BALANO-POSTHITIS

By

Major. M.P.Vora, M.B.B.S., D.V.D., I.M.S. (Rtd.)

Ex. Hon. Sr. Venereologist, St. George’s Hospital, Bombay

Indian Medical Record

A monthly journal of Public Health, Tropical Medicine and Surgery etc .

Volume LXXXVIII, Number-3 of March 1968

Pages 35-38

This article was solely contributed to Indian Medical Record

Balano-posthitis is a manifestation due to number of causes of different origin. The inflammation of the membrane covering the glans penis is called balanitis; while the inflammation of the membrane covering the prepuce is called posthitis. When the inflammation affects both the surfaces of the glans penis and the inner side of the prepuce at the same time-and this often true-the term balano-posthitis is applied. The condition is frequently met with in men and is a common cause of confusion and mis-diagnosis. Phimosis either congenital or acquired as the result of inflammatory swelling and oedema due to fibrotic changes in the prepuce-at times observed in elderly men-predisposes to the condition.

Balano-posthitis may be confused with subpreputial chancre, chancroid or acute gonorrhoea. Chancroid gives rise to multiple, small, superficial and painful ulcers on the opposing surface. It is an acute process with a short incubation period. It gives rise to inflammatory swelling and purulent subpreputial discharge simulating an attack of acute urethritis. There is no localized induration or burning while passing urine. The nature of the condition can easily be guessed and confirmed bacteriologically if the prepuce can be retracted to expose the glans penis. If this is not possible, it is advisable to slit the prepuce dorsally under local anaesthesia so as to expose the part for clear inspection, examination, diagnosis and to facilitate local treatment. In every case of balano-posthitis, it is of the utmost importance to eliminate by adequate examination and laboratory tests the possibility of either syphilis or gonorrhoea or both before the institution of specific treatment.

Symptoms

There is some irritation and itching referable to the glans and the prepuce. Sometimes, pain and burning while passing urine and frequency of micturation may be complained of. Oedema and swelling of the prepuce, yellowish purulent discharge exuding from the preputial opening and tender lymphadenitis in the groin are obvious on inspection. Retraction of prepuce- if possible- reveals bright red mucous membrane with submucosal swelling and oedema. Superficial epithelium is macerated and full of erosive small superficial ulcers. The inflammatory oedema and swelling of the prepuce often make the retractable prepuce irretractable, in which case the true nature of the condition cannot be visualized. If the condition is neglected in the early stages, perforation of the prepuce or phagedenic gangrene may supervene, causing extensive destruction of the tissues.

Diagnosis

It is accomplished in three stages: first the diagnosis of infection, second the exclusion of syphilis and gonorrhoea by appropriate tests, and third, identification of the causative organism responsible. The recognition of the first phase is usually easy and is based on the local and general features of the clinical picture. Since early syphilis and gonorrhoea or both can associate with the condition or may be the primary cause of the condition , their exclusion is of paramount importance. Isolation and identification of the causative organism may not be very simple, but has an importance which cannot be exaggerated. Precise diagnosis becomes essential now that drugs which are effective and often specific exist. This may involve bacteriologic examination to confirm certain organism and to exclude other types of serious infections. Very often a physician is tempted to prescribe straight way antibiotic treatment before a complete and detailed physical examination and isolation and identification of the organism concerned, but this in no way absolves him from taking every step to identify the responsible bacterium and to exclude possibility of syphilis and gonorrhoea by collecting necessary specimens and subjecting them to examinations before specific treatment is instituted.

A very careful and thorough examination is of the utmost importance for the establishment of the true diagnosis and to avoid many common errors to which an average physician falls a victim. Very often a subpreputial discharge associated with dysuria is confused with an attack of acute gonorrhoea or an ulcer on the glans penis or prepuce is taken for a chancre or chancroid, and specific treatment is instituted. Such a practice is not only unfair but also amounts to medical incompetency, the results of which can be serious in the long run. A hasty conclusion of the “balanitis” is full of dangers. Balano-posthitis may be due to various causes which may be classified:-

(A) Inflammatory

(a) Specific infections

• Acute gonococcal urethritis or Tysonitis-Gonococcal discharge produces excoriation of the lining membrane and paves the way for secondary infection.

• Sub-preputial chancre or secondary syphilitic lesions on the glans penis.

• Sub-preputial chancroid.

• Trichomonas vaginalis infestation of the urethra or the sub-preputial sac.

• Mixed bacterial infection of the glans and the subpreputial sac. Impetigo contigiosa, infected scabies and Reiter’s disease giving rise to ‘circinate balanitis’ are at times met with. Staphylococcus aureus & streptococcus pyogenes are often the cause.

Women with vaginal discharges harbour many types of organisms. It is not easy to decide which one will be an innocent saprophyte or aggressive pathogen. The writer has come across recently two cases subjected to I.U.D. leading to inflammation of cervix, which was found to be responsible for the recurrent attacks of balanitis in their male partners. Attacks of inflammatory balanitis invariably followed marital relations. Removal of the I.U.D. resulted in the permanent cessation of trouble, for the couples.

(b) Non-specific infection- Non-specific infection of the subpreputial

sac following sexual exposure or secondary to non-specific

urethritis.

(c) Fungus infection-Monilial infection and aphthous ulceration.

Diabetic men are prone to develop fungus infection of the glans penis. Women who take contraceptive pills are found to develop candidiasis, which is then passed on their male partners; balano-posthitis of candida albicans origin is not uncommon these days, when broad spectrum antibiotics are freely used. Seborrhoeic balanitis is at times met with. Erythrosma glandis-the eruption of dark reddish-brown patches with abrupt edges on the glans penis is at times met with. Removal of the horny layer shows a dense felt-work of the fungus, microsporan minutissimum consisting of threads with joints.

(d) Traumatic- chemical, thermal, mechanical etc. Use of strong

antiseptics or chemicals for prophylaxis or as contraceptives

may give rise to balano-posthitis. It is quite common as the result of insufficient instruction to the patient.

(e) Virus infection- Herpes progenitalis, virus urethritis.

• Constitutional causes :-

• Diabetes mellitus or Hyperparathyroidism often predisposes to balano-posthitis either of fungal or bacterial origin.

• Neglect of personal hygiene leads to accumulation of smegma, formation of concretions and ulceration. Secondary infection may take place.

(C) Neoplastic causes:-

• Subpreputial papillomata or venereal warts.

• Subpreputial epithelioma in its early stages.

Laboratory investigation

If one desires to practice good medicine by modern methods, one has to carry out most of the following investigations. All of them may not be necessary in every case. One has to use one’s discretion. These investigations offer valuable help in the diagnosis and right treatment.

• Dark-field examination for Treponema pallidum on three consecutive days.

• Smear and culture for gonococci. Specimens should be taken from the urethra and the Tyson’s gland.

• Smear for Ducrey’s bacilli.

• Wet preparation for Trichomonas vaginalis.

• Smear and culture for fungi.

• Blood for serologic test for syphilis.

• Urine examination for sugar and albumin.

• Microscopic examination of the tissue to rule out malignancy.

Even though D.G.I. for Tr.pallidum on three successive days and the first S.T.S. are negative, every patient should be submitted at regular intervals for physical check-up and serologic test for over three months to exclude syphilis. It must be remembered that presence of more than one type of infection in a patient is not uncommon in a venereal practice. Accurate diagnosis is not difficult on careful examination, laboratory investigations and detailed interrogations.

Treatment

Specific treatment of balano-posthitis must depend on its cause or causes but much can be done symptomatically for the relief of patient, without interfering with procedures for precise etiologic diagnosis.

(A) Preliminary treatment

Until the exact cause of balano-posthitis has been found out and the possibility of syphilis and gonorrhoea are provisionally excluded, no local applications or other drugs be prescribed which might prejudice the demonstration of the causative organism such as Tr.pallidum or gonococcus. If the prepuce can be retracted, local cleanliness can be carried out by frequent washing with normal saline; the glans penis and the preputial sac are then dried and dusted with sulphur powder, two to three times a day. Sometimes it is advisable to keep a small strip of gauze soaked in saline in between two surfaces. The dressing should be changed 2 to 3 times a day. This type of treatment promotes healing at the same time does not interfere with the process of finding the etiology and arriving at the correct diagnosis.

If there is phimosis or inability to retract the foreskin, dorsal slitting of the prepuce should be recommended. It allows clear view, facilitates investigations and local treatment. If this minor surgical procedure is objected, copious subpreputial irrigation with warm saline (in case oedema swelling) every four hours should be given. Besides, one can use concentrated magnesium Sulphate solution compresses four hourly to reduce swelling. Once the serious infections like syphilis and gonorrhoea are remarkably eliminated, there could be no objection to the use of local antiseptics like 1% picric acid in spirit and sulpha drugs orally.

(B) Specific treatment- This depends on the actual cause, and will vary with etiology.

• If the presence of syphilis is confirmed, anti-syphilitic treatment should be given. The dosage of penicillin-G varies with the stage of disease; 4.8 M.U. in seronegative primary stage and 6 M.U. for sero positive primary stage are considered adequate. Subsequent follow-up must confirm to the standard observations and testings. If there is additional gonococcal infection, it will get treated by the anti-syphilitic treatment.

• If trichomonas vaginalis infestation is detected, Metronidazole 200mg three times a day orally for seven days is indicated. Of course, the contact must be investigated and treated side by side.

• If fungus infection is detected, 1% gentian violet solution in water should be applied locally twice a day. There are many antifungal agents such as Nystatin, Candicine, Primaricine which can be employed with success.
• If diabetes is confirmed, control of glycosuria will be of help. If strong chemicals or antiseptics are at the root, they must be stopped forthwith.

• If herpes genitalis is diagnosed, ordinary dusting powder consisting of equal parts of zinc oxide and boric powder can be prescribed. If mixed bacterial flora is at the root, a course of sulpha drug plus local dressings should suffice. ‘Triadcortyl’ is useful for mixed infection.

• In non-gonococcal urethritis and virus urethritis, there is no one line of treatment which is universally efficacious in all cases. A combination of a course of sulpha drug orally and streptomycin one gm I.M. daily for five days can be tried. Other broad spectrum antibiotics such as Spiramycin, Methacycline, and Lymecycline may be found useful.

• If there are venereal warts, they need cauterization either chemical or electrical or excision.

• If there is chancroid infection, local cleanliness plus a course of sulpha drugs for five days in enough ordinarily.

• If there is phagedenic complication, and fusiform bacillus of Vincent with the spirochaete and streptococci are found, an intensive and energetic treatment with penicillin and local measures have to be given at the earliest. If neglected in the early stages, necrosis and loss of tissues are common.