Candidal balanoposthitis is an inflammation of the glans penis and foreskin caused by opportunistic fungi of the genus Candida. Microtrauma of the external genitalia, metabolic and immune disorders, prolonged antibiotic therapy contribute to the development of the disease. Fungal balanoposthitis is manifested by itching and burning in the intimate area, swelling of the foreskin, painful erosions that are covered with a grayish coating. For diagnosis, microscopy of urogenital smears, cultural examination of the discharge, PCR testing are prescribed. Treatment involves the use of local and systemic antimycotics, correction of predisposing factors.
ICD 10
B37.4 Candidiasis of other urogenital localizations
Meaning
The defeat of the genitals by Candida fungi is a typical localization of superficial candidiasis in men, which accounts for more than 87% of all nosological forms. Candida inflammation accounts for 35% of infectious balanoposthitis. There are 2 peaks of diagnosis: the age of 18-30 years, which is associated with an active sexual life, and the age over 50 years, when various health disorders occur that contribute to the activation of pathogens. Candidal balanoposthitis is extremely relevant in practical urology due to its prevalence, frequent recurrence and possible dangerous complications.
Causes
The causative agent of the disease is yeast–like Candida fungi. More than 90% of cases are associated with the reproduction of Candida albicans, the remaining 10% are affected by non-albicans forms: C. glabrata, C. tropicalis, C. krusei, C. parapsilosis. Pathogens belong to the conditionally pathogenic flora and live on the surface of the penis for a long time without causing symptoms. The appearance of candidal balanoposthitis is associated with the action of predisposing factors:
- Traumatization of the genitals. Permanent microtrauma on the head of the penis and the inner sheet of the prepuce contribute to the penetration of the pathogen deep into the tissues and the development of inflammation. Most often, the injuries are associated with sexual contacts and occur in young men who are sexually active.
- Urological diseases. Candidal balanoposthitis is often observed in men with a short frenulum, congenital phimosis, elongated foreskin and other anatomical features that make hygiene difficult. Viral or bacterial infection of the genitals, chronic prostatitis, orchoepididymitis contributes to the development of the disease.
- Metabolic disorders. The most well—known provoking factor of candidal balanoposthitis in middle-aged and older men is type 2 diabetes mellitus. With this disease, the activity of local protective factors decreases, favorable conditions are created for the reproduction of pathogens on the surface of the skin and mucous membranes.
- Somatic diseases. The frequency of genital candidiasis increases in patients with atherosclerosis, chronic venous insufficiency, diseases of the thyroid gland and adrenal glands. Severe and recurrent course of the disease is typical for cancer patients receiving chemotherapy and radiation therapy.
- Decreased immunity. A high frequency of candidal balanoposthitis is observed in people with congenital and acquired immunodeficiency, including in patients with HIV-positive status. The starting factor of the disease can be the intake of glucocorticosteroids and other immunosuppressants.
- Antibiotic therapy. Prolonged antibiotic treatment disrupts the normal composition of the microflora in the intimate area, promotes the activation of opportunistic and pathogenic microorganisms. A similar situation is observed not only with the systemic use of drugs, but also with the abuse of intimate hygiene gels containing antimicrobial components.
Pathogenesis
In the mechanism of development of candidal balanoposthitis, pathogenicity factors of the pathogen are of great importance: adhesion, dimorphism, formation of biofilms. The stable attachment of fungi to cells on the surface of the penis is ensured by nonspecific hydrophobic contacts and specific ligand-receptor interactions. Then there is an invasion based on endocytosis with the help of invading proteins and direct penetration into the cell.
The most important role in the invasion and further spread of pathogens is played by the ability to dimorphism – transformation from a yeast-like form into true hyphae, depending on temperature, oxygen content and pH level in the medium. Fungi are also able to form biofilms that have increased resistance to antimycotics and factors of the patient’s immune system, which causes difficulties in the treatment of candidal balanoposthitis.
Symptoms
According to clinical manifestations, there are 3 typical forms of the disease: erosive, papular, erythematous-pustular. Basically, fungal balanoposthitis begins with reddening of the skin of the head of the penis and the inner sheet of the foreskin, the formation of small papules and vesicles, burning and itching in the intimate area. Then the skin is macerated, a whitish-gray plaque appears, when trying to remove it, pain occurs and bright red erosions are detected.
With the further development of the disease, the foreskin swells, which is why a man experiences difficulties in exposing the head, soreness and discomfort during penetrating sexual contacts. A small amount of liquid exudate with an unpleasant odor is released from the preputial sac. In the case of secondary infection, an erythematous-pustular form occurs, a purulent discharge appears.
Atypical variants of candidal balanoposthitis are distinguished in a separate group, which are accompanied by a deeper lesion of the tissues of the genitals. Erosive-ulcerative form of the disease is manifested by discharge ulcerative defects and necrosis sites on the head of the penis. This variant of the disease is associated with systemic immunodeficiency and develops at a T helper level of less than 400 cells/ml.
Complications
With the chronization of candidal balanoposthitis, cracks appear along the edge of the preputial sac, which lead to scarring and narrowing of the foreskin — the formation of acquired phimosis. The inability to expose the head of the penis and conduct intimate hygiene aggravates the existing inflammation, makes it impossible to have a full sexual life, under unfavorable conditions can cause paraphimosis.
Candidiasis inflammation acts as a predisposing factor for infection with sexually transmitted infections (STIs) and other types of bacterial pathogens. In severe cases, gangrene and erysipelas of the genital organ occur. The long-existing inflammatory process causes verrucose growths and the formation of granulomas. With immunodeficiency, hematogenic dissemination of fungi with the development of systemic candidiasis is not excluded.
Diagnostics
Patients with signs of candidal balanoposthitis need to consult a urologist. When examining the affected area, red erosions, plaque and other typical manifestations of fungal infection are determined, on the basis of which a preliminary diagnosis is made. To confirm the candidiasis etiology of the inflammatory process, a number of specific laboratory tests are prescribed:
- Microscopy. Native preparations of urogenital smears and Gram-stained samples are used for the study. The criterion for confirming the diagnosis is the predominance of vegetative forms of fungi — budding cells or pseudomycelia. The specificity of the diagnosis is 100% if the patient has typical clinical symptoms of fungal balanoposthitis.
- Cultural research. Sowing of biomaterial on specific nutrient media is prescribed for clinical symptoms of candidiasis and a negative result of microscopy, with recurrent forms of the disease to determine the sensitivity of fungi to antimycotics. The diagnostic significance is the detection of the pathogen in an amount of more than 10×4 CFU per 1 ml.
- PCR diagnostics. The molecular biological research method is used to determine the DNA fragments of Candida fungi. This is the most accurate way by which Candida albicans and non-albicans species of the pathogen are distinguished. Polymerase chain reaction plays a crucial role in the choice of therapeutic tactics in men with frequently recurrent candidal balanoposthitis.
- Additional methods. According to the indications, the examination is supplemented by ultrasound of the scrotum and pelvic organs in order to exclude concomitant urological diseases and complications of candidiasis. To identify other predisposing factors, a man is referred for consultation by an immunologist, an endocrinologist, a gastroenterologist and other specialists.
Differential diagnosis
When making a diagnosis, it is necessary to exclude alternative causes of inflammation: banal bacterial balanoposthitis, syphilitic chancre-balanoposthitis, herpes infection. With chronic candidiasis and the presence of verrucous growths, differential diagnosis is carried out with genital warts, rupioid syphilis. Atypical forms of the disease are differentiated with Keir’s erythroplasia, penile cancer, sclerotrophic lichen.
Treatment
To eliminate fungal inflammation, etiotropic drugs — antimycotics for external and internal use are prescribed. Uncomplicated cases of candidal balanoposthitis require the use of local antifungal agents in the form of ointments, creams, sprays. The appointment of systemic antimycotics is justified in cases of deep ulcerative lesions, severe candidiasis in immunocompromised patients, recurrent balanoposthitis.
In the acute period of the disease with active wetness, treatment is supplemented with antiseptic lotions and baths. After the inflammatory manifestations subside, external therapy is enhanced with aqueous solutions of aniline dyes, which contribute to the speedy healing of erosions and vesicles. To increase the effectiveness of antimycotics, external immunomodulators are used, prescribed according to strict indications under the supervision of an immunologist.
In addition to the specific treatment of fungal infection, with candidal balanoposthitis, it is necessary to identify and eliminate the factors supporting the pathological process. For this purpose, treatment of concomitant urological diseases, correction of glycemia and blood lipid spectrum, change of antibacterial and immunosuppressive drugs (if possible) is carried out. With frequent relapses of the disease, vitamin therapy and a diet with a restriction of simple carbohydrates are recommended.
Prognosis and prevention
Thanks to complex therapy, it is possible to completely eliminate the manifestations of candidal balanoposthitis, therefore, the outcome of the disease is favorable for most patients. A less optimistic prognosis is for people with immunosuppression, which contributes to the dissemination of the pathogen and fungal damage to internal organs. Prevention of the disease involves the observance of intimate hygiene, treatment of STIs and other urological diseases, strengthening immunity.
