BALANITIS
Inflammation of the glans penis is termed balanitis. Inflammation of the
preputial skin is referred to as balanoposthitis. Clinically, these conditions
usually coexist, with the surface of the glans and prepuce both swollen,
hyperemic, tender, and itchy. A yellow exudate and superficial ulcers or
denudation of the glans surface are characteristic of balanoposthitis. In
chronic balanitis, the glans epithelium becomes thickened and assumes a whitish
appearance (leukoplakia).
By far
the most frequent cause of simple balanitis is congenital or acquired phimosis
(see Plate 2-17). In infants, balanoposthitis results from retained
smegma, bacteria, and lack of hygiene associated with phimosis and dribbling
urine or moist diapers. In adults, urinary incontinence may play an etiologic
role. Seborrheic dermatitis, most commonly seen on the scalp, can also be found
on the glans penis. Superficial fungal infections from Candida albicans are
also common, especially in diabetics. Contact allergy from latex in condoms or
ingredients in skin care products must also be considered. Balanitis circinata
is a skin manifestation of Reiter syndrome, characterized by arthritis, urethritis,
and conjunctivitis. Generalized skin conditions such as lichen planus,
psoriasis, erythema multiforme, erythrasma due to Corynebacterium, and
erythema fixum are less common conditions that cause simple balanitis.
Pemphigus, a group of autoimmune blistering diseases of the skin, and scabies
usually produce distinctive lesions on the penile shaft rather than the glans
penis. Rarely, phimosis secondary to obstruction of the inguinal lymph nodes
from cancer, edema, or elephantiasis may also cause balanitis. Precancerous and
cancerous lesions of the glans and prepuce are shown in Plate
2-27.
Balanitis
xerotica obliterans, also termed lichen sclerosis, is a progressive form of
balanoposthitis that primarily affects the foreskin, leading to whitening and
loss of skin color, scarring, and phimosis. Involvement of the urethral meatus
can lead to irritation, burning, and stenosis and may require a meatoplasty in
cases of stricture. Long-term follow-up is needed to assess for recurrence.
Genital
herpes simplex virus 2, caused by a double-stranded RNA virus, is a relatively
common, venereally transmitted, painful, itching form of balanitis. Multiple
lesions develop as small red areas upon which rounded translucent vesicles
appear, containing clear, viral-rich, infectious fluid. After rupture of the
vesicles, small round ulcers with a reddish base remain and heal. The infection
usually recurs and is currently incurable.
Erosive
balanitis may be venereal, such as due to syphilis or chancroid, or nonvenereal
in origin, such as that due to histoplasmosis. Although unusual, anaerobic
balanoposthitis is a classic form of nonvenereal, erosive balanitis caused by
anaerobic gram-negative rods (genus Bacteroides). It is characterized by
intense inflammation and edema of the prepuce, superficial glans ulcers,
foulsmelling discharge, and bilateral inguinal lymphadenopathy. Infection tends
to be locally destructive with severe tenderness and can result in tissue
necrosis. The presence
of phimosis and suboptimal hygiene appear to be prerequisites for this
condition. The infection can be transmitted through sexual intercourse,
contamination by colonized saliva, or extension from the perirectal area. It
generally responds to the timely use of antibiotics and debridement if necessary.
Gangrenous
balanitis, in some cases the evolution of erosive balanoposthitis, is generally
caused by the same organisms. However, it progresses with such rapidity that an erosive stage
may be entirely absent. The ulcers are covered by gangrenous membranes that,
when debrided, reveal deep extension of the process into the glans and
preputial tissues. The ulcer bases are uneven yet have distinct borders
surrounded by inflamed tissue. Within a day, the foreskin and even the entire
glans and portions of the penile shaft can slough. Abscesses may also develop
that involve the scrotum and extend superiorly to the abdominal wall and
laterally to the thighs.
