Balanitis, Bacterial Vaginosis and Other Genital Conditions

1. BALANITIS

1.1. Introduction

Balanitis is defined as inflammation of the glans penis. The condition often involves the prepuce and the term balano-posthitis should be used.

1.2. Aetiology

According to the different aetiology, balanitis can be classified into various clinical varieties:

1.2.1. Infective

This is the commonest cause of balanitis.

1. Candidal balanitis

   Candidal balanitis most frequently follows intercourse with an infected sexual partner. However, infection may occur without sexual contact, usually in diabetic patients or patients taking oral antibiotics. The pathogenicity of the yeast depends on the host factors. There is no significant difference between carriage rate in circumcised and uncircumcised male although the chance of symptomatic infection is higher in the uncircumcisedmen.

   The clinical features include a non-purulent surface, a slightly scaling edge and eroded satellite pustules. The groins may also be affected. Microscopy and culture confirm the diagnosis and should be taken from both partners and from the anal as well as the genital areas.

   Recurrent candidal balanitis causes fissuring of the prepuce, with fibrosis and sclerosis.

2. Trichomonal balanitis

   This occurs more commonly in those with long prepuce. It presents as superficial or erosive balanitis. Phimosis may occur. More severe lesions of chancriform type or penile abscess are occasionally seen. The micro-organism may be seen by taking a specimen from the subpreputial sac and preparing a wet mount.

3. Mycoplasma balanitis

   Balanitis may accompany mycoplasma urethritis, either as a primary infection or secondary to gonorrhoea.

4. Chlamydial balanitis

   In men the most common manifestation chlamydial infection is non-gonococcal urethritis but it may also present as non-specific irritant balanitis.

5. Anaerobic balanitis

   Anaerobes may be isolated in healthy individuals. However, the chance of isolating the organisms is much higher in balanitis. Bacteroides species are the commonest anaerobes seen. The clinical features include superficial erosions, oedema of the prepuce, foul smelling discharge and inguinal lymphadenopathy.

1.2.2. Irritant

Poor hygiene, retained soap, detergent, retained smegma or inadequate drying may cause an irritant dermatitis. Contact dermatitis affects the shaft rather than the glans, except when medicament or contraceptives are involved.

1.2.3. Traumatic

Frictional trauma and accidental wounds cause fissures, erosions or localised area of erythema and oedema. Postcoital frenal erosions are not uncommon.

1.2.4. Premalignant, Malignant or Idiopathic

In chronic unresolving 'balanitis', the following conditions should be excluded:

1. Erythroplasia of Queyrat (Bowen's disease)
2. Extramammary Paget's disease
3. Plasma cell balanitis of Zoon
4. Balanitis xerotica obliterans (BXO, Lichen sclerosus et atrophicus)
5. Circinate balanitis in Reiter's disease
6. Lichen planus
7. Psoriasis

1.3. Treatment

Mild forms of balanitis respond to repeated cool bathing with potassium permanganate (1:8000) and the application of antibacterial creams, with or without weak corticosteroids.

The underlying cause should be treated if possible. Specific remedies are available for candidal balanitis. Both partners should be treated concurrently. There is now large variety of effective anticandidal agents of the polyene or azole group. Ketoconazole, Itraconazole and fluconazole are the oral alternatives for severe cases. Cure rate is about 90 percent. Intestinal or urethral reservoir and re-infection account for the 10% failure rate of refractory cases.

Anaerobic balanitis responds to metronidazole rapidly. Trichomonas infection responds to metronidazole or tinidazole. Mycoplasma balanitis responds to tetracyclines in high dose.

2. BACTERIAL VAGINOSIS

2.1. Definition

It is a polymicrobial clinical syndrome distinguished by a disturbance of the normal microbial ecology of the vagina with displacement of peroxide-producing lactobacillary flora by a proliferation of anaerobes and characteristic abnormalities of the vaginal secretions but not characterized by an inflammatory response.

2.2. Clinical Diagnostic Criteria

1. pH >4.5
2. homogeneous vaginal discharge
3. clue cells by microscopy
4. fishy amine odour after the addition of 10% KOH

The diagnosis of bacterial vaginosis is established when 3 of the 4 criteria are present. The Gram Stain method of vaginal fluid is useful in diagnosing bacterial vaginosis, predicting which woman is at an increased risk of acquisition of bacterial vaginosis later in pregnancy, and identifying women at an increased risk of sexually transmitted disease. A positive culture for Gardnerella vaginalis is not diagnostic and it should not be used as a test of cure following treatment since many women who are colonised by Gardnerella vaginalis lack any objective signs of bacterial vaginosis.

2.3. Clinical Features

It is the commonest type of vaginal infection worldwide among women of reproductive age and accounts for at least one third of all vulvovaginal infections. Women with bacterial vaginosis may be asymptomatic. When they have symptoms, they usually complain of excessive vaginal discharge (whitish or grayish-white) and a fishy vaginal odour especially after sexual intercourse when alkaline seminal fluid causes volatilisation of the amines.

Conditions that are epidemiologically linked to bacterial vaginosis include urinary tract infection, cervical dysplasia, non-puerperal endometritis, pelvic inflammatory disease, mucopurunlent cervicitis, chorioamnionitis, postpartum endometritis, premature labor and low birth weight. Unequivocal sexual transmission of bacterial vagnosis remains to be proven.

2.4. Treatment

1. Oral metronidazole 500 mg bd for 1 week or single oral dose of 2 gm Tinidazole.
2. Clindamycin vaginal cream once daily for 1 week.
3. In pregnancy, metronidazole should be avoided in the first trimester; an alternative drug is ampicillin 500 mg qid for one week orally but it is less effective than metronidazole.

3. OTHER GENITAL CONDITIONS

Patients who are worried about the possibility of venereal diseases may inspect the genitalia frequently. They may notice for the first time in their life certain conditions of no clinical significance and for which require only reassurance.

1. Penile pearls (syn. pearly penile papules, papillae of the coronal sulcus or glans penis, hirsuties papillaris penis, coronal papilla)

   These congenital tiny swellings look like early genital warts but are arranged in rows regularly around the coronal sulcus or scattered over the glans penis. They are merely hypertrophic papillae with normal epidermal covering. They have no clinical significance and it is important not to misdiagnose them as genital warts.

2. Tysons glands

   These are secretory glands which are symmetrically located on either side of the frenulum. They appear as small para-frenal papules which can easily be mistaken by anxious patients as genital warts.

3. Fordyce Spots

   This condition arises from the presence of ectopic sebaceous glands. It may be found under the prepuce and on the vulva. The lesion appear as multiple small, white or yellowspots in submucosa.

4. Lymphocele (syn. sclerosing lymphangitis, benign transient lymphangiectasis)

   In this condition the lymphatics in or near the coronal sulcus may become temporarily blocked and appear as worm-liked translucent masses of cartilage-like hardness. Some cases may follow prolonged or frequent intercourse or are associated with a genital lesion. However in the largest series reported, the majority were unexplained although the patients had coitus. The condition resolves within a few weeksand no treatment is necessary.

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