Clinical Features and management of recurrent
balanitis; association with atopy and genital
washing

H D L Birley, M M Walker, G A Luzzi, R Bell, D Taylor-Robinson, M Byrne,
A M Renton

Abstract
Objective - To evaluate clinical features and diagnostic investigations in patients with recurrent or unresponsive balanitis in order to institute rational management.

Design - Forty three patients presenting to a genitourinary medicine clinic with recurrent or persistent balanitis were studied. All patients were asked whether they had a history of atopic illness and about their practice of genital washing. All patients were investigated by taking a swab specimen from the preputial area for bacterial and viral culture and 30 underwent biopsy of the affected skin. Follow up was between three and six months.

Setting - Outpatient genitourinary medicine clinic, St. Mary's Hospital, London, UK

Results - In 31 (72%) of the patients a diagnosis of irritant dermatitis was made. In comparison with the remaining patients, they had a greater lifetime incidence of atopic illness and more frequent daily washing of the genitals with soap. For 28 (90%) of these patients, use of emollient creams and restriction of soap washing alone controlled symptoms satisfactorily. For the remaining 12 patients, a variety of diagnoses were made. Biopsy proved a well tolerated and diagnostic investigation, but the isolation of microbial pathogens from preputial swabs was irrelevant to management.

Conclusion - A history of atopic illness and of the practice of penile washing are important aspects in the evaluation of patients with recurrent balanitis. Biopsy is an important investigation in the condition when it does not seem to be caused by irritant dermatitis.

(Genitourin Med 1993;69:400-403)

[CIRP Note: Atopy is a genitically determined hypersensitivity to environmental allergens. --Stedman's Medical Dictionary]

Introduction
Balanitis is a common condition. At the Jefferiss Wing walk-in Genitourinary Medicine clinic at St. Mary's Hospital, Paddington there were 2006 male attendances for conditions requiring treatment in a 3 month period in 1992. Of these, 234 (11%) were diagnosed as balanitis. Furthermore, in a review of 100 men presenting consecutively at this clinic, 32 had been treated for balanitis at least twice in the previous six months. Nevertheless, despite its frequency, this condition often receives scant attention. In some cases, there is a clearly defined cause for balanitis, for example a generalized skin condition for which balanitis is a component.^1,2 In many cases, however, the cause is assumed to be fungal and the patient treated with repeated courses of topical antifungal creams. Our aim was to study patients with recurrent or stubborn problems in which a cause had not been identified in an attempt to establish a firm diagnosis and institute rational management.

PATIENTS AND METHODS.
Forty-three consecutive patients who had had two or more episodes of itching or soreness of the preputial or glans area within the previous six months, or who had not responded to topical antifungal creams were recruited into the study. Local ethical committee approval had been granted and signed consent was obtained from the patients. No topical treatment was given for at least two weeks before assessment. Time was allocated for careful history taking, including a personal or family history of atopic disease (eczema, hayfever or asthma) and information about the patient's usual habit of genital washing. Patients were examined for the presence of rashes both within and without the anogenital area and swabs were taken from the preputial sac for bacterial, fungal, and herpes simplex virus (HSV) culture by routine diagnostic methods. All patients were screened serologically for syphilis (VDRI and TPHA), for gonorrhoea by gram stain and culture of an urethral swab and for the presence of a purulent urethral discharge (defined as more than 5 neutrophils per high-power field on microscopy of an urethral smear). A 2 mm. pinch biopsy specimen was taken from an inflamed area of the prepuce or glans of 30 of the patients using a technique described previously.³ Apart from five patients, whose biopsy sties took up to four weeks to heal completely, the remainder had healed within two weeks, and there were no complications. Biopsy specimens were fixed in formalin, processed routinely and sections stained by haematoxylin and PAS were examined by a single histopathologist (MMW). All patients were reviewed monthly in the clinic for between three and six months and they were encouraged to self-refer in case of relapse or new symptoms.

Results
CHARACTERISTICS OF PATIENTS AND PREVIOUS TREATMENT
Forty-three men, mean age 35 years (range 20-77 years), of whom five were homosexual, were seen with balanitis that had been present for a mean period of 18 months (range 1-96 months). Sixteen of the men had previously received topical imidazole topical steroid creams and eight topical preparations of combined steroid and imidazole. No patient had serological evidence of syphilis or a positive culture of microscopy for gonorrhoea. Five patients had microscopic evidence of a urethral discharge. All had florid balanitis at the time and none had detectable urethral pus on repeat testing two weeks later when the balanitis had settled. No patient had a history or signs of arthritis or conjunctivitis suggestive of Reiter's syndrome.

HISTOLOGICAL DIAGNOSES
The results of histological analysis of biopsy specimens from 30 patients are shown in table 1. In specimens from 18 patients, there was a patchy, principally perivascular chronic inflammatory infiltrate in the dermis, often with oedema and spongiosis of the epidermis consistent with a diagnosis of non-specific dermatitis (NSD).⁴ Of the specimens from the remaining 12 patients, four had histological evidence of human papillomavirus (HPV) infection, including hyper-keratosis and para-keratosis as well as koilocytosis; additional dyplastic changes were observed in two of these (PIN1 and PIN2). A variety of other diagnoses based on histological changes, were ascribed to the remaining eight patients.

Table 1. Histological features of biopsy specimens

Histological features                                   No of
                                                        patients

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Dermatitis: non specific                                  18
Dermatitis: specific      Lichen sclerosus                 2
                          Lichen planus                    1
                          Plama cell balanitis             1
                          Dermatitis artefacta             2
Dermatosis: infective     Post scabetic                    1
                          Candida                          1
                          Wart virus                       2
                          Wart virus with dysplasia        2
Total                                                     30

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MICROBIOLOGICAL FINDINGS
The results of the microbiological investigations are shown in table 2. Organisms which are usually not found in the normal skin flora were cultured from some of the preputial swabs. Thus, various streptococci were isolated from three patients with a histological diagnoses of NSD and Staphyloccus aureus with herpes simplex virus from the fourth NSD patient. Candida albicans was recovered from the swab of the patient whose balanitis was ascribed to this organism and Pseudomonas aeruginosa and herpes simplex virus from the patient with plasma cell balanitis. No organisms were cultured from the other patients who were biopsied or from the unbiopsied group.

Table 2 Recovery of micro-organisms from preputial swabs
in relation to histological diagnosis.

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Micro-organism              Number of        Histological
                            patients         diagnosis
BACTERIA
Group A Streptococcus           1            Non-specific
                                             dermatitis (NSD
Group B Streptococcus           1            NSD
Streptococcus milleri           1            NSD
Staphylococcus aureus
and Herpes simplex              1            NSD
Pseudomonas aeruginosa
and Herpes simplex              1            NSD
FUNGI
Candida albicans                1            Candidal balanitis
VIRUSES
Herpes Simplex                  2            NSD (1)
                                             Plasma cell
                                             balanitis (1)

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RELATION BETWEEN HISTOLOGICAL DIAGNOSIS AND CLINICAL FEATURES
Patients with NSD. Observations on 18 patients with a histological diagnosis of NSD are shown in table 3. Of these, 12 (67%) had a history of atopy, a significantly greater proportion than noted for patients with other histological diagnoses (p<0.02, Fisher's exact test). In all but one of the former group, there was a history of frequent genital washing with soap or shower gel and the mean number of daily washings was larger in this group than in the other patients. In addition, 11 patients had an eczematous rash elsewhere on the body. Six (33%) were circumcised. In 14 of the patients, symptoms fluctuated with an onset within 24 hours. None of the other patients biopsied gave a history of fluctuating symptoms. Five patients ascribed relapses to sexual activity but had also increased their genital washing after intercourse.

Table 3. Relation between histological diagnosis and clinical features

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Histological                   Non-specific  Other       All
category                       dermatitis    histology   patients

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Number of patients             18            12          43

Mean age (years)               36            33          35
 (Range)                       (24-60)       (27-77)     (20-77)

Number with a                  12            2           23
history of atopy (%)           (67)          (17)        (53)

Mean number                    2.7           1.2         1.6
of washes/day
(range)                        (1-7)         (1-2        (1-7)

Number circumcised             6             2           10

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Patients with other histological diagnoses. In the remaining 12 patients who were subjected to biopsy, the histological examination provided a specific diagnosis (table 1). Although the lower lifetime incidence of atopy and lower frequency of genital washing (table 3) helped to distinguish these patients from those with NSD, the clinical appearance of the rash was often not pathognomonic and other investigations, particularly histological examination of the biopsy specimen, were important in making the correct diagnosis.

For example, in the single patient who had a proven diagnosis of candidal infection, C. albicans was cultured from the sub-preputial swab specimen and fungal hyphae were visible in the superficial epidermis of the biopsied skin, and in addition, glycosuria and a random blood glucose of 15 mM were found; the patient had previously unsuspected diabetes mellitus. In some cases, histological examination of the biopsy specimen helped to elicit previously undisclosed details of the history. Thus, the two patients with dermatitis artefacta admitted to debrading the glans only after being told that the the result of examining the biopsy specimen suggested this.

Management of patients
Management of patients with NSD. Patients with a histological diagnosis of NSD were advised to restrict use of soap and were prescribed emollient cream (E45 cream; Crookes products, UK) for use twice daily. This completely prevented further episodes of balanitis in all but three of the patients who responded to topical hydrocortisone cream 1% applied three times daily for one week. Two patients needed a repeat course of topical steroid during the period of followup.

In view of the success of this regimen, and the emergence of clinical recognition of irritant dermatitis,⁵ a further 13 patients who attended the clinic with a similar history and rash were managed without recourse to biopsy. Putative pathogenic organisms were not isolated from the preputial sac swabs of any of these patients and all of them responded satisfactorily.

Management of patients with other histological diagnoses. Management of those patients with histological features other than those of NSD was often critically dependent upon the histological features of the biopsy specimen. The patient with candida balanitis was treated with topical imidazole cream (Clotrimazole 1%, "Canesten"; Bayer, UK) and was referred for further management of his diabetes. The two patients with dermatitis artefacta were cured promptly by a one week course of moderate potency steroid cream (Clobetasone butyrate 0.05%, "Eumovate", Glaxo, U. K.) and instructions to discontinue abrasion. The patient with plasma cell balanitis had been treated previously with oral anti-viral medication (acyclovir 200 mg. five times a day for five days). and topical neomycin ointment in view of the isolation of HSV and pseudomonas but showed no improvement. Both this patient and the patient with lichen sclerosis were referred for circumcision with great improvement. Both the patient with lichen planus and the patient with post-scabetic dermatitis improved over four weeks with an anti-pruritic cream (Crotamiton 10%, `Eurax'; Ciba Consumer, UK).

The two patients with HPV-related changes and the patient with PIN1 on biopsy were treated with E45 cream. Although the patients showed no immediate relief, the symptoms and signs of inflammation resolved gradually over the period of follow-up. The patient with PIN2 had small discrete areas of patchy inflammatory change and these were ablated with diathermy with resolution of symptoms. No follow-up biopsies have been performed on the normal appearing skin.

Discussion
The 43 patients in this study were a consecutive series and are representative of the patients attending this clinic with the problem of chronic or recurrent balanitis. Our observations indicate that this entity has multiple causes including metazoon, fungal and viral infections together with premalignancy. However, irritant dermatitis was found to be the most common cause. The ability to indentify the cause in a particular case aids rational management considerably and biopsy of the affected skin proved an important diagnostic investigation for our patients. Biopsy was also a well tolerated procedure in this as in previous series.^3,6 Although patients initially were often unsure about undergoing biopsy, many felt reassured by the histological diagnosis that it provided.

A history of fluctuating episodes, with a rapid onset, as well as that of atopy and of zealous washing were predictive of a histological diagnosis of NSD. The proportion of NSD patients with a history of atopy (67%) was much larger than that in the general population.⁷ It is possible that the balanitis was due to hypersensitivity to a specific allergen,⁸ but we could ascribe it to nothing other than frequent soap washing. Dermatological and generalised sensitivity to allergens encountered during sexual activity are well described⁹ but in this series, washing after sexual intercourse could easily have explained the association.

Bacterial pathogens have been implicated as a cause of balanitis in previous series^10,11 and they could act as allergens, but in our patients it is far from clear whether the isolates from preputial swabs were involved in the inflammatory process or were merely incidental to it. The latter seems likely since although bacterial pathogens were isolated from four of the 18 patients with a diagnosis of NSD, recovery swiftly followed the use of emollient creams only and no specific further treatment was required.

Circinate balanitis is associated with Reiter's sydrome but no biopsy specimen had histological features to suggest this diagnosis and no patient had arthritis or conjunctivitis. Five patients had more than five pus cells seen in a high power field of an urethral smear which is usually taken as evidence of urethritis. All of these patients had florid balanitis which resolved after two weeks of treatment with an emollient cream and none had pus cells on a further urethral smear taken at this time. Because none of these patients was treated with antibiotics, it is unlikely that any had an infection such as chlamydial urethritis. Instead the pus cells seen in the first smear were probably due to contamination from the acute balanitis.

Circumcision, so commonly recommended in children with recurrent balanitis, might be of benefit in a patient whose balanitis relapses despite these measures,¹² and remains the principal treatment for specific conditions such as lichen sclerosus and plasma cell balanitis.¹³ However, in our series, six out of the 18 patients with NSD had been circumcised so the condition seems not to to confined to circumcised men.

Dr. Birley is supported by a grant from the North-West Thames Regional Health Authority.

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