Balanitis, chancroid, Chlamydia

Question 1

What is balanitis, posthitis and balanoposthitis?

Answer 1

balanitis - inflammation of the glans penis
posthitis - inflammation of the foreskin
balanoposthitis - inflammation of the glans penis and foreskin

Question 2

What is the epidemiology of balanitis?

Answer 2

Balanitis is common in young boys with a non-retractile foreskin and in the elderly where there may be predisposing factors such as malignancy or diabetes. The organisms most commonly involved are faecal bacteria and candida.

Question 3

What are the signs and symptoms of balanitis / presentation?

Answer 3

Presentation is with irritation or pain in the penis and discharge from beneath the foreskin. Inflammation is visible. Recurrent balanitis may cause a phimosis with disturbance of micturition.

Question 4

What is anyone with balanitis advised to do?

Answer 4

avoid contact with any potential skin irritants (e.g. soap)
keep area clean by bathing twice daily with a weak saline solution while symptoms persist

Question 5

What do we do to men with acute balanitis?

Answer 5

refer all men with acute balanitis and suspected urethritis, ulceration, or lymphadenopathy to a genito-urinary medicine clinic (2)
with the exception of recurrent ulceration due to herpes simplex in someone with an established diagnosis
swab the sub-preputial space prior to starting empirical treatment (2)

Question 6

What do we give for balanitis secondary to candida?

Answer 6

imidazole cream
antifungal

Question 7

What are the treatment options for adults with balanitis?

Answer 7

topical imidazole e.g. econazole, ketoconazole, sulconazole,clotrimazole 1% or miconazole 2% applied twice a day till the symptoms resolve
oral fluconazole - 150mg stat if symptoms are severe
topical nystatin - in case of resistance and allergy to imidazole (3)
topical terbinafine

Question 8

What are the treatment options for children with balanitis?

Answer 8

a topical imidazole e.g. clotrimazole, econazole, ketoconazole, miconazole, sulconazole
topical nystatin
recommended that treatment with a topical antifungal should be continued for 2-3 days after clinical cure

Question 9

What is the treatment for bacterial balanitis?

Answer 9

may require oral antibiotic treatment (e.g. flucloxacillin or erythromycin)
sometimes a combined steroid/antibiotic cream (e.g. hydrocortisone acetate 1%, fusidic acid 1%) or combined antifungal/steroid cream (e.g. hydrocortisone 1%, clotrimazole1%) is used to reduce inflammation caused by infection
topical corticosteroid should be applied until the inflammation has cleared
twice a day for up to 2 weeks (3)

Question 10

What is balanitis xerotica et obliterans?

Answer 10

Balanitis xerotica et obliterans refers to thickening and depigmentation of the foreskin which is often adherent to the glans penis. The cause is unknown

Question 11

S + S or presentations of balanitis xerotica

Answer 11

May be asymptomatic. Patients could present with itching, dyspareunia, white patches on the glans often with involvement of the prepuce, meatal thickening and narrowing (1).

Elsewhere in the body, the condition may be known as lichen sclerosus.

Diagnosis is through clinical features and biopsy (1).

Question 12

Treatment of balanitis xerotica?

Answer 12

topical steroid creams – used once daily until remission and then gradually tapered
treatment of secondary infection
circumcision – in phimosis and resistant cases
surgery for meatal narrowing.

Question 13

What is balanitis plasmocellularis?

Answer 13

shiny, moist, erythematous, well-dermacated plaque on the glans penis in an older uncircumcised male
well-demarcated, moist, shiny, bright-red or autumn-brown multiple pinpoint patches involve the glans and prepuce - “cayenne pepper spots”

Question 14

What is the presentation often for balanitis?

Answer 14

Indolent and asymptomatic

Question 15

What are the DDs for balanitis plasmocellularis

Answer 15

seborrhoeic dermatitis,erosive lichen planus, psoriasis, fixed drug eruption, secondary syphilis, erythroplasia of Queyrat and Kaposi’s sarcoma

Question 16

Treatment for balanitis plasmocellularis

Answer 16

may improve with altered washing habits plus intermittent application of a mild or potent topical corticosteroid (with or without antibiotics and anticandidal drugs)
often persists or relapses
almost all cases occur in uncircumcised men and nearly all are cured by circumcision
alternative methods – CO2 laser (1)

Question 17

Features of circinate balinitis

Answer 17

characterised by serpiginous, annular lesions with slightly raised borders on the glans penis of an uncircumcised man
in circumcised men papulosquamous plaques and papules occur on the penis
occurs in Reiter’s syndrome

Question 18

What is the definition of Chancroid?

Answer 18

Chancroid is a tropical sexually transmitted disease caused by Haemophillus ducreyi, a gram negative bacterium.

Question 19

What is the epidemiology of chancroid?

Answer 19

It is endemic in Africa, Asia and South America, and is more common in men, particularly uncircumcised men. HIV is a very important cofactor, with a 60% association in Africa.

Question 20

What are the pathological causes of chancroid?

Answer 20

Lipooligosaccharide
Pili
Isolation specimen
Media

Question 21

What is the pathogenesis of chancroid?

Answer 21

Incubation - 4-10 days
Inoculation through epiderman microabrasions > attachment of bacteria to ecm in skin via pili, lipooligosaccharide > attachment to cells via specific heat shock protein (GroEL) > cytotoxin release, epithelial injury > formation of erythematous pauple > evolves into pustule > pustule ruptures, forms ulcers

Question 22

RFs for chancroid

Answer 22

Uncircumcised
poverty
Hoes

Question 23

Complications of chancroid

Answer 23

HIV contraction

Question 24

S + S of chancroid

Answer 24

Painful genital ulcers
Prepuce
Glans penis
Dysuria, dyspareunia,
vaginal discharge
rectal bleeding
inguinal lymphadenopathy

Question 25

Investigations for chancroid

Answer 25

Culture
NAAT
PCR
Histological characteristics

Question 26

Criteria for chancroid diagnosis (other diagnostics)

Answer 26

• one painful genital ulcers
• no evidence of treponema pallidum infections
• no evidence of herpes
• appearance of genital ulcers, regional lymphadenopathy
• purulent exudate in superficial epidermis with perivascular, interstitial mononuclear infiltrate in dermis

Question 27

Treatment for chancroid

Answer 27

Single dose therapy with azithromyocin/ ceftriaxone
Alternative - multiple - dose therapy with ciprofloxacin/ erythromycin
Fluctuant lymphadenopathy - needle aspiration, drainage to prevent spontaneous rupture

Question 28

What is chlamydia

Answer 28

Chlamydia trachomatis is a gram-negative bacteria

Question 29

How does chlamydia trachomatis work

Answer 29

it enters and replicates within cells before rupturing the cell and spreading to others.

Question 30

Most common STI?

Answer 30

Chlamydia

Question 31

What makes you have a higher risk of catching the infection of chlamydia?

Answer 31

-Being young,
-sexually active
-multiple partners increase the risk of catching the infection.

A large number of cases are asymptomatic (50% in men and 75% in woman). Asymptomatic patients can still pass the infection on.

Question 32

What is the National Chlamydia Screening programme

Answer 32

Public Health England has set out a National Chlamydia Screening Programme (NCSP). This program aims to screen every sexually active person under 25 years of age for chlamydia annually or when they change their sexual partner.

Question 33

2 types of swabs used in sexual health testing

Answer 33

Charcoal swabs
Nucleic acid amplification test (NAAT) swabs

Question 34

What do Charcoal swabs allow for

Answer 34

microscopy (looking at the sample under the microscope),
culture (growing the organism)
sensitivities (testing which antibiotics are effective against the bacteria).
Charcoal swabs look like a long cotton bud that goes into a tube with a black transport medium at the end. The transport medium is called Amies transport medium, and contains a chemical solution for keeping microorganisms alive during transport.

Question 35

What does microscopy involve

Answer 35

gram staining and examination under a microscope. A stain is used to highlight different types of bacteria with different colours. Charcoal swabs can be used for endocervical swabs and high vaginal swabs (HVS).

Question 36

What testing is used specifically for Chlamydia and Gonorrhea

Answer 36

Nucleic acid amplification tests (NAAT) check directly for the DNA or RNA of the organism

Question 37

Presentation of Chlamydia in women

Answer 37

Abnormal vaginal discharge
Pelvic pain
Abnormal vaginal bleeding (intermenstrual or postcoital)
Painful sex (dyspareunia)
Painful urination (dysuria)

Question 38

Chlamydia presentation in men

Answer 38

Urethral discharge or discomfort
Painful urination (dysuria)
Epididymo-orchitis
Reactive arthritis

Question 39

First line treatment for uncomplicated chlamydia

Answer 39

doxycycline 100mg twice a day for 7 days.

Question 40

Doxycycline issues + alternatives

Answer 40

contraindicated in pregnancy and breastfeeding.

Erythromycin 500mg four times daily for 7 days
Erythromycin 500mg twice daily for 14 days
Amoxicillin 500mg three times daily for 7 days

Question 41

Non medical management of chylmadia

Answer 41

Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection
Refer all patients to genitourinary medicine (GUM) for contact tracing and notification of sexual partners
Test for and treat any other sexually transmitted infections
Provide advice about ways to prevent future infection
Consider safeguarding issues and sexual abuse in children and young people

Question 42

Normal complications of chlamydia

Answer 42

Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Ectopic pregnancy
Epididymo-orchitis
Conjunctivitis
Lymphogranuloma venereum
Reactive arthritis

Question 43

Pregnancy-related complications of chlamydia

Answer 43

Preterm delivery
Premature rupture of membranes
Low birth weight
Postpartum endometritis
Neonatal infection (conjunctivitis and pneumonia)