Infectious balanoposthitis: management, clinical and laboratory features
Carmen Lisboa, MD Department of Microbiology Faculty of Medicine Hospital de S. João Rua Prof Hernani Monteiro 4202-451 Porto Portugal E-mail: firstname.lastname@example.org
Background Balanitis is defined as inflammation of the glans penis, often involving the prepuce (balanoposthitis). It is a common condition due to a wide variety of causes with infection being the most frequent and several microorganisms reported. The clinical aspect is often non specific. The management of balanoposthitis remains a clinical challenge.
Objective To evaluate the prevalence of infectious balanitis, its management, clinical features, laboratory procedures and treatment options.
Subjects and methods One hundred eighteen patients with infectious balanitis were evaluated between 1995 and 2004 and laboratory data were collected.
Results Balanitis was diagnosed in 219 (10.7%) of the men that have attended the sexually transmitted disease (STD) Clinic. One hundred eighteen (53.9%) had clinically been assumed to suffer from infectious balanitis. In 75 (63.6%) patients the diagnosis was confirmed by culture studies. Candida albicans was isolated from 24 patients. Staphylococcus spp. and groups B and D Streptococci were the most frequently isolated bacteria. All men were uncircumcised. Ninety-one (77.1%) of infectious balanitis patients were treated with antifungal agents. Twelve patients with infectious noncandida balanitis were treated with general antibiotic therapy. Fifty-five (46.6%) patients had a follow-up of 3 to 12 months during which recurrences were registered in 7 (12.7%) patients.
Conclusions Infectious balanitis was a common condition, affecting 53.9 % of male STD clinic patients in this study. Candida spp. were the most frequently isolated microorganisms. The clinical aspect is of little value in predicting the infectious agent associated with balanoposthitis.
Balanitis is defined as inflammation of the glans penis, which often involves the prepuce (balanoposthitis). There are a wide variety of causes, but infection is the most commonly reported etiology.1,2 Balanitis is a common condition in male patients at sexually transmitted disease (STD) clinics.1–3 Candida albicans and other species are considered to be responsible for up to 35% of all cases of infectious balanitis,4,5 most being sexually acquired.2,6 The clinical features of candida balanitis include mild glazed erythema and papules with or without satellite eroded pustules. Usually, patients complain of local burning and pruritus; however, this clinical aspect is often nonspecific.3,7 Predisposing factors to male genital candidosis include diabetes mellitus, immunosuppression, and the condition of being uncircumcised.1–3 Indeed, the condition of being uncircumcised is considered to be a major predisposing factor for balanoposthitis, and poor hygiene, buildup of smegma, and a tight foreskin favor this inflammatory condition.6,8 Bacteria represent the second most common cause of infectious balanitis:2 Streptococcus spp., Staphylococcus aureus, Pseudomonas spp., Gardnerella vaginalis, anaerobes, Treponema pallidum, Chlamydia trachomatis, and Mycoplasma spp. have all been reported as causes of balanitis.2,3,9 Less commonly reported causes of balanitis are viral and parasitic.1,2 We report a series of 118 consecutive patients with a clinical diagnosis of infectious balanitis evaluated at the STD clinic of Hospital de S. João, with special emphasis on etiology, predisposing factors, clinical features, diagnostic procedures, treatment options, and follow-up.
All the clinical records from patients with balanitis and balanoposthitis, evaluated at the STD Clinic of Hospital de S. João, a university hospital in Porto, Portugal, between 1995 and 2004, were reviewed. Age, marital status, sexual orientation, number of partners during the last 6 months, any history of STDs, concomitant diseases, microbiologic results, biopsy, final diagnosis, prescribed treatment, and follow-up data were collected. The diagnosis of balanitis was established on the basis of the presence of pronounced, generalized or patchy erythema with or without erosions on the glans or under the prepuce, and with or without subprepucial exudate.
In the group of patients with a clinical diagnosis of infective balanitis, a subprepucial and glans cotton swab was obtained, placed into transport medium, and cultured (fungal and bacterial). When genital herpes was suspected, a cotton swab was taken and immediately transported to the laboratory for the detection of herpes simplex virus, diagnosed as either type 1 or 2 using polymerase chain reaction (PCR). A lesional biopsy for histologic studies was performed in patients suffering from persistent balanitis in which the cause remained unclear. All patients were also tested for syphilis (serology), hepatitis B and C, and human immunodeficiency virus (HIV) 1 and 2, according to the standard evaluation protocol of our STD clinic.
Two hundred and nineteen (10.7%) consecutive patients were clinically diagnosed with balanitis between 1995 and 2004; 118 (53.9%) had a clinical diagnosis of infectious balanitis. The latter patients were aged between 20 and 83 years (mean age, 42.2 years), 67% (79/118) were married, 96.6% (114/118) were heterosexuals, 62.7% (74/118) reported a single sexual partner during the last 6 months, and 57.6% (68/118) denied a previous history of any STD. All patients were uncircumcised. The most common complaints consisted of genital mild burning and pruritus with erythema of the glans and/or the prepuce, and subpreputial discharge.
Microbiologic culture was performed in 75 (63.6%) patients (Table 1). In brief, 26 candida balanitis and 22 infectious noncandida balanitis cases were confirmed; 27 patients were culture negative. Forty-three patients were clinically assumed to have candida balanitis; in 17, culture was not performed because of previous recent antifungal treatment. The microbiologic results are shown in Table 2. Twenty-two patients with a negative culture for yeasts had a positive bacterial culture. Staphylococcus spp. and group B and D streptococci were the most frequently isolated bacteria. Interestingly, Candida spp. and bacteria were isolated from six patients suffering from lichen sclerosus.
Table 1. Results of microbiologic culture in 75 patients
|Infectious noncandida balanitis||22†|
|Balanitis with negative culture||27|
Table 2. Isolates from 75 patients with infectious balanitis
|Candida balanitis||Candida albicans||23*|
|C. albicans + C. krusei|| 1*|
|C. albicans + group D streptococci + Escherichia coli|| 1*|
|C. albicans + group D streptococci + Citrobacter|| 1*|
|Infectious noncandida balanitis||Coagulase-negative staphylococci||12|
|Staphylococcus aureus|| 1|
|Staphylococcus aureus + group B streptococci|| 2|
|Group A streptococci|| 1|
|Group D streptococci|| 1*|
|Group D streptococci + Haemophilus influenzae|| 1*|
|Group B streptococci + Klebsiella pneumoniae|| 1|
|Klebsiella pneumoniae|| 1|
|Gardnerella vaginalis|| 2|
Diabetes mellitus (20; 16.9%), HIV infection (2; 1.7%), iatrogenic immunosuppression (2; 1.7%), and hepatitis C (2; 1.7%) were the underlying diseases diagnosed in the 118 patients with infectious balanitis. All 20 patients suffering from diabetes mellitus had candida balanitis; six had a previous medical history of balanitis. Candida balanitis was the first manifestation of diabetes mellitus in eight of the culture-positive patients.
Ninety-one (77.1%) of the patients with infectious balanitis were treated with antifungal agents; 38 (32.2%) were treated with topical azoles (clotrimazole, econazole, and sertaconazole), six (5%) with oral azoles (fluconazole and itraconazole), and 47 (39.8%) with topical and oral azoles simultaneously. Twelve patients with infectious noncandida balanitis were treated with general antimicrobial therapy. All patients were also advised to perform genital hygiene twice daily with a weak salt solution or potassium permanganate (diluted at 1 : 20,000).
Fifty-five (46.6%) patients with infectious balanitis had a follow-up of 3–12 months during which recurrences were registered in seven (12.7%) patients. In five, candida balanitis was diagnosed again, and all of these patients had poorly controlled diabetes mellitus. Recurrent candida balanitis cases had previously been treated with topical antifungal agents in two cases and topical plus oral antifungal agents in three cases.
Balanitis is a common condition affecting up to 11% of STD clinic patients.1–3 In this study, balanitis was diagnosed in 10.7% of the men evaluated at the STD clinic at the University Hospital of S. João. As reported by others,2,3 an infectious etiology was the most prevalent, with Candida albicans being the most frequently isolated microorganism.
Candida balanitis accounts for 30–35% of infectious balanoposthitis;4,5 we found a figure of 34.7%; however, this value was higher (53.9%) for diagnosis relying solely on clinical examination. In 43 (36.4%) patients, the diagnosis of candida balanitis was clinical, without laboratory confirmation. Indeed, previous studies have reported that, in clinical practice, candida balanitis is often a clinical diagnosis without systematic laboratory confirmation;4,10 however, some investigators have stressed the relevance of the isolation of yeasts for the definitive proof of a fungal infection.4,7,11
It is known that the sampling method for culture has a strong influence on the percentage of isolates. Dockerty and Sonnex4 evaluated the diagnostic methods of candida balanoposthitis. They found that the method of material collection was critical in confirming or ruling out a clinical diagnosis of candida balanitis. The quantity of material collected is often small and certainly contributes to the incidence of negative cultures. We found negative cultures in 36% (27/75) of patients, although the procedures adopted in our clinic followed the described recommendations.7,9,12 Some patients who were diagnosed with candida balanitis by examination, but who showed a negative fungal culture, had a favorable response to antifungal therapy.
Bacteria represent the second most common cause of infectious balanitis, Streptococcus spp. being most frequently incriminated.2,9 In our study, infectious noncandida balanitis yielded mainly group B and D streptococci and Staphylococcus spp. The pathogenic nature of some bacteria remains controversial.3,9 Their presence does not necessarily mean that they are the cause of balanitis,7 as such organisms are common members of the indigenous mucosal microbial population. Some authors have reported that bacteria, such as Staphylococcus epidermidis, Klebsiella, Enterococcus, and Escherichia coli, cause mild balanoposthitis.13
Six patients with lichen sclerosus showed, concomitantly, an infectious cause of balanoposthitis. Indeed, superinfection of skin lesions can occur.6,7 Patients suffering from lichen sclerosus, usually with a nonretractable foreskin, frequently show predisposing conditions to infectious balanitis.
Diabetes mellitus was the underlying disease most frequently associated with candida balanitis. The prevalence of 16.4% found was much higher than the corresponding value in the Portuguese sex- and age-matched population (18.2–20.6 per 1000 persons).14 We found that 76.9% of patients with microbiologically confirmed candida balanitis had diabetes. In addition, confirmed candida balanitis was the initial manifestation of diabetes mellitus in eight patients, which is in accordance with previous studies.2,3
The condition of being uncircumcised is considered to be a predisposing factor for balanitis.1–3 Accordingly, all our patients with balanoposthitis were uncircumcised. Nevertheless, balanitis does not seem to be confined to uncircumcised men.10,15
The guidelines for the treatment of candida balanitis have not yet been standardized.7,16 Treatment options usually involve topical or oral azole agents. Clotrimazole, miconazole,7,16 and econazole16 are the topical antifungal agents usually recommended, but, in our study, other azole agents, such as sertaconazole, were used, with a favorable outcome. Oral treatment with fluconazole (150 mg as a single dose) is recommended when symptoms are severe,7 in recalcitrant cases, or with concomitant diabetes.16 In our setting, some patients were treated with itraconazole (200 mg twice daily for 1 day), similar to the recommended regimen for vaginal candidosis. Interestingly, this regimen was chosen in diabetic patients with severe inflammatory candida balanoposthitis. However, conclusive studies regarding the advantages of topical antifungal therapy, either associated or not with systemic antifungal treatment, are lacking. According to our results, there is a preference by clinicians towards a combination of topical and oral antifungal agents. Antifungal therapy is commonly used in suspected mucocutaneous candidosis cases, despite the lack of laboratory confirmation. Abdennader et al.3 reported that the abusive use of topical antifungals promotes irritant balanitis and aggravates local inflammation. Accordingly, we found six patients with irritant balanitis at the time of observation, with topical azoles being incriminated; however, 36.4% (43/118) of patients empirically treated as candida balanitis showed a favorable response to antifungal therapy, supporting the diagnosis of candida balanitis. Nevertheless, certain antifungal agents have been shown to have intrinsic anti-inflammatory activity.17 Thus, the prescribed antifungal agents may have the potential to provide clinical benefit beyond fungal eradication. Interestingly, this anti-inflammatory activity has not yet been characterized in the mucocutaneous genital area.
In conclusion, the management of infectious balanoposthitis should be based on the identification of a specific etiologic agent. The clinical aspect is often nonspecific and has little value in predicting the etiology of the infectious agent. Thus, diagnosis based solely on clinical grounds is often inadequate. Some patients are often assumed to suffer from candida balanitis without laboratory confirmation. In agreement with previous studies, we found that Candida albicans was the most common infectious agent of balanitis; however, 36% of our patients had negative cultures. Improved diagnostic procedures, with higher sensitivity and specificity, are mandatory in order to rule out an over-diagnosis of candida balanitis. In addition, the standardization of therapeutic modalities and the clarification of the hypothetical anti-inflammatory activity of antifungal agents would be much welcomed.
The authors would like to thank Professor Per-Anders Mårdh for critical review of the manuscript.