Aetiology
The aetiology of balanoposthitis depends on the underlying condition. The genitalia may be a site of predilection for inflammatory dermatoses in part due to the Koebner phenomenon (the tendency for skin disorders to appear at sites of trauma). Exposure to potential irritants (e.g., urine, soap), allergens, or infective agents may predispose the delicate tissue of the foreskin to become dysfunctional.
Common causes of balanoposthitis include:[1]
Atopic eczema/dermatitis: a common dermatosis associated with a personal and familial predisposition to dry skin and other atopic diseases such as hay fever and asthma. Atopic eczema in isolation, however, is a rare cause of balanoposthitis.
Allergic contact eczema: caused by a type IV allergic reaction involving cell-mediated immunity after prior sensitisation to the agent concerned. A number of common allergens (e.g., lanolin, fragrance, nickel, rubber) cause a significant proportion of reactions. The risks to the anogenital area (and occasionally the resultant balanoposthitis) result from 3 possible factors:
Direct contact with the allergen
Transfer of the allergen from another part of the anatomy
Involvement in a more generalised eczematous response (e.g., to a medicine or dressing used on venous eczema or ulceration, as in the auto-sensitisation/secondary spread/secondary generalisation syndrome)
Irritant contact eczema: occurs from direct toxicity and can occur in patients without prior sensitisation. The prepuce and glans penis may be considered as vulnerable sites. Irritation may be due to friction from adjacent skin and clothing, toilet paper and towels, sweat, sebum, desquamated corneocytes, dirt, excreta, sexual secretions, detergents, toiletries and cosmetics, contraceptives, some topical treatments, or systemic medicine secreted in the urine (e.g., foscarnet).[3][4] Excessive washing with soap and toiletries is another important factor, and there may be an association with atopy.[5]
Seborrhoeic dermatitis: a very common pattern of eczematous or psoriasiform inflammation that probably results from a diathesis that confers an abnormal hypersensitivity to the normal commensal cutaneous yeast Pityrosporum ovale.
Psoriasis: a common anogenital diagnosis in isolation or supported by other clinical signs. The cause of psoriasis is unknown. Psoriasis is regarded as a disorder of primary immuno-dysregulation determined both by a genetic predisposition and environmental triggers (perhaps streptococcal or other super-antigens) that results in the pathological hallmarks of the disease-vascular changes, leukocyte infiltration, and epidermal hyper-proliferation.
Reactive arthritis (Reiter's disease): part of the same continuum as psoriasis in genetically predisposed people. Reiter's syndrome is defined as arthritis, urethritis, and conjunctivitis.[6] It is precipitated by non-gonococcal urethritis or bacillary or amoebic dysentery and associated with HLA-B27.
Lichen sclerosus: a chronic, inflammatory, and scarring dermatosis with a predilection for the genitalia and a low-grade risk of squamous cell carcinoma.[7][8][9] Genital disease affects only the uncircumcised male.[10][11] Lichen sclerosus of the penis may be asymptomatic, but diverse and vague symptomatology is often encountered.[12][13][14] Infectious agents are not implicated but dysbiosis has been demonstrated.[15] The irritant effect of occluded urine may play a role.[10][16] Gene expression profiling suggests a non-specific inflammatory tissue response in male genital lichen sclerosis and supports the hypothesis that lichen sclerosus is a chronic non-specific inflammatory disease.[17]
Zoon balanitis: a disorder of middle-aged and older uncircumcised men with uncertain aetiology. Evidence suggests that Zoon balanitis is a chronic, reactive, principally irritant mucositis related to a dysfunctional prepuce.[18][19] True Zoon balanitis is probably rare, with most cases actually being due to lichen sclerosus with prominent zoonoid balanoposthitis clinically and histologically. Chronic infection with Mycobacterium smegmatis has been postulated and human papillomavirus (HPV) infection has been implicated.[20][21] Trauma and irritation by urine are probably important factors, and it is possible that most if not all cases are due to lichen sclerosus.[20][22]
Non-specific balanoposthitis: a diagnosis of exclusion and probably not common. Candidiasis may be present as a secondary opportunistic phenomenon, rather than as a primary cause of disease, in most if not all cases. Preputial dysfunction is the likely cause and many cases probably have lichen sclerosus as the underlying condition.
Candidiasis: genitourinary physicians believe that Candida can be the cause of urethritis and balanoposthitis.[23][24]Candida may also be a secondary pathogen in anogenital dermatoses. Candidal balanoposthitis could be an STI with an affinity for the anatomically abnormal penis or in people predisposed by underlying disease or other factors.
Gonorrhoea: usually presents around 4-7 days after infection as urethritis (with purulent semen-like discharge), or more rarely as pharyngitis or conjunctivitis. Anogenital skin manifestations commonly include balanoposthitis and meatal, preputial, and penile oedema and, less commonly, painful lymphadenopathy.
Carcinoma in situ of the penis/penile intraepithelial neoplasia (PeIN): principal underlying causes are HPV infection and/or lichen sclerosus.[25][26] May be referred to as erythroplasia of Queyrat when it occurs on the unkeratinised glans of the uncircumcised male, Bowen's disease when it occurs on the keratinised penile shaft, or Bowenoid papulosis if clinically similar to plain viral warts. Pseudoepitheliomatous keratotic and micaceous balanitis (PEKMB), a manifestation of chronic undiagnosed and untreated lichen sclerosus, is a rare presentation with a high propensity for multifocal PeIN and verrucous carcinoma.[27]
Rare causes of balanoposthitis include:[28][29][30][31][32]
Dermatological bacterial infections (e.g., streptococcal dermatitis, staphylococcal cellulitis, mycoplasma)
Dermatological fungal infections (e.g., tinea)
Dermatological parasitic infections (e.g., myiasis, scabies, amoebiasis)
Sexually transmitted infections (e.g., syphilis, trichomonas vaginalis, lymphogranuloma venereum, non-syphilitic spirochetal ulcerative balanoposthitis)
Auto-immune diseases (e.g., inflammatory vitiligo, Crohn's disease)
Neoplastic conditions (e.g., Kaposi's sarcoma, chronic lymphocytic leukaemia)
Drug related (e.g., fixed drug eruption)
Other conditions (e.g., lichen planus, eccrine syringofibroadenomatosis)
Pathophysiology
The foreskin is a delicate tissue in contact with sweat, moisture, heat, urine, sexual secretions, desquamative products, detergents, potential allergens, and infectious agents. Any of these factors can lead to genital irritation, pain, and dysfunction (e.g., paraphimosis/phimosis, dribbling of urine, dyspareunia). Further progression of infection or inflammation can cause scarring, disfigurement, and, rarely, pre-cancerous or cancerous lesions.
Classification
Conditions affecting the glans and prepuce[1]
Infective
Candida albicans
Streptococci
Anaerobes
Staphylococci
Trichomonas vaginalis
Herpes simplex virus
Human papillomavirus
Mycoplasma genitalium
Inflammatory dermatoses
Lichen sclerosus
Lichen planus
Psoriasis and circinate balanitis
Zoon balanitis
Eczema (including irritant, allergic, and seborrhoeic)
Allergic reactions (including fixed drug eruption and Stevens-Johnson syndrome)
Pre-malignant (penile carcinoma in situ; penile intraepithelial neoplasia [PeIN])
Bowen’s disease
Bowenoid papulosis
Erythroplasia of Queyrat
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