Sexually Transmissible Infections in Clinical Practice

12. A Man with a Red, Itchy Penis

Alexander McMillan1, 2  

(1)

Department of Genitourinary Medicine, NHS Lothian, Edinburgh Royal Infirmary, Edinburgh, Uk

(2)

University of Edinburgh, Edinburgh, Uk

Alexander McMillanFormerly, Consultant Physician, part-time Senior Lecturer

Email: a.amcmm@btinternet.com

Abstract

Michel, a 19-year-old student, attends a Sexual Health clinic with a 2-day history of having an itchy red penis. He is otherwise well, and he is not receiving any medication. There have not been previous episodes of genital inflammation. His first sexual intercourse had been 3 days previously with a young woman whom he had met at a club. He used a condom only toward the end of vaginal intercourse.

Michel, a 19-year-old student, attends a Sexual Health clinic with a 2-day history of having an itchy red penis. He is otherwise well, and he is not receiving any medication. There have not been previous episodes of genital inflammation. His first sexual intercourse had been 3 days previously with a young woman whom he had met at a club. He used a condom only toward the end of vaginal intercourse.

There is erythema of the glans penis and the mucosal surface of the prepuce which is mildly edematous with minor fissuring (Fig12.1 ).

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12.1 What Is This Condition, and What Are Possible Causes?

This is balanoposthitis,1 a term encompassing a variety of conditions, the appearance of some of which is characteristic.

A common predisposing factor for balanoposthitis is poor hygiene with the accumulation of smegma in the preputial sac. Irritants such as antiseptics, spermicidal lubricants, soap, or shower gels may cause balanoposthitis.

Bacteria, yeasts, or Trichomonas vaginalis are recognized infective causes. Edema of the glans and prepuce from such infective causes may result in phimosis, with secondary anaerobic infection producing a malodorous subpreputial discharge sometimes with painful, tender ulceration, and inguinal lymphadenitis. Aerobic infections such as Group B β-hemolytic streptococci and Group A hemolytic streptococci can also cause balanoposthitis.

Characteristic symptoms of candidiasis are soreness and itching of the penis, accompanied sometimes by material collecting under the prepuce. On examination there may be a balanoposthitis with superficial erosions and sometimes eroded maculopapular lesions and preputial edema. There may be fissuring of the prepuce, particularly at its orifice. On occasions there may be a balanoposthitis with erosions without detectable yeasts appearing 6–24 h after intercourse with a partner who has vaginal candidiasis. Such a balanitis may be due to sensitivity to yeast-containing vaginal discharge.

Balanoposthitis, which may rarely be ulcerative, can be caused by Trichomonas vaginalis. Herpes simplex virus may be isolated from erosions, and rarely, causes a necrotizing balanitis. Chronic or recurrent balanoposthitis has been associated with human papillomavirus infection.

Balanoposthitis may be a component of a generalized skin disease such as fixed drug eruption or erythema multiforme exudativum and may be associated with diabetes or debilitating disease, particularly in the elderly. Circinate balanitis (psoriasis) may be a feature of sexually acquired reactive arthritis (see Case 24).

All forms of balanitis may become chronic or relapse frequently, particularly in the elderly, when fibrotic changes are those seen in lichen sclerosus.

Plasma cell balanitis (of Zoon) (Fig. 12.2) is a chronic condition diagnosed in middle-aged or elderly uncircumcised men. There is a localized shiny moist erythematous plaque on the glans penis. Biopsy shows a dense plasma cell infiltration of the dermis.

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Figure 12.2.

Plasma cell balanitis.

12.2 What Investigations Would You Undertake in This Case?

Bacterial culture can exclude an infective etiology and is sometimes diagnostic. It is also helpful to look for Candida species. As balanoposthitis, particularly candidal, can be the presenting feature of diabetes mellitus, the urine should always be tested for glucose. Culture of herpes simplex virus from ulcers or erosions should be attempted. When trichomonal infection is suspected, material from the subpreputial sac should be examined microscopically, and, if available, by culture or a nucleic acid amplification assay.

Tests for sexually transmitted infections should be undertaken after the appropriate interval (see Case 1).

Gram-smear microscopy of material collected from the subpreputial sac shows fungal hyphae.

12.3 How Would You Treat This Patient, and How Would You Manage the Other Causes of Irritant or Infective Balanoposthitis?

Candidal balanoposthitis is treated with a topical imidazole, or with fluconazole given in a single dose of 150 mg by mouth (see Case 11). The use of an imidazole cream containing 1% hydrocortisone is often used in patients with marked inflammation and preputial edema.

In the management of mild irritant balanoposthitis, the topical application emollients such as Dermol®cream may be helpful. Sensitizing agents such as soaps should not be used during acute inflammation, and emollients can also be used as soap substitutes. Topical hydrocortisone cream 1% w/w applied three times per day for 7 days is often successful in those patients whose irritant balanoposthitis fails to resolve to emollients. When they have been implicated as the cause of the balanoposthitis in the individual, spermicides should be avoided subsequently.

Mild forms of infective balanitis are cleared readily by retracting the prepuce and bathing with physiological saline. This treatment should be repeated twice or thrice daily. The prescription of metronidazole in an oral dosage of 400 mg twice daily by mouth for 7 days is useful in the treatment of anaerobic balanoposthitis. When phimosis is present, subpreputial lavage with saline 3–6 hourly, using a disposable hypodermic syringe is often sufficient to promote drainage and healing.

The management of plasma cell balanitis should only be undertaken by an experienced clinician. Treatment is with a potent topical corticosteroid cream such as clobetasol, with circumcision being indicated when a satisfactory response is not observed after a reasonable interval, of, say 3 months.

Footnotes

1

The terms balanitis and posthitis refer, respectively, to inflammation of the glans and mucosal surface of the prepuce.