Social Hygiene Handbook, Hong Kong.____________________________________________________________ BALANITIS AND OTHER GENITAL CONDITIONS Dr. K.W. CHOW An extract of: BALANITIS INTRODUCTION Balanitis is used to describe acute and chronic forms of the inflammation of the glans penis and prepuce owing to traumatic, irritant or infective. The condition should more properly be called balano-posthitis. Balanitis means inflammation of the glans and posthitis means that of the prepuce. AETIOLOGY According to the different aetiological causes, balanitis can be classified into various clinical varieties: 1. Irritant Poor hygiene, retained soap, detergent, retained smegma or inadequate drying may cause an irritant dermatitis. Contact dermatitis affects the shaft rather than the glans, except when medicament or contraceptives are involved. 2. Traumatic Frictional trauma and accidental wounds cause fissures, erosions or localized area of erythema and oedema. Postcoital frenal erosions are not uncommon. 3. Infective This is the common cause of balanitis. a. Candidal balanitis Candidal balanitis most frequently follows intercourse with an infective sexual partner. The pathogenicity of the yeast depends on the host factors and diabetes is the most important one. The clinical features include a non-purulent surface, a slightly scaling edge and satellite erode pustules. The groins may also be affected. Microscopy and culture confirm the diagnosis and should be taken from both partners and from the anal as well as the genital areas. Recurrent candidal balanitis causes fissuring of the prepuce, with fibrosis and sclerosis. b. Trichomonal balanitis This occurs more commonly in those with long prepuce. It presents as superficial or erosive balanitis. Phimosis may occur. More severe lesions of chancriform type or penile abscess are occasionally seen. c. Mycoplasma balanitis Balanitis may accompany mycoplasma urethritis, either as a primary infection or secondary to gonorrhoea. d. Chlamydial balanitis In men the most common manifestation is non-gonococcal urethritis but it may also present as non-specific irritant balanitis. 4. Premalignant, malignant or idiopathic In chronic unresolving 'balanitis', the following conditions should be excluded: a. Erythroplasia of Queyrat (Bowen's disease) b. Extramammary Paget's disease c. Plasma cell balanitis of Zoon d. Balanitis xerotica obliterans (BXO, Lichen sclerosus et atrophicus) e. Circinate balanitis in Reiter's disease f. Lichen planus g. Psoriasis TREATMENT Mild forms of balanitis respond to repeated cool bathing with potassium permanganate (1:8000) and the application of mild antibacterial creams, with or without weak corticosteroids. The underlying cause should be treated if possible. Specific remedies are available for candidal balanitis. Both partners should be treated concurrently. There is now large variety of effective anticandidal agents of the polyene or azole group. Ketoconazole, Itraconazole and fluconazole are the oral alternatives for severe cases. Cure rate is about 90 percent. Intestinal or urethral reservoir, and re-infection account for the 10% failure rate of refractory cases. Mycoplasma balanitis responds to tetracyclines in high dose. OTHER GENITAL CONDITIONS Patients who are worried about the possibility of venereal diseases may inspect the genitalia frequently. They may notice for the first time in their life certain conditions of no clinical significance and for which require only reassurance. 1. Penile pearls (syn. pearly penile papules, papillae of the coronal sulcus or glans penis, hirsuties papillaris penis, coronal papilla) These tiny swellings which are congenital anomalies may look like early acuminate warts but are arranged in rows around the coronal sulcus or scattered over the glans penis. They are merely hypertrophic papillae with normal epidermal covering. They have no clinical significance and it is important not to misdiagnose them as genital warts. 2. Tysons glands These are secretory glands which are symmetrically located on either side of the frenulum. They appear as small para-frenal papules which can easily be mistaken by anxious patients as genital warts. 3. Fordyce Spots This condition arises from the presence of ectopic sebaceous glands. It may be found under the prepuce and on the vulva. The lesion appear as multiple small, white or yellow spots in submucosa. 4. Lymphocele (syn. sclerosing lymphadenitis, benign transient lymphangiectasis) In this condition the lymphatics in or near the coronal sulcus may become temporarily blocked and appear as worm-liked translucent masses of cartilage-like hardness. Some cases may follow prolonged or frequent intercourse or are associated with a genital lesion. However in the largest series reported, the majority were unexplained although the patients had coitus. The condition resolves within a few weeks and no treatment is necessary.
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