Acorn Inflammation (Balanitis): Causes

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).
  • 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).

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