Inflammation of the glans penis (balanitis) and of the prepuce (posthitis) usually occur together.
16.1 IRRITANT BALANOPOSTHITIS
Very common and usually the result of poor hygiene. An accumulation of smegma may be visible (Figure 16.1). Advise gentle bathing twice daily with plain or slightly salty water followed by application of a barrier cream (e.g. aqueous cream).
Usually presents as a diffuse erythema with numerous scattered small, red, slightly "eroded" spots (Figure 16.2), although an erosive balanitis has been reported.
16.1.2 BACTERIAL INFECTION
Anaerobic bacteria and group B streptococci occasionally cause a balanoposthitis (Figure 16.3). In the early stages of infection, gentle bathing followed by a barrier cream may be sufficient treatment.
Seborrheic dermatitis and contact dermatitis may present on the penis. Ask about other skin problems (e.g. affecting the scalp or face) and whether there is a history of allergy. Treat initially with hydrocortisone cream. If there is secondary infection, consider using a combined steroidal/antibacterial/antifungal preparation.
16.2 LESS COMMON CAUSES OF BALANOPOSTHITIS
16.2.1 Circinate Balanitis
Associated with Reiter's syndrome or, more frequently, with the incomplete syndrome (i.e. reactive arthritis with or without urethritis or conjunctivitis) (Figure 16.4).
Figure 16.1. Irritant posthitis - smegma present
Figure 16.2. Penile candidiasis
Figure 16.3. Streptococcal balanoposthitis
Figure 16.4. Circinate balanitis
Figure 16.5. Lichen planus
16.2.2 Lichen Planus
Usually presents with well-demarcated red-purplish lesions and may be confused with flat warts or psoriasis (Figure 16.5).
Genital lesions frequently lose the classical silvery scale and present as erythematous plaques (Figure 16.6).
16.2.4 Lichen Sclerosus
Areas of erythema with whitened, atrophic patches are the typical features (Figure 16.7). Adhesions may occur between the glans penis and the prepuce and long-standing cases may progress to phimosis. Perimeatal disease leads to narrowing of the urethral meatus (Figure 16.8). Treat initially with a potent topical steroid (e.g. clobetasol propionate) and then slowly "wean down" according to clinical response. Daily application for 4-weeks and then 2-3 times weekly for a further 2 months is a reasonable approach with review at 3 months. As some patients are hesitant to apply steroids to their genitalia, it is important to explain the importance of this treatment and provide reassurance that long-term application is safe under clinical supervision. Preputial tightening secondary to lichen sclerosus can be dramatically improved with topical steroids and may obviate the need for circumcision. Long-term follow-up is recommended because of the small risk of developing squamous cell carcinoma.
Figure 16.6. Psoriasis
Figure 16.7. Lichen sclerosus - note early adhesions between the prepuce and glans
Figure 16.8. Lichen sclerosus - atrophic changes and narrowing of the meatus
16.2.5 Human Papillomavirus Infection
A patchy balanoposthitis may predate the appearance of classical condylomata acuminata (genital warts).
Penile intraepithelial neoplasia (frequently caused by HPV type 16) may present as mildly erythematous papules (Figure 16.9).
Figure 16.9. Penile intraepithelial neoplasia (PIN)
16.2.6 Fixed Drug Eruptions
Although many drugs have the potential to cause a fixed drug eruption, it is more commonly seen with tetracyclines, trimethoprim, sulphonamides, non-steroidal anti-inflammatories, paracetamol, and salicylates. Lesions may first appear as a patch of erythema or a small blister and can rapidly progress to produce large areas of ulceration (Figure 16.10). Secondary infection can occur and treatment should include gentle bathing with salty water and, in some cases, a mild anti-inflammatory plus antibacterial cream. Oral prednisolone is very occasionally required for the more severe and extensive cases.
16.2.7 Zoon’s Balanitis (Plasma Cell Balanitis)
An uncommon condition seen mostly in middle-aged and elderly men. The lesions present as flat, moist, red, shiny plaques affecting the glans and mucosa of the prepuce (Figure 16.11). Irritation is common. Although circumcision is a recommended treatment, some cases do respond to aeration and topical moderate-strength steroids, particularly those preparations containing an antibacterial agent.
16.2.8 Erythroplasia of Queyrat
An uncommon condition now falling under the diagnostic category of "penile intraepithelial neoplasia" (PIN). Erythroplasia is seen almost exclusively in uncircumcised men and lesions appear as well-demarcated shiny, red, velvety plaques. Malignant change is well documented.
Figure 16.10. Fixed drug eruption
Figure 16.11. Zoon's balanitis
16.2.9 Other Penile and Scrotal Rashes
22.214.171.124 Kaposi’s Sarcoma
Kaposi's sarcoma is seen mostly in patients with HIV infection in the UK and is caused by human herpes virus type 8. Lesions are initially flat and dusky red and may appear on the glans penis or shaft.
These small lesions usually affect the scrotum rather than the penis and appear as tiny, often multiple, bright red vascular spots. They may increase in number and size with age and are harmless.
126.96.36.199 Melanocytic Naevi
These may appear on the penis or scrotum and have the same characteristics as naevi elsewhere on the body.
16.3 GENERAL ADVICE FOR PATIENTS WITH BALANOPOSTHITIS
Aeration is helpful for most causes of balanitis but can sometimes be difficult to achieve. Keeping the foreskin retracted for an hour or so each evening and allowing a good circulation of air, perhaps under a dressing gown or nightshirt for social acceptability, is worth trying. A combined topical steroid and antibacterial cream, if indicated, can then be applied and the foreskin pulled back over the glans. it is unnecessary to use large amounts of cream and patients should be advised accordingly.
Gentle bathing with salty water is often soothing, particularly for moist lesions. The area can then be dried with a hair dryer on cool setting.