Balanitis and Balanoposthitis

BALANITIS AND BALANOPOSTHITIS. The inflammation that usually occurs simultaneously in the skin of the glans penis (balanitis) and the inner layer of the prepuce (posthitis) is called balanoposthitis. The disease may appear independently, accompany, or be the consequence of other local, and sometimes general, diseases. In the first case, the inflammation is the result of irritation from smegma accumulated in the preputial sac. A narrow and long prepuce is a predisposing factor. In individuals without a prepuce, this disease is usually not observed. Between the reddened, edematous tissue of the glans and the prepuce, a purulent secretion forms, caused by pathogenic microbes. In other cases, balanitis is caused by pus flowing abundantly from the urethra (gonorrhea), various types of ulcers, papular syphilitic eruptions, condylomas, eczema, and seborrhea (B. seborrhoica). Gouty patients and diabetics are especially predisposed to this disease, as their urine, entering the preputial sac, serves as a nutrient medium for microbes. Usually, balanitis runs a chronic course. Patients complain of itching and tickling in the glans penis. When the prepuce is retracted, a significant amount of pus, sometimes foul-smelling, flows from the preputial sac. The surface of the glans and the inner layer appears swollen and red (B. simplex). On this macerated surface, erosions and abrasions may develop, usually located in the coronal sulcus (B. erosiva), and in neglected cases, superficial ulcers may form. In the absence of treatment, the process may exacerbate. The patient's general condition worsens, chills appear, body temperature rises, and the infection, having penetrated the lymphatic vessels, causes lymphangitis, which can be felt on the genital organ in the form of thick dorsal, and sometimes lateral, cords. The inguinal glands are often involved in the process. With a rapidly developing process, phimosis may develop, or conversely, the swollen prepuce, when retracted, may not always be easily reduced, and the disease may be complicated by paraphimosis. In diagnosis, the origin of the pus is determined (whether it is the result of urethral inflammation or a primary disease of the prepuce). For this, the preputial sac is first washed, and then the patient is made to urinate. Clear urine and the absence of burning during urination exclude a gonorrheal lesion of the urethra. The initial form of balanitis, when the prepuce can be retracted behind the glans, is easily distinguished from hard and soft chancres. In the presence of erosions and ulcerations, it is necessary to differentiate from secondary syphilids. Erosions caused by balanitis do not have the infiltrate characteristic of syphilitic papules; other manifestations of syphilis are also absent. The question is more difficult to resolve in the presence of phimosis; here it should be borne in mind that a soft chancre infection often gives a characteristic picture of ulcera mollia radiata at the opening of the prepuce. The presence of a hard infiltrate, palpable through the thickness of the prepuce, inguinal adenitis, and other phenomena of syphilis facilitate the diagnosis of syphilis. Balanitic erosions can also give rise to confusion with herpetic eruptions. The latter are characterized by limited localization and polycyclic outlines. On the basis of chronic balanitis, condylomas may develop. The prognosis is not always favorable; sometimes balanitis leads, especially in childhood, to adhesion of the glans to the prepuce (synechiae). For prophylactic purposes, daily washing of the preputial sac with warm water and soap is useful. Treatment. In developed balanitis, especially erosive, the best remedy is placing gauze soaked in a 1/4–1/2% silver nitrate solution between the glans penis and the prepuce. The preputial sac is pre-washed with some liquid using an irrigator, syringe, or pediatric enema. Powders of dermatol, airol, xeroform, and bismuth are useful. Balanitis on the basis of gout and diabetes, in addition to local treatment, requires treatment of the underlying condition. In gonorrheal balanitis, the localization of gonococci in folds, pockets, and sometimes in paraurethral ducts can cause relapses of the gonococcal process in the urethra. In persistent balanitis caused by the presence of phimosis (especially often in children), surgical intervention (circumcision or incision of the prepuce) is indicated. I. Lipskerov. B. erosiva circinata (Berdal and Batallie) is characterized by the appearance on the glans penis and the inner layer of the prepuce of one or several erosions of a rounded shape, which gradually increase, merge with each other into discs of irregular outlines; at the periphery, the erosions are surrounded by a narrow whitish rim of necrotic epithelium. The authors managed to inoculate pus by inoculation onto areas devoid of epidermis and cause this disease. It was firmly established that this disease never begins with a pustule, but with necrosis of the epithelium, turning into erosions. Through autoinoculation, erosions appear on healthy areas. With the development of the painful process, inflammatory phenomena intensify, the amount of secreted pus increases, edema of the prepuce, lymphangitis, bubonuli, phimosis, and enlargement of the inguinal glands develop; temperature rises; suppuration and breakdown of these are never observed. If ulceration of the bubonuli or inguinal glands occurs, this is explained by a secondary infection caused by streptococci. Sometimes the process spreads into the depth and leads to the formation of ulcerations; the ulcers reach the size of a pinhead to a millet seed, are elongated-oval in shape, with an inflammatory rim at the periphery, and are covered with a yellowish-white diphtheritic coating. This disease is caused by Gram-positive vibrioform bacilli and spirochetes: Spirochaeta refringens (Schaudinn - Hoffmann), transitional forms of Dreyer (attributed by E. Hoffmann, Lowenthal, Schmoll, and Noguchi to the Treponema minutum group), and Sp. cerelina (Krantz). The disease appears after coitus after 36–48 hours; it can also develop spontaneously under the influence of bacilli and spirochetes found in smegma. With treatment, this disease passes within 2–5 days; sometimes it lasts 3–4 weeks. B. acuta erosiva circinata et gangraenosa (Scherber and Müller) is identical to the previous disease. With this form, erosions and ulcerations appear rapidly (circinate form); it can turn into a gangrenous form, in which gangrene of the glans penis and prepuce is observed, perforation of the formed phimosis; the general condition is disturbed, body temperature rises significantly, and significant bleeding is also observed due to damage to blood vessels. B. pustulo-ulcerosa du Castel appears a few days after suspicious coitus on the inner layer of the prepuce and the glans penis; it is characterized by the development on an inflamed base of pustules of a dark yellow color, which ulcerate and are covered with a diphtheritic coating; the edges of the ulcers are polycyclic or irregular in shape; they are painful to the touch, can be multiple, take on a significant size, and heal with the formation of a scar. Pautrier and Rietmann found small thin coccobacilli in the secretion of the pustules and in the diphtheritic coating that do not stain by Gram. B. chronica ulcerosa hypertrophica Tieche is identical to leukoplakia penis (see Leukoplakia), described by Kraus. Balanoposthitis diabetica. Diabetes creates favorable conditions for the reproduction of all kinds of bacteria on the genitals and the formation of balanoposthitis. The disease begins with itching and the discharge of foul-smelling pus; the opening of the urethra appears reddened, and the edges of the mucous membrane are swollen. The glans penis is pink, smooth, and sensitive to touch; in the further course, it takes on a dark color, loses its smooth surface, becomes velvety, and is covered with a coating of decomposed smegma; with a longer duration of balanitis, proliferation of the papillae of the glans penis occurs; the vegetations are rich in vessels and bleed easily; in the future, they can lead to the formation of epithelioma. According to Englisch, ulcerations can form on the prepuce. The ulcers are round or oval in shape, with non-undermined edges, but in the form of steps; their base is flat and covered with a whitish coating. Ulcers appear especially early at the opening of the prepuce, where numerous cracks form; its edema, gradually increasing, leads to an increase in the volume of the glans penis, the preputial sac becomes dense and unyielding (prepuce de carton de Fournier); its outer layer turns red and, finally, in rare cases, can lead to gangrenous decay. In the acid-reacting secretion, Englisch discovered fungi, which Friedreich attributes to Aspergillus, and Beauvais to Oidium. B. diabetica develops relatively rarely: 7% of diabetic patients suffer from it. Kraurosis glandis et praeputii penis (Delbanco), a process described by Delbanco, leading to the shrinking of the inner layer of the prepuce and glans penis, to the loss of their elasticity, a peculiar pallor of their surface, and, subsequently, to a grayish-white to grayish-bluish color of the epithelium.

As a result of chronic irritation, deep furrows form on the surface of the glans penis and the preputial sac; with further wrinkling and induration of the tissue, cracks and excoriations form due to mechanical irritation, leading to the development of epithelioma. Brocq links the development of Kraurosis glandis penis to a specific involution of the genital organs in men, especially after the extinction of sexual function. The disease usually appears after the age of 50. Balanitis atrophica, described by R. Crocker, is analogous to leukoplakia glandis penis et praeputii; erosions forming due to mechanical irritation lead to the formation of epithelioma; the disease is usually observed in the elderly. Lit.: Kallomon F., Non-venereal diseases of the genital organs, Kharkov, 1928; Handbuch der Haut- und Geschlechtskrankheiten, herausg. v. J. Jadassohn. B. XXI, 1927.