Balanoposthitis Flashcards by Yvonne McFarlane

What is balanoposthitis?

Balanitis - inflammation of glans penis

Posthitis - inflammation of prepuce (foreskin)

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What proportion of GUM attendees present with balanoposthitis?

11%

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Who is balanitis uncommon in?

Circumcised men

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What are the symptoms of balanoposthitis?

Local rash 
dyspareunia
Itch
Odour
Inability to retract foreskin
discharge from glans/behind foreskin

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What other symptoms associated with balanoposthitis elsewhere on the body?

Rash elsewhere
Sore mouth
JOint pains
Swollen/painful glands
general malaise

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When describing changes to the genitals in balanoposthitis what might be present?

COLOUR change
- erythema
- leukoplakia
- purpura
TEXTURAL change
- scaling
- sclerosis
- ulceration
- fissuring
- crusting
- exudate
- oedema
- odour
- phimosis

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What complications may arise from balanoposthitis?

Phimosis
Meatal stenosis
Malignant transformation

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What is a sub-preputial swab useful for in balanoposthitis?

To exclude infective cause/superinfection

candida
bacterial culture

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When should urinalysis for glucose be performed in balanoposthitis?

Most cases

especially in candida suspected

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What should initial assessment of ulcerative balanoposthitis include?

Swab of ulcer for HSV and treponema pallidum PCR +/- dark ground microscopy

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What STI is most commonly associated with balanoposthitis?

Chlamydia trachomatis

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What should be screened for in circinate-type balanitis?

STIs

Urethritis

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When is biopsy indicated for balanoposthitis?

Diagnosis uncertain

Condition persists

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Balanoposthitis - general advice

avoid soaps while inflammation

effect on condoms if cream treatment being applied

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Balanoposthitis - describe step-wise/flow chart approach to balanoposthitis?

Culture
Pathogen found - treat
No pathogen
- good hygiene - emollients and washing advice
- poor hygiene - salt washes and washing advice
No improvement
- hydrocortisone 1% BD 2weeks
then biopsy if no improvement

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Candidal balanitis - symptoms & signs?

symptoms
- rash, soreness +/- itch
signs
- blotchy erythema with small papules eroded or dry dull red areas with glazed appearance

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Candidal balanitis - treatment?

Topical
-Clotrimazole 2%
-miconazole 2%
Oral (if severe)
-fluconazole 10mg STAT
marked inflammation
-Add topical hydrocortisone

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Anaerobic balanitis - symptoms & signs?

symptoms
- foul smelling, swelling, inflamed glans
signs
- preputial oedema, superficial erosion, inguinal adenitis

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What investigation should be performed I ulceration in anaerobic balanitis?

Swab for HSV

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Anaerobic balanitis - treatment?

Metronidazole 400mg BD 7 days
or
co-amoxiclav 375mg 3 times daily 7 days

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Aerobic balanitis - clinical features?

non-specific balanitis

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Organism implicated in aerobic balanitis?

Streptococcal group A
Staphylococcus aureus
Gardnerella vaginalis

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What are other causes of non-specific balanitis?

HSV
TV
syphilis

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Lichen sclerosus aka balanitis xerotica obliterans (BXO) - aetiology?

inflammatory skin condition

autoimmune pathogenesis

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Who gets balanitis xerotica obliterans (lichen sclerosus)?

ALL ages | 12.1% of preputial surgical cases in paediatrics

Lichen sclerosus aka balanitis xerotica obliterans (BXO) - symptoms and signs?

``` symptoms - itching, soreness, splitting, haemorrhagic blisters, dyspareunia, problems with urination signs - white patches on glans +/- prepuce - haemorrhagic vesicles, purpura ARCHITECTURAL changes - blunting of coronal sulcus - phimosis - wasting of prepuce - meatal thickening and narrowing ```

Lichen sclerosus aka balanitis xerotica obliterans (BXO) - complications?

Phimosis Urethral stenosis Malignant transformation

What proportion of penile cancer has histological changes of lichen sclerosus?

28%

Where is extra-genital disease common in men with lichen sclerosis?

Perianal disease

Lichen sclerosus aka balanitis xerotica obliterans (BXO) - biopsy?

LAYERS 1) thickened epidermis to atrophic with follicular hyperkeratosis 2) band of dermal hyalinisation with loss of elastin fibres 3) perivascular lymphocytic infiltration

Lichen sclerosus - treatment?

Topical/initial -POTENT topical steroid DAILY until remission then reduce -may require INTERMITTENT Surgical -CIRCUMCISION if phimosis -surgical management of urethral stenosis

Balanitis xerotica obliterans (BXO) - follow up?

Dependent on case | At least annually in case of malignant transformation

Zoon's (plasma cell) balanitis - aetiology?

disease of older men typically uncircumcised irritation partially from urine within a 'dysfunctional prepuce'

Zoon's (plasma cell) balanitis - clinical appearance?

``` variable well circumscribed orange-red glazed areas glans AND multiple pin point redder spots 'cayenne pepper spots' ```

Zoon's (plasma cell) balanitis - investigation?

Early biopsy

Zoon's (plasma cell) balanitis - treatment?

Circumcision Topical steroids Hygiene measures

Psoriasis balanitis - clinical appearance?

``` Circumcised - similar to psoriasis elsewhere on body - red scaly plaques Uncircumcised - scaling lost - red and glazed patches ```

Psoriasis balanitis - diagnosis?

Clinical if psoriasis elsewhere on body | BIopsy

Psoriasis balanitis - biopsy?

Parakeratosis | acanthosis with elongation of rete ridges

Psoriasis balanitis - treatment?

Emollient MILD to MODERATE topical steroid Topical CALCITRIOL

Why should coal tar preparation be avoided for psoriasis balanitis?

Increases risk of genital cancers

Circinate balanitis - aetiology?

Post infective syndrome (Reiter's disease) Triggered by urethritis or enteritis Overlaps with psoriasis

Circinate balanitis - signs?

Greyish white areas on glans coalesce to form 'geographical' areas white margin Look for other features of Reiter's

Circinate balanitis - management?

screen for STIs including syphilis Treat STI Treat as for psoriasis but may require more potent steroid

Irritant/allergic balanitis - aetiology?

Associated with IRRITANTS - frequent washing with soaps History of ATOPY - immediate hypersensitivity eg latex condoms - delayed hypersensitivity eg exposure to topical agents

What may be useful in the investigation of allergic balanitis?

Patch testing | Intradermal skin tests

Irritant/allergic balanitis - treatment?

Avoid precipitant - stop soaps Emollient for moisturiser and soap substitute Hydrocortisone 1% once to twice daily +/- anti fungal or antibiotic

Fixed drug eruption balanitis - aetiology?

Uncommon Penis more commonly affected part of body Rarely due to drug taken by sexual partner

Fixed drug eruption balanitis - potential precipitants?

Tetracyclines Salicylates Paracetamol Hypnotics

Fixed drug eruption balanitis - appearance?

Well demarcated lesions Erythematous Bullous +/- ulceration sometimes Brown pigmentation as inflammation settles

Fixed drug eruption balanitis - treatment?

No treatment - usually resolve mild to moderate topical steroids twice daily Systemic steroids (rarely)

Erythroplasia of Queyrat - what is it?

PRE-MALIGNANT condition of PENIS | Glans, meatus, prepuce

What proportion of Erythroplasia of Queyrat progress to invasive cancer?

30%

Erythroplasia of Queyrat - aetiology

triggered by co-infection with multiple types of PAPILLOMA VIRUS

Erythroplasia of Queyrat - clinical appearance?

``` Red Velvety well circumscribed glans raised white patches ```

If induration is present on examination of Erythroplasia of Queyrat what does this suggest?

Squamous cell carcinoma

Erythroplasia of Queyrat - diagnosis?

BIOPSY essential

Erythroplasia of Queyrat - treatment?

``` SURGICAL excision (local excision) Topical is option - fluorouracil cream 5% - cryotherapy - imiquimod - photodynamic therapy ```

Erythroplasia of Queyrat - follow up?

Obligatory to assess for recurrence | minimum annually

Bowen's disease of penis - what is it?

cutaneous carcinoma in siu

Bowen's disease - clinical features?

Scaly, discrete, erythematous plaque

What proportion of Bowen's disease progress to squamous cell cancer?

20%

Bowen's disease - diagnosis?

BIOPSY essential

Bowen's disease - treatment?

Similar to Erythroplasia of Queyrat - local surgical excision - topical

Bowenoid papulosis - clinical feature?

Discrete PAPULES to PLAQUES | often PIGMENTED

Bowenoid papulosis - which HPV type is linked to it?

Bowenoid papulosis - management?

BIOPSY essential - premalignant change local excision topical

What are the premalignant conditions that may present as balanoposthitis?

Erythroplasia of Queyrat Bowen's disease Bowenoid papulosis these form a continuum with penile intraepithelial neoplasia (PeIN) but vary in clinical presentation and natural history

What is the approach to management of premalignant conditions that may present as balanoposthitis?

``` BIOPSY local excision or topical treatments annual follow up minimum ```