Balanitis

Introduction

Balanitis is an inflammation of the glans of the penis, though it is sometimes used (incorrectly) to describe any infection of the glans or foreskin. Posthitis is an infection of the foreskin, and obviously occurs only in uncircumcised males. When both glans and foreskin are affected, the condition is known as balanoposthitis. It is thought to occur in 3-4% of boys[6], and upto 11% of adult men[1]. It is much more common in diabetics. 35% of diabetic men may suffer from balanitis[32,1]. It is very rare in young babies (0.002%), and may be a rare complication of circumcision[35].

Males with balanitis often present symptoms of pain or tenderness, edema (swelling), discharge, and ulceration and/or plaques. Phimosis is often co-morbid with balanitis, and can be caused by it.

Balanitis may be caused by irritation, trauma, or most commonly, infection[30].

Infection is the most common cause, though irritation is often a contributing factor.[7] Candida is the most common cause of infection. Streptococcus infection may be more common than is recognised[9], and occurs only in uncircumcised males[33].

Irritation due to smegma is common[7,30]. Retained soap is another common cause of irritation[7,27,30]. Care must be taken to rinse and dry thoroughly after washing[7], though washing too frequently may itself be a factor[27].

Plasma cell balanitis, also known as Zoon's balanitis, is characterized by a red-orange plaque on the glans or foreskin[8]. It usually occurs in middle-aged to elderly uncircumcised men[8], and may be confused with erythroplasia of Queyrat (a form of penile cancer)[7,8]. In some cases, cancer has developed after Zoon's balanitis[17,19], suggesting that long-term irritation by balanitis might be one cause[17].

Protective effect of circumcision

Herzog and Alvarez[2] demonstrated that uncircumcised boys had approximately twice the risk of developing balanitis or irritation (irritation is itself a form of balanitis). A later study by Fergusson et al.[3] confirmed this finding.

The protective effect may be greater in adulthood. In a cross-sectional study of 398 patients, Fakjian et al.[1] reported that balanitis occurred more than five times as often in uncircumcised men than in circumcised men. Another study by Mallon et al.[5] provided supportive evidence for this.

Mycobacterium smegmatis has been implicated in the formation of Zoon's balanitis[34].

Dissenting views

One study, by Van Howe[4], suggested that circumcised boys were at greater risk of developing balanitis, though his study was limited by the small number of uncircumcised males in his sample (only 36 of the 468 in total were uncircumcised).

Table 1: Summary of comparative findings (studies with available data)

Study	Balanitis, Circumcised %	Balanitis, Uncircumcised %	Relative risk for Circumcised	Notes
Fakjian[1]	2.3	12.5	0.2	398 adults
Herzog[2]	2.9	5.9	0.5	545 children, 4 months - 12 years
Herzog (Irritation)[2]	1.1	3.6	0.3	545 children, 4 months - 12 years
Fergusson[3]	7.6	14.4	0.5	1,265 children, 0-8 years
Wiswell[35]	0.002	0	-	136,086 infants, < 1 month of age

Treatment

Circumcision is recommended for recurrent attacks of balanitis[6]. It is very effective for treating Zoon's balanitis[10,18,22,23,24], and is the preferred treatment[8].

Zoon's balanitis has been treated by laser[11,13,14,]. This is not always successful[13].

Conclusions

Uncircumcised males are 2-5 times as likely to develop balanitis.

References

1. Fakjian N, Hunter S, Cole GW, Miller J. An argument for circumcision: prevention of balanitis in the adult. Arch Dermatol. 1990 Aug; 126: 1046-1047
2. Herzog LW, Alvarez SR. The frequency of foreskin problems in uncircumcised children. Am J Dis Child. 1986; 140: 254-256
3. Fergusson DM, Lawton JM, Shannon FT. Neonatal circumcision and penile problems: an 8-year longitudinal study. Pediatrics. 1988; 81(4): 537-41.
4. Van Howe RS. Variability in penile appearance and penile findings: a prospective study. Br J Urol 1997; 80: 776-782.
5. Mallon E, Hawkins D, Dinneen M, Francics N, Fearfield L, Newson R, Bunker C. Circumcision and genital dermatoses. Arch Dermatol. 2000 Mar; 136(3): 350-4.
6. Escala JM, Rickwood AM. Balanitis. Br J Urol. 1989 Feb; 63(2): 196-7.
7. Edwards S. Balanitis and balanoposthitis: a review. Genitourin Med. 1996 Jun; 72(3): 155-9.
8. Buechner SA. Common skin disorders of the penis. BJU Int 2002 Sep; 90(5): 498-506
9. Kyriazi NC, Costenbader CL. Group A beta-hemolytic streptococcal balanitis: it may be more common than you think. Pediatrics. 1991; 88(1): 154-156.
10. Kumar B, Sharma R, Rajagopalan M, Radotra BD. Plasma cell balanitis: clinical and histological features: response to circumcision. Genitourin Med 1995; 71: 32-4.
11. Baldwin HE, Geronemus RG. The treatment of Zoon's balanitis with the carbon dioxide laser. J Dermatol Surg Oncol 1989; 15(5): 491-4.
12. Barber NJ, Chappell B, Carter PG, Britton JP. Is preputioplasty effective and acceptable? J R Soc Med. 2003 Sep; 96(9): 452-3.
13. Retamar RA, Kien MC, Chouela EN. Zoon's balanitis: presentation of 15 patients, five treated with a carbon dioxide laser. Int J Dermatol. 2003 Apr; 42(4): 305-7.
14. Albertini JG, Holck DE, Farley MF. Zoon's balanitis treated with Erbium:YAG laser ablation. Lasers Surg Med. 2002; 30(2): 123-6.
15. Ashfield JE, Nickel KR, Siemens DR, MacNeily AE, Nickel JC. Treatment of phimosis with topical steroids in 194 children. J Urol. 2003 Mar; 169(3): 1106-8.
16. Tang A, David N, Horton LW. Plasma cell balanitis of Zoon: response to Trimovate cream. Int J STD AIDS. 2001 Feb; 12(2): 75-8.
17. Davis-Daneshfar A, Trueb RM. Bowen's disease of the glans penis (erythroplasia of Queyrat) in plasma cell balanitis. Cutis. 2000 Jun; 65(6): 395-8.
18. Pellice i Vilalta C, Casalots i Casado J, Cosme i Jimenez MA. Zoon's balanoposthitis. A preliminary note. Arch Esp Urol. 1999 Jan-Feb; 52(1): 69-72.
19. Querol Nasarre I, Cordoba Iturriagagoitia A, Castillo Jimeno JM, Ripa Saldias L, Monzon Munoz FJ. Keratotic pseudoepitheliomatous and micaceous balanitis. Arch Esp Urol. 1998 Oct; 51(8): 824-6.
20. Altmeyer P, Kastner U, Luther H. Balanitis/balanoposthitis chronica circumscripta benigna plasmacellularis--entity or fiction? Hautarzt. 1998 Jul; 49(7): 552-5.
21. Davis DA, Cohen PR. Balanitis circumscripta plasmacellularis. J Urol. 1995 Feb; 153(2): 424-6.
22. Jolly BB, Krishnamurty S, Vaidyanathan S. Zoon's balanitis. Urol Int. 1993; 50(3): 182-4.
23. Murray WJ, Fletcher MS, Yates-Bell AJ, Pryor JP, Darby AJ, Packham DA. Plasma cell balinitis of Zoon. Br J Urol. 1986 Dec; 58(6): 689-91.
24. Ferrandiz C, Ribera M. Zoon's balanitis treated by circumcision. J Dermatol Surg Oncol. 1984 Aug; 10(8): 622-5.
25. Vaughan ED Jr, Alfert HJ, Gillenwater JY. Obstructive uropathy secondary to phimosis and balanoposthitis. Am J Dis Child. 1970 Jul; 120(1): 72-3.
26. Porter WM, Bunker CB. The dysfunctional foreskin. Int J STD AIDS. 2001 Apr; 12(4): 216-20.
27. Birley HD, Walker MM, Luzzi GA, Bell R, Taylor-Robinson D, Byrne M, Renton AM. Clinical features and management of recurrent balanitis; association with atopy and genital washing. Genitourin Med. 1993 Oct; 69(5): 400-3.
28. Thornton GF. Infection and diabetes: symposium on diabetes. Med Clin North Am. 1971; 55: 931-936
29. Murdock MI, Selikowitz SM. Diabetes related need for circumcision. Urology. 1974; 4: 60-62
30. Taylor PK, Rodin P. Herpes genitalis and circumcision. Br J Ven Dis. 1975; 51: 274-277
31. Au TS, Yeung KH. Balanitis, Bacterial Vaginosis and other genital conditions. In: Lo Kuen-kong, Chong Lai-yin, Tang Yuk-Ming, eds., Handbook of Dermatology and Venerology (Social Hygiene Handbook, 2nd Ed.) Hong Kong: Social Hygiene Service, Department of Health, 1997) (ISBN 962 3340303).
32. Kohn FM, Pflieger-Bruss S, Schill WB. Penile skin diseases. Andrologia. 1999;31 Suppl 1: 3-11.
33. Orden B, Martin R, Franco A, Ibanez G, Mendez E. Balanitis caused by group A beta-hemolytic streptococci. Pediatr Infect Dis J. 1996 Oct;15(10):920-1.
34. English JC, Laws RA, Keough GC, Wilde JL, Foley JP, Elston DM. Dermatoses of the glans penis and prepuce. J Am Acad Dermatol. 1997; 37: 1-24.
35. Wiswell TE, Geschke DW. Risks from circumcision during the first month of life compared with those for uncircumcised boys. Pediatrics. 1989 Jun; 83(6): 1011-1015
36. CEG. National guideline for the management of balanitis. Sexually Transmitted Infections 75(Suppl 1), S85-S88