Balanitis and Balanoposthitis

BALANITIS AND BALANOPOSTHITIS. The inflammation that usually simultaneously affects the skin of the glans penis (balanitis) and the inner leaf of the prepuce (posthitis) is called balanoposthitis. The disease can appear independently, accompany, or be a consequence of other local, and sometimes general, diseases. In the first case, inflammation is the result of irritation from accumulated smegma 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, swollen tissue of the glans and the prepuce, a purulent secretion forms, caused by pathogenic microbes. In other cases, balanitis is caused by purulent discharge from the urethra (gonorrhea), various types of ulcers, papular syphilitic eruptions, condylomas, eczema, and seborrhea (seborrhea). Gouty and diabetic patients are particularly predisposed to this disease, as their urine, entering the preputial sac, serves as a nutrient medium for microbes. Balanitis usually runs a chronic course. Patients complain of itching and tickling in the glans penis. When the prepuce is retracted from the preputial sac, a large amount of pus is discharged, often foul-smelling. The surface of the glans and inner leaf appears swollen and red (simple balanitis). On this macerated surface, erosions and abrasions may develop, usually located in the coronal sulcus (erosive balanitis), and in advanced cases, superficial ulcers may form. Without treatment, the process may worsen. The patient's general condition deteriorates, chills appear, temperature rises, and infection penetrating the lymphatic pathways causes lymphangitis, which can be palpated on the genital organ as a thick dorsal, and sometimes lateral, cord. The inguinal glands are often involved in the process. In a rapidly developing process, phimosis may develop, or conversely, the swollen prepuce, when retracted, may not always be easily returned, and the disease may be complicated by paraphimosis. In diagnosis, the origin of the pus is determined (whether it results from urethral inflammation or primary disease of the prepuce). For this, the preputial sac is first washed out, and then the patient is made to urinate. Clear urine and absence of burning during urination rule out gonorrheal urethral involvement. The initial form of balanitis, when the prepuce is retracted from the glans, is easily distinguished from hard and soft chancre. When erosions and ulcers are present, differentiation must be made from secondary syphilitids. Erosions caused by balanitis do not have the infiltrate characteristic of syphilitic papules, and other manifestations of syphilis are also absent. The question is more difficult to resolve when phimosis is present; here it should be borne in mind that soft chancre infection often gives at the orifice of the prepuce the characteristic picture of radiating ulcers molia. The presence of a hard infiltrate palpable through the thickness of the prepuce, inguinal adenitis, and other manifestations of syphilis facilitate the diagnosis of syphilis. Balanitic erosions may also be confused with herpetic eruptions. The latter is characterized by limited localization and polycyclic outlines. On the basis of chronic balanitis, condylomas may develop. The prognosis is not always favorable; sometimes balanitis, especially in childhood, leads to adhesion of the glans to the prepuce (syneciae). 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 a pad of gauze moistened in a 1/7-1/7% solution of silver nitrate placed between the glans penis and the prepuce. The preputial sac is first washed out with some liquid using an irrigator, syringe, or enema. Powders of dermatol, irol, xeroform, and bismuth are useful. Balanitis based on gout and diabetes, in addition to local treatment, requires treatment of the underlying condition. In gonorrheal balanitis, the localization of gonococci in the folds, pockets, and sometimes in the paraurethral passages can cause recurrences of the gonococcal process in the urethra. In persistent balanitis caused by phimosis (especially common in children), surgical intervention (circumcision or incision of the prepuce) is indicated. m. Zutraev. Erosive circinata balanitis (Berdal and Batallle), characterized by the appearance on the glans penis and inner leaf of the prepuce of one or more round erosions, which gradually increase, merge with each other into disks of irregular outlines; at the periphery, the erosions are surrounded by a narrow white border of necrotic epithelium. The authors succeeded in inducing the disease by inoculating pus onto areas devoid of epidermis. It was firmly established that this disease never begins with pustules, but with epithelial necrosis that turns into erosions. Through autoinoculation, erosions appear on healthy areas. With the development of the pathological process, inflammatory phenomena intensify, the amount of purulent discharge increases, edema of the prepuce develops, lymphangitis, buboes, phimosis, and enlargement of the inguinal glands occur; temperature rises; suppuration and disintegration of the glands are never observed. If ulcers form in the buboes or inguinal glands, this is explained by secondary infection caused by streptococci. Sometimes the process spreads deeply and leads to ulcer formation; the ulcers range in size from pinhead to millet seed, are elongated-oval in shape, with an inflammatory border at the periphery, 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 (classified by E. Hoffmann, Loewenthal, Schmoll, and Noguchi in the group Treponema minutum) and Sp. cerelina (Krantz). The disease appears after coitus in 36-48 hours; it can also develop spontaneously under the influence of bacilli and spirochetes present in smegma. In treatment, this disease resolves within 2-5 days; sometimes it lasts 3-4 weeks. Acute erosive circinata and gangrenous balanitis (Scherber and Mueller) is identical to the previous disease. In this form, erosions and ulcers (circinate form) appear rapidly; it can progress to a gangrenous form, in which gangrene of the glans penis and prepuce occurs, perforation of the resulting phimosis; the general condition is disturbed, body temperature significantly rises, and significant bleeding also occurs due to vessel damage. Pustulo-ulcerative balanitis (du Castel) appears several days after suspicious coitus on the inner leaf of the prepuce and glans penis; it is characterized by the development on an inflamed base of pustules of a dark yellowish color, which ulcerate and are covered with a diphtheritic coating; the edges of the ulcers are polycyclic or irregular in shape; they are painful on touch, may be multiple, reach considerable size, and heal with scar formation. Pautrier and Rietmann found in the pustule secretions and diphtheritic coating small thin cocco-bacilli that do not stain by Gram. Chronic ulcerative hypertrophic balanitis (Tieche) is identical to leukoplakia penis (see Leukoplakia), described by Kraus. Diabetic balanoposthitis. Diabetes creates favorable conditions for the multiplication of various bacteria on the genital organs and the formation of balanoposthitis. The disease begins with itching and discharge of foul-smelling pus; the urethral orifice appears reddened, the edges of the mucous membrane swollen. The glans penis is pink, smooth, and sensitive to touch; with further progression, it takes on a dark color, loses its smooth surface, becomes velvety, and is covered with a coating of decomposed smegma; with longer duration of balanitis, papillae of the glans penis proliferate; the vegetations are rich in blood vessels, bleed easily; they can later lead to the formation of epithelioma. According to Englisch, ulcers may form on the prepuce. The ulcers are round or oval in shape, with undermined edges but in the form of ledges; their base is flat, covered with a white coating. Ulcers appear particularly early at the orifice of the prepuce, where numerous cracks form; its gradually increasing edema leads to enlargement of the glans penis, the preputial sac becomes dense and inelastic (cartilage-like prepuce of Fournier); its outer leaf reddens, and finally, in rare cases, it may lead to gangrenous disintegration. In the acid-reacting secretion, Englisch found fungi, which Friedreich attributes to Aspergillus, and Beauvais to Oidium. Diabetic balanoposthitis develops relatively rarely: 7% of diabetic patients suffer from it. Kraurosis of the glans and prepuce of the penis (Delbanco), a process described by Delbanco, leading to wrinkling of the inner leaf of the prepuce and glans penis, loss of their elasticity, characteristic pallor of their surface, and subsequently, a grayish-white to grayish-blue discoloration of the epithelium.

As a result of chronic irritations, deep grooves form on the surface of the glans penis and the preputial sac; with further wrinkling and hardening of the tissue, cracks and excoriations form under mechanical irritations, leading to the development of epithelioma. Brocq associates the development of Kraurosis glandis penis with a special involution of the sexual organs in men, especially after the cessation of sexual function. The disease usually appears after 50 years. V. atrophica, described by Crocker, is similar to leukoplakia glandis penis et praeputii; erosions that form under mechanical irritations lead to the formation of epithelioma; the disease is usually observed in old men. Lit.: Kallomon F., Non-venereal diseases of the sexual organs, Kharkov, 1928; Handbuch der Haut- und Geschlechtskrankheiten, herausg. v. J. Jadassohn. B. XXI, 1927.

I. Lipskerov. BALAN0P0ST0MIK03, an extremely rare form of balanoposthitis with a whitish-gray, scaling, shiny coating, which when removed reveals a dull-red, moist, non-bleeding surface. Bacteriologically in scrapings and in cultures, fungi of Soor's or oidomycetes are most often found. Benedek described a case of infection with balanoposthomycosis oidiomycotica from a wife who suffered from vulvo-vaginitis oidiomycotica. Diabetes is sometimes a predisposing factor. The prognosis is favorable. Washing with weak solutions of sublimate (1 : 3,000-1 : 1,000) and weak sulfur-resorcinol ointments (2-3%) lead to recovery in a few days.