Pathogenesis (development of disease)
Balanitis refers to inflammation of the glans penis (glans). It is often caused by inadequate hygiene or mechanical/chemical irritation. Balanitis is often combined with inflammation of the inner preputial leaf (foreskin leaf) (balanoposthitis). It is not uncommon for phimosis to be a causative factor in balanitis. Phimosis leads to a secondary infection due to urine retention in the preputial sac (= cavity between the prepuce and glans penis, i.e. between the foreskin and glans; colloquially: “urine sump”). According to the cause, three forms of balanitis can be distinguished:
- Acute infectious balanitis
- Bacteria:
- Group B streptococci (GBS) (very rarely: Group A (GAS)), staphylococci (Staphylococcus aureus); Haemophilus parainfluenzae, Escherichia coli.
- Gardnerella vaginalis and other anaerobes such as enterococci, Klebsiella, Morganella, Proteus (anaerobic balanitis).
- Gonococci; Treponema pallidum
- Viruses; herpes virus; human papillomavirus (HPV).
- Mycoses / fungi (Candida albicans) → Balanitis candidomycetica
- Protozoa (unicellular organisms) – trichomads, Entamoeba histolytica (Ruhramöbe).
- Bacteria:
- Non-infectious balanitis – e.g., due to mechanical irritation and degreasing of the glans skin by too frequent cleaning; smegmaretention; rarely contact dermatitis (e.g., condoms, lubricants).
- Chronic non-infectious balanitis – lichen sclerosus (see below Balanitis xerotica obliterans).
Other forms of balanitis are:
- Balanitis simplex – redness and swelling of the glans penis (glans) [most common form].
- Balanitis erosiva – inflammation of the glans penis with erosions (superficial substance defects confined to the epidermis, without scarring).
- Balanitis ulcerosa – inflammation of the glans penis with the formation of ulcers (ulcers).
- Balanitis gangraenosa – inflammation of the glans penis associated with gangrene (tissue death due to reduced blood flow or other damage).
- Balanitis mycotica – inflammation of the glans penis caused by mycoses (fungi).
- Balanitis circinata – inflammation of the glans penis with erythema (areal redness of the skin) and garland-shaped erosions bordered by a whitish epithelial fringe; periurethral (“around the urethra“) area of the glans (“glans”) remains mostly free; occur spontaneously or as a symptom of Reiter’s disease (synonyms: Reiter’s syndrome; Reiter’s disease; arthritis dysenterica; polyarthritis enterica; postenteritic arthritis; posturethritic arthritis; undifferentiated oligoarthritis; urethro-oculo-synovial syndrome; Fiessinger-Leroy syndrome; Engl. Sexually acquired reactive arthritis (SARA)) – special form of “reactive arthritis” (see above. ); secondary disease after gastrointestinal or urogenital infections, characterized by the symptoms of Reiter’s triad; seronegative spondyloarthropathy, which is triggered especially in HLA-B27 positive persons by an intestinal or urinary tract disease with bacteria (mostly chlamydia); Can manifest as arthritis (joint inflammation), conjunctivitis (conjunctivitis), urethritis (urethritis) and partly with typical skin changes.
- Balanitis plasmacellularis (synonym: Balanoposthitis chronica circumscripta benigna plasmacellularis Zoon, Morbus Zoon) – bright sharply circumscribed glans redness with brownish-red color striking plaques (areal or plate-like substance proliferation of the skin) without palpable increase in consistency, often also petechial punctate bleeding / flea-like skin bleeding (“cayenne pepper spots”); mostly unilocular (“in one place”), more rarely multilocular or erosive; occurs mainly in non-circumcised men in the fifth to eighth decade of life; no precancerous lesions, thus favorable prognosis; course: Untreated for years; differential diagnosis: erythroplasia Queyrat (for this, see penile carcinoma / penile cancer).
- Balanitis psoriatica (synonym: psoriasis glandis) – sharply defined, inflammatory reddened foci, which are covered with pearly foci; possibly the only manifestation of psoriasis vulgaris (most common form of psoriasis).
- Balanitis xerotica obliterans – inflammation of the glans penis as a manifestation of lichen sclerosus et atrophicans (chronic disease of the connective tissue, which is probably one of the autoimmune diseases).
The following are the promoting factors of infectious and non-infectious balanitis.
Etiology (Causes)
Biographic causes
- Age – the risk of balanitis increases with age because the top layer of skin is thinner with age
Behavioral causes
- Excessive hygiene (“overtreatment”), as well as lack of hygiene.
- Uncontrolled application of skin care creams → irritation of the genital skin with redness (“overtreatment balanitis”).
- Mechanical/chemical irritation (“overtreatment”).
Disease-related causes
Blood-forming organs – immune system (D50-D90).
- Immunodeficiency, unspecified
Endocrine, nutritional, and metabolic diseases (E00-E90).
- Metabolic disorders, especially diabetes mellitus (diabetes).
Skin and subcutaneous (L00-L99).
- Contact allergies (latex condoms; perfume as well as the alcohol contained therein; ointments; soaps; intimate cosmetics or intimate jewelry).
- Penile dermatoses (skin diseases in the area of the penis): eg psoriasis (psoriasis), atopic eczema (neurodermatitis).
Infectious and parasitic diseases (A00-B99).
- Condyloma acuminatum (synonyms: tip condyloma/peaked condyloma, pointed condyloma, genital wart/fever wart, wet nipple, and genital wart; HPV 6, 11, 40, 42, 43, 44).
- HPV infection (human papillomavirus).
- Syphilis
Neoplasms (C00-D48)
- Bowen’s disease – intraepidermal carcinoma in situ referred to and considered a precursor to squamous cell carcinoma; affects mostly older men; raised, brown-red, scaly plaques on penile scalp skin.
- Bowenoid papulosis of the penis (occurs mainly in younger men).
- Erythroplasia Queyrat – precancerous lesion (possible precancerous lesion) of the transitional epithelium and mucous membranes similar to Bowen’s disease; clinical presentation: solitary roundish and polycyclic configured foci with reddish shiny surface; predilection site in males is the inner preputial blade and glans penis (glans), in females is the transitional mucosa of the vulva (female pubis); progression into invasive spinocellular carcinoma has been described in approx. one third of cases described
Genitourinary system (kidneys, urinary tract-genital organs) (N00-N99).
- Phimosis (narrowing of the foreskin) (children: usually in the context of an existing primary or secondary phimosis).
Other causes
- Iatrogenic (doctor-related): local applications of podophyllotoxin, imiquimod or green tea extract due totreatment of condylomata acuminata (genital warts).
- Drug allergy
- Clothing rubbing
- Secondary infection in intimate jewelry (piercings, etc.)
- Trauma