilgr 1961;68:164-7.
- Beljaards RC, VanDijk E, Hausman R. Is pseudoepitheliomatous, micaceous and keratotic balanitis synonymous with verrucous carcinoma? Br J Dermatol 1987;117:641-6.
- Read SI, Abell E. Pseudoepitheliomatous, keratotic balanitis. Arch Dermatol 1981;117:435-7.
- Keat A. Reiter's syndrome and reactive arthritis in perspective. N Engl J Med 1983;309;1606.
- Kaneva L, Kousa M, niemi K-M, Lassus A, Juvakoski T, Lauharanta J. Ultrahistopathology of balanitis circinata. Br J Venereal Dis 1982;58:188-95.
- Lassus A, Tiilikkainen A, Stubb S, reunala T, Johansson E. Circinate erosive balanitis and HL-A27. Acta Dermatol Venereol 1975;55:199-201.
- Csonka GW, Rosedale N, Walkden L. Balanitis due to fixed drug eruption associated with tetracyline therapy. Br J Venereal Dis 1971;47:42-47.
- Dodds PR, Chi TN. Balanitis as a fixed drug eruption to tetracyline. J Urol 1985;133:1044-5.
- Csoka GW. Balanitis due to fixed drug eruption. Br J Venereal Dis 1973;49:316-7.
- Coles RB, Wilkinson DS. Necrosis and dequalinium. I. Balanitis. Trans St John's Hosp Dermatol Soc 1966;51:46-8.
- Dundas SA, Laing RW. Titanium balanitis with phimosis. Dermatologica 1988;176:305-7.
- Hindson CT. Studies in contact dermatitis contraceptives. Trans St. John's Hosp Dermatol Soc 1966;51:1-9.
- Ridley CM. Contraception and the skin. Br J Fam Plann 1981;7:67-70.
- Van Ulsen J, Stoltz E, Van Joost TH, Guersen-Reitsima AM. Allergy to spermicidal lubicant in a contraceptive. Contact Dermatitis 1987;17:115-6.
- Finnerty EE. Dermatitis artefacta of the genitals. Cutis 1976;18:199-200.
- Wijesurenda CS, Singh G, Manuel ARG, Morris JA. Balanoposthitis: An unusual feature of Crohn's disease. Int J STD AIDS 1993;4:184.
- Lytde PH. Ulcerative colitis and balanoposthitis. Int J STD AIDS 1994;5:72-3.
- Arumainayagam JT, Sumathispala AHT. Value of performing biopsies in genitourinary clinics. Genitourin Med 1990;66:407.
- Hillman RB, Walker MM, Harris JRW, Taylor-Robinson D. Penile dermatoses: a clinical and histopathological study. Genitourin Med 1992;68:166-9.