Balanitis is an inflammation of the glans penis against the background of infection or other causes. Symptoms include local hyperemia, plaque on the head, swelling, pain, the appearance of cracks and erosions, difficulty urinating. With inadequate therapy, a number of complications can join. Diagnostic methods involve the determination of diseases and factors affecting the development of the condition, the identification of the pathogen if balanitis is caused by an infectious agent. Treatment is individual and depends on the cause; it may include hygienic procedures, topical application of ointments, antibacterial and antifungal therapy, if indicated, circumcision.
Balanitis is experienced by 3-11% of men of any age, but more often the pathology is diagnosed in age-related patients. In summer, the incidence is higher, the prevalence of balanitis correlates with the standard of living, hygienic culture, religious and ethnic traditions. It has been proven that inflammation of the glans penis is practically not found in men with circumcised foreskin. In uncircumcised men, smegma accumulates in the preputial sac, creating conditions for the reproduction of microflora. In almost 100% of cases, balanitis occurs in combination with inflammation of the inner leaf of the foreskin – postitis (balanoposthitis). The relevance of the problems in uroandrology is associated with the frequent recurrent course of the disease and the occurrence of a number of complications that reduce the quality of life (including intimate).
Causes of balanitis
The etiology of inflammation of the glans penis is multifactorial. The disease may have an infectious genesis or occur against the background of local and systemic pathological processes. Infectious balanitis is caused by fungal (candida), viral (HPV), bacterial agents (pale treponema, hemolytic streptococcus, Neisser’s gonococci), protozoa (trichomonas), etc. Non-infectious forms often occur against the background of allergodermatoses, diabetes mellitus, sclerotrophic lichen, pemphigus, diseases of the genitourinary tract and urological operations. Predisposing factors for the development of the inflammatory process in the head area are:
- Improper hygiene. Poor or excessive hygiene of the genitals reduces the factors of local protection. Infection easily penetrates into the resulting microcracks against the background of dryness of the mucous membrane. The presence of a short frenulum and phimosis contributes to the accumulation of smegma, which causes mechanical and chemical irritation of the head. In addition, in such conditions, the growth of pathogenic microflora begins, causing an inflammatory reaction.
- Local irritating factors. Local contraceptives, antiseptics, chlorinated water, and some medications are considered as factors provoking balanitis. Aggressive substances not only corrode the skin, but also contribute to allergization. Rare replacement of diapers in children and bedridden adult patients, wearing a uropreservative is often complicated by inflammation of the genitals.
- Immunosuppressive states. Patients with reduced immune reactivity (after organ transplantation, chemoradiotherapy, while taking hormones, antibiotics, and certain diseases) are more likely to suffer from balanitis. In these cases, a fungal pathogen is usually isolated — candida albicans.
- Diseases of the urogenital tract. Phimosis, short frenulum, nephrourolithiasis, urological operations and medical manipulations are common causes of balanitis. The combination of mechanical traumatization, weakening of immunity and activation of secondary infection is typical for patients after surgery. Urine containing salts provokes inflammation in the urethra and the head of the penis.
Pathogenesis is represented by a dynamic complex of cytological and chemical processes occurring in tissues in response to trauma or exposure to a physical, chemical or biological agent, including local reactions and resulting morphological changes. Aseptic inflammation, its transition to infectious and smegma compaction enhance the overall reaction. In children under 5 years of age, when forcibly shifting the foreskin, synechial membranes are damaged, pathogenic bacteria penetrate through the wound surface, as a result of which balanitis develops. In elderly patients, urine changes its physico-chemical properties, often its density is higher, there are salts, and sometimes sugar. Concomitant phimosis and accumulation of urine leads to mechanical and then chemical irritation of the skin. Secondary attachment of microbial flora aggravates inflammation.
Classification of balanitis
By the nature of the course, acute and chronic inflammatory process are distinguished. Pathology can be primary or accompany any disease. According to the type of pathogen, viral, fungal, bacterial balanitis is distinguished; according to the mechanism of occurrence ‒ post-traumatic, allergic, drug (chemical), etc. For an acute infectious process, taking into account the severity of inflammation and the peculiarities of the course, the following forms are characteristic:
- Simple (catarrhal). Balanitis is most often found in the form of catarrhal inflammation. Hyperemia and swelling are moderately pronounced, general well-being suffers slightly. There is a slight itching and burning sensation. With timely and properly selected treatment, recovery occurs quickly and without the formation of scar tissue.
- Erosive (ulcerative). The inflammatory process progresses, and erosive defects form on the skin, with clear boundaries and wetness. Gradually, erosion engulfs an increasingly large area, almost always involving the inner leaf of the foreskin. It is impossible to completely expose the head because of the pain syndrome and the formed phimosis. Inguinal lymph nodes may be enlarged.
- Gangrenous. Further development of inflammation, deepening and merging of erosions covered with a purulent plaque leads to necrotization of the tissue. The patient’s well-being is severe, which is caused by intoxication, pain syndrome and an increase in temperature reaction. Inguinal lymphadenitis and phimosis are registered in almost all men with gangrenous balanitis.
Symptoms of balanitis
Symptoms of balanitis depend on the severity of inflammation and the stage of the disease: in the acute process, clinical manifestations are brighter. The disease is characterized by redness and swelling of the head, plaque with an unpleasant odor, ulceration (often with the release of blood) and plaques, difficulty urinating, narrowing of the external opening of the urethra, itching and pain, violation of erectile function. Acute urinary retention with balanitis is less common.
If phimosis has joined, during the act of urination, urine accumulates under the foreskin and inflates it. In some patients, a reaction of regional lymph nodes is recorded — inguinal lymphadenitis or lymphadenopathy. In the chronic course of the disease, symptoms are moderately pronounced, relapses are typical against the background of weakened immunity of any genesis: taking antibiotics, hypothermia, errors in nutrition, changes in the climatic zone, etc.
Further progression of infectious inflammation can lead to urethritis, cellulite (bacterial infection of the deeper layers of the skin) and gangrene of the penis. The outcome of a recurrent inflammatory process may be phimosis (including scarring) and paraphimosis, meatostenosis and urethral strictures. There may be urinary retention, vesicoureteral reflux, erectile dysfunction. With timely access to a urologist or dermatovenerologist, many undesirable consequences can be avoided. Men with balanitis and phimosis have an increased risk of developing penile cancer: due to the inability to open the head, diagnosis is difficult, and the existing tumor in the initial stages has no pain manifestations.
A presumptive diagnosis is established after an examination by a urologist-andrologist. To clarify the cause, you may need to consult a dermatovenerologist, endocrinologist, rheumatologist, oncologist. Diagnostic measures include testing for diabetes mellitus, sowing biomaterial from the affected areas for flora and sensitivity to drugs, serological studies for syphilis, HIV and STI tests, a potassium hydroxide test for suspected genital candidiasis. In severe balanitis, ultrasound of the bladder with control of residual urine is justified, which allows to establish obstructive disorders.
If the cause of balanitis remains unclear, the disease has a recurrent course, or there is no effect from the therapy, a biopsy of suspicious areas is performed with subsequent morphological examination. Differential diagnosis is carried out with psoriasis, soft and hard chancre, herpesvirus infection, malignant neoplasm.
Treatment of balanitis
With a confirmed venereal disease, drugs are prescribed taking into account the pathogen. Additionally, the scheme includes immunomodulators, multivitamins, treatment of the head with antiseptic solutions. Both partners receive treatment. Patients with nonspecific balanitis without phimosis are recommended:
- Careful care of the genitals. Daily retraction of the foreskin and elimination of smegma is the basic rule of hygienic care. The naked head of the penis is washed with warm water without the use of irritating detergents. Baths with decoctions of herbs with anti-inflammatory effect (chamomile, calendula, sage), irrigation with a solution of baking soda, lotions with antiseptics (dioxidin, chlorhexidine, etc.) relieve pain and reduce inflammation.
- The use of corticosteroids. In patients (regardless of age) with mild symptoms of balanitis of non-infectious genesis, local use of hormones is possible. In boys older than 3 years, the foreskin is carefully pulled back. The success rate of treatment with no relapses is 65-95%. Hormonal preparations should not be applied for more than 14 days, as this can lead to thinning of the skin. Circumcision is more justified for patients with xerotic balanitis, since they are more likely to develop cicatricial phimosis.
- Dermatotropic agents with immunosuppressive effect. With frequent relapses, instead of corticosteroids, it is preferable to prescribe drugs based on macrolactam ascomycin, which has an immunosuppressive, anti-inflammatory, dermatotropic effect. The effect of therapy is 64%. In the absence of positive dynamics, surgical intervention is resorted to.
- Antibacterial therapy. If a secondary bacterial infection has joined, the local and systemic use of antibiotics is justified. With pronounced clinical manifestations and complications (for example, penile cellulite), oral administration of broad-spectrum antibacterial drugs is initially empirically indicated. After receiving the results of bakposeva, correction of the therapy regimen is performed, if necessary.
- Antifungal drugs. Balanitis of candidiasis etiology implies the use of antifungal drugs of local and systemic action, a diet with the rejection of sweets, yeast-containing products and alcohol. Repeated attacks of fungal infection may indicate serious violations of the immune system. With background diabetes, it is important to achieve the target glucose level.
Phimosis with frequent relapses of balanitis is the main indication for circumcision, which greatly facilitates the condition and allows you to lead a full sexual life. In case of erectile dysfunction, the patient is recommended to consult a sexologist.
Prevention and prognosis
In most cases, if you follow all the doctor’s recommendations, unpleasant symptoms decrease in 3-5 days. The prognosis for life is favorable. Preventive measures include the use of hypoallergenic condoms for casual sexual intercourse, refusal of local contraceptives, wearing cotton underwear of the appropriate size, regular sex life. When wearing a uropreservative or a diaper, timely replacement of products and special care products with moisturizing and antiseptic properties are recommended.
Particular attention is paid to the hygiene of the genitals: the penis must be washed with warm water with soap or gel with a neutral medium without irritating effect. The foreskin must be shifted. Detergents should not be used more than 1 time a day, because lysozyme is destroyed – an antibacterial enzyme that protects against infectious microorganisms, and sebaceous gland secretions that moisturize, lubricate and protect the urethral mucosa and skin from infection. With all the symptoms of trouble, you need to consult a doctor.
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