Approach
Every attempt should be made to make a precise diagnosis when patients present with symptoms and signs of balanoposthitis. Non-specific balanoposthitis is a diagnosis of exclusion and probably not common. STIs, immunosuppression, and diabetes must all be excluded.
A full history should be taken and a thorough examination performed. Investigations may include appropriate swabs and skin biopsy.[1] Two major goals of diagnosis and management should be to minimise problems with sexual and urinary function and identify any conditions placing the patient at risk of developing cancer of the penis.
A primary dermatosis is often present, such as psoriasis, seborrhoeic dermatitis, Zoon balanitis, lichen sclerosus, lichen planus, warts, or carcinoma-in-situ. A suitably targeted biopsy can be helpful in the diagnosis, but histology may be non-specific. Preputial dysfunction is probably the cause in cases of non-specific balanoposthitis, and many patients are likely to have lichen sclerosus as the underlying morbid state.
Candidiasis may be present as a secondary opportunistic phenomenon rather than as a primary cause of disease, in most if not all cases. Candidal balanoposthitis could be an STI with an affinity for the anatomically abnormal penis or in people predisposed by underlying disease or other factors. Screening should be done for other STIs.[1]
History and symptoms
The history of the presenting complaint should include an enquiry into the nature of current symptoms. These will often include:
Pruritus (patients often complain of the cosmetic insult rather than of itch, which may be mild)
Pain or soreness
Dribbling (incontinence can cause skin irritation/dermatitis)
Factors in social and sexual history applicable to further evaluation include:
Age of the patient: younger men are more likely to suffer from an infectious cause of balanoposthitis, while neoplasm may be a more likely cause in older men
Relationship status: single or married, or in a long-term relationship
Sexual history: number of partners, recent sexual activity, route of intercourse (vaginal, oral, anal) and sexual orientation
Contraception: regular and consistent condom use makes an STI less likely, but does not rule it out entirely. In rare instances, allergy to latex or lubricants in condoms may be a contributing factor
Important factors in personal and family medical history include:
Circumcision: removal of the foreskin protects men from many of the causative conditions of balanoposthitis[33][34]
Atopy (eczema, hay fever, asthma, type I allergies): examine patient for evidence of atopic dermatitis elsewhere on the skin
Psoriasis: examine for evidence of psoriasis elsewhere on the skin (e.g., elbows, knees, scalp and lumbosacral areas) and nails (nail pits and onycholysis)
Urological history and symptomatology: consider any history of genital warts, penile discharge or dysuria
Drug history should attempt to determine allergies to any of the following:
Systemic medicines: these can be associated with drug eruption, including fixed-drug eruption, which often is localised to the genitalia
Topical medicines: can be associated with local irritant or allergic reactions at sites of application
Non-prescription medicines
Examination
Examination should include the genital region, and the rest of the body. Special attention should be given to inguinal folds and lymph nodes, scrotum and contents, perineum and anus. The mucous membranes, scalp and hair, nails, teeth, ears, glabella and brows, nasolabial folds, axillae, chest and back all also require examination.
Examine the prepuce for phimosis/paraphimosis and the presence/absence of rash and inflammatory changes. Evaluation of a rash should consider distribution and morphology. Other possible findings include:
Complete loss of pigmentation (vitiligo)
Post-inflammatory hypo-/hyper-pigmentation (lichen sclerosus, lichen planus, Zoon balanitis and other inflammatory dermatoses)
Purpura (lichen sclerosus)
Red scaly patches (psoriasis, reactive arthritis, atopic dermatitis, allergic or irritant contact dermatitis)
Red scaly patches or plaques (Zoon balanitis, erythroplasia of Queyrat, gonorrhoea)
Erosions (herpes simplex, lichen sclerosus, candidiasis, syphilis [chancre], squamous cell carcinoma)
Blisters (allergic contact dermatitis)
Papules/micro-papules (lichen planus)
Pustules (candidiasis)
Tumours
Any lump should be assessed in terms of the site and morphology. Common causes of genital nodules include benign cysts (e.g., median raphe cysts, epidermoid cysts), scabies (especially if pruritic nodules are present on the glans) and squamous cell carcinoma (may have an ulcerated surface).
Lesions of significance can display slight erythema, slight to moderate scaling, and often peri-follicular or frank follicular involvement.
Investigations
Perform as needed to identify specific causative factors. Investigations may include:[1]
Microbiology: Gram stain and culture for bacteria and Candida species, including specific testing for gonorrhoea if indicated; nucleic acid amplification test (NAAT) for: C trachomatis, Mycoplasma genitalium, Neisseria gonorrhoeae, Treponema pallidum.
Dark-field examination of serum from an ulcer: indicated in suspected cases of syphilis.
Virology: preferred tests are PCR or other NAATs, or viral culture.
Mycology: KOH preparation for Candida may be indicated if this agent/fungal infection is suspected or needs to be excluded.
Skin biopsy: may be indicated to clarify diagnostic uncertainty.[1] If balanoposthitis does not improve after implementation of indicated therapy, consider skin biopsy to exclude pre-malignant (e.g., carcinoma in situ/penile intraepithelial neoplasia [PeIN]) and malignant (e.g., squamous cell carcinoma) skin conditions.[40] Zoonoid inflammation is common histologically (especially in lichen sclerosus) and suprabasal differentiated carcinoma in situ/PeIN as seen in lichen sclerosus can be very subtle, so the histology has to be interpreted carefully.
Patch testing: performed only if allergic contact dermatitis is suspected or needs to be excluded.
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