THE CIRCUMCISION REFERENCE LIBRARY
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
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
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.
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)
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
Histological Non-specific Other All category dermatitis histology patients
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
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 series10,11 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.
Department of Genitourinary Medicine
H D L Birley
G A Luzzi
R Bell
D Taylor-Robinson
M Byrne
Department of Pathology
M M Walker
St. Mary's
Hospital Medical School
London W2 1NY
Division of Sexually Transmitted Diseases,
Clinical Research Centre
Harrow
Middlesex HA1 3UJ
D Taylor-Robinson
Academic
Department of Public Health
St. Mary's Hospital Medical School,
London
W2 1PG
A M Renton
Accepted for publication
18 May 1993.
http://www.cirp.org/library/disease/balanitis/birley/