Consensus Statement
Zhang, Li1,2; Abdulrahman, Amer A.A.1,2; Guo, Hao1,2; Zhang, Jia’an3; Gao, Xinghua1,2; Pan, Weihua4; Wang, Gang5; Xu, Jinhua6; Shi, Yuling7; Chen, Liuqing8; Chen, Hongxiang9; Geng, Songmei10; Ran, Yuping11; Wang, Hongwei12; Man, Xiaoyong13; Chang, Jianmin14; Zhang, Furen15; Zhang, Litao16; Yin, Guangwen17; Zhang, Jianzhong18; Lai, Wei19; Niu, Zhibin20; Jiang, Hongkun1; Liu, Haibo1; Chen, Yaolong21; Wang, Jianjian22
Editor(s): Guo, Lishao
1Department of Dermatology, The First Hospital of China Medical University, Shenyang, Liaoning 110001, China
2Key Laboratory of Immunodermatology, Ministry of Education and NHC, National Joint Engineering Research Center for Theranostics of Immunological Skin Diseases, Shenyang, Liaoning 110001, China
3Department of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu 210042, China
4Department of Dermatology, Second Affiliated Hospital of Naval Medical University, Shanghai 200003, China
5Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi 710032, China
6Department of Dermatology, Huashan Hospital, Fudan University, Shanghai 200040, China
7Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai 200443, China
8Department of Dermatology, Wuhan No. 1 Hospital, Wuhan, Hubei 430022, China
9Department of Dermatology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, Guangdong 518052, China
10Department of Dermatology, Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi 710004, China
11Department of Dermatovenereology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
12Department of Dermatology, Huadong Hospital, Fudan University, Shanghai 200040, China
13Department of Dermatology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
14Department of Dermatology, Beijing Hospital, Beijing 100730, China
15Shandong Provincial Hospital for Skin Diseases & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong 250061, China
16Department of Dermatology, Tianjin Academy of Traditional Chinese Medicine Affiliated Hospital, Tianjin 300120, China
17Department of Dermatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
18Department of Dermatology, Peking University People’s Hospital, Beijing 100044 China
19Department of Dermatology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510630, China
20Department of Pediatric Surgery, Shengjing Hospital Affiliated to China Medical University, Shenyang, Liaoning 110004, China
21School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu 730000, China
22West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan 610041, China
Correspondence to: Xinghua Gao, Department of Dermatology, No. 1 Hospital of China Medical University, 155N. Nanjing Street, Shenyang, Liaoning 110001, China E-Mail: [emailprotected]
How to cite this article: Zhang L, Abdulrahman AAA, Guo H, Zhang JA, Gao XH, Pan WH, Wang G, Xu JH, Shi YL, Chen LQ, Chen HX, Geng SM, Ran YP, Wang HW, Man XY, Chang JM, Zhang FR, Zhang LT, Yin GW, Zhang JZ, Lai W, Niu ZB, Jiang HK, Liu HB, Chen YL, Wang JJ. Chinese expert consensus on the diagnosis and treatment of balanoposthitis. Chin Med J 2024;XXX:1–3. doi: 10.1097/CM9.0000000000003172
This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0
Chinese Medical Journal ():10.1097/CM9.0000000000003172, June 11, 2024. | DOI: 10.1097/CM9.0000000000003172
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Balanoposthitis (BP), a common male genitalia inflammation, is managed by clinicians from different specialties, including urology, pediatrics, dermatology, and venereology. Due to this diverse array of clinicians involved, there exists lack of consistent, evidence-based recommendations for BP. The development of the consensus engaged 19 representative hospitals and it adhered to rigorous protocols, encompassing international registration (IPGRP-2021CN003) and the application of evidence grading criteria. Over the period from December 2020 to October 2022, consensus on 12 clinical issues was reached through comprehensive evidence searches and two iterations of Delphi surveys [Supplementary File, https://links.lww.com/CM9/C42].
Disease concept
European guidelines define BP as inflammation from infection (e.g., Candida), dermatoses (e.g., Lichen sclerosus), or premalignancy (e.g., Bowen’s disease).[1] Glans and foreskin regions are commonly affected; hence, the term “balanoposthitis” is recommended,[2] with BP symptoms varying depending on the underlying causes.
Recommendations: BP encompasses inflammatory disorders affecting the glans and foreskin, presenting with erythema, edema, erosion, ulceration, and smegm* secretion. Symptoms include discomfort, itching, and odor (D, 5).
Classification
Previously, BP was categorized into infectious balanitis, balanitis xerotica obliterans, zoon’s plasma cell balanitis, non-specific balanitis, and balanitis circinate.[3] While infection is a common cause of balanitis, a significant number of BP cases also involve non-infectious inflammatory diseases, emphasizing the importance of considering non-infectious causes.
Recommendations: Experts categorize BP into infectious and non-infectious, excluding specific skin conditions. Infectious BP occurs due to pathogens such as fungi and bacteria and non-infectious BP occurs due to unknown causes and in the absence of obvious infections (C, 4).
Correlation with microbial colonization
In a cohort study of 478 men with BP and asymptomatic individuals, Candida colonization prevalence was 26.2%, and candidal balanitis prevalence was 18%.[4]Malassezia, Staphylococcus aureus, Candida albicans, and group B Streptococcus were also reported in BP patients. High rates of gram-positive cocci, fungi, and mycoplasma have also been observed in BP cases. Mycoplasma genitalium was present in 37% of the BP patients, while Chlamydia trachomatis and Ureaplasma urealyticum showed no association.[5]
Recommendations: Microbial infections, including gram-positive cocci (S. aureus, Group B Streptococcus, S. angina, and S. warneri) and fungi (C. albicans and Malassezia spp.), are common in BP (B, 3b). M. genitalium and anaerobic bacteria are occasionally involved (B, 2b).
Correlation with sexual activity
Pathogenic bacteria, including Candida, were detected in balanitis patients and their spouses, indicating a risk factor.
Recommendations: BP is not considered as a sexually transmitted disease (STD), but can also be transmitted through sexual contact, with Candida infection being the main cause. Fungal testing is recommended for patients and their partners, and sexual activity should be avoided during antifungal therapy (B, 2c).
Inducing and aggravating conditions
A greater BP risk is present in diabetics, particularly in untreated individuals, with a link to hemoglobin A1c levels and diabetes management. Circumcision offers protection against penile dermatoses.[6] Antibiotic overuse, immunosuppressants, and glucocorticoids increase the risk for opportunistic infections and BP.
Recommendations: BP risk factors include diabetes (A, 1b), uncircumcision (A, 1b), and immune deficiency. Candidal infection is common (B, 2b). Poor hygiene, excessive cleaning, and use of irritants may contribute to BP (C, 4).
Diagnostic criteria
Male genital inflammation with unknown triggers is suggested to be non-specific BP. UK guidelines recommend penile biopsy for persistent or uncertain balanitis. Biopsy is also critical to exclude precancerous lesions. Increased microbial presence in BP patients underscores the need for swabs and cultures to identify infectious causes.
Recommendations: BP diagnosis relies on clinical manifestations and excludes specific skin disorders, with swabs and cultures used to identify infectious causes (B, 2b). With the absence of infections or non-specific histological abnormalities, the diagnosis is non-specific (non-infectious) BP (D, 5).
Identifying other conditions
Dermoscopy serves to distinguish BP from psoriasis, erythroplasia, and zoon’s plasma cell balanitis, while reflectance confocal microscopy distinguishes BP from psoriasis, lichen sclerosis, and other common inflammatory balanitis. Histopathological examination is strongly recommended for indistinct clinical features, treatment failure, or suspicion of neoplasms. Swabs and cultures are effective for identifying specific penile infections, including STDs [Supplementary Table1, https://links.lww.com/CM9/C42].
Recommendations: Differentiating BP from other skin disorders is aided by dermoscopy, reflectance confocal microscopy, and pathological examination. Swabs and cultures aid in ruling out infections. Testing for herpes simplex virus, syphilis, and gonorrhea is considered in the presence of genital ulcers (C, 4).
Disease severity evaluation
Aside from Li et al,[7] no approved measures of BP severity exist. While this tool lacks rigorous validation and will require further studies, experts agree that it provides a representative evaluation of the disease’s extent.
Recommendations: The 4-point scale of Li et al[7] is recommended. This scale has eight items with scores ranging from 0 to 24 and higher values indicating greater severity (D, 5).
Therapeutic principle
Previous guidelines stress avoiding excessive washing, over-the-counter medications, poor hygiene, and non-retraction of the foreskin.
Recommendations include good hygiene practices, gentle washing (A, 1c); circumcision for congenital phimosis or recurrent BP (A, 1b); antimicrobial medications for infectious BP along with partner treatment (A, 1c); and skin barrier restoration, glucocorticoids, or calcineurin inhibitors for non-infectious BP (D, 5).
Antifungal therapy (systemic and topical)
Recommended topical antifungal agents include 2% ketoconazole, 1% butenafine hydrochloride, 1% clotrimazole, clioquinol (twice daily for 1–2weeks), 1% bifonazole, 1% luliconazole (once daily for 1–2weeks) (A, 1b), and pevisone (twice daily for 14days) (B, 2c). Oral antifungal drugs, fluconazole (150mg single dose) (A, 1b), itraconazole (200mg once daily for 5days), and terbinafine (250mg once daily for 1–2weeks) (B, 2a) are recommended for ineffective/severe cases.
Antibacterial therapy (systemic and topical)
Recommended topical antibiotics include erythromycin, mupirocin (twice daily) (A, 1b), and 2% fusidic acid (thrice daily) (D, 5) for 7–14days. Severe/refractory cases may require oral antibiotics such as fosfomycin tromethamine (3g once daily for 3days) (A, 1b) or erythromycin (500mg once daily for 1 week) (C, 4). Topical 0.75% metronidazole can be used for mild anaerobic bacterial infections and oral metronidazole 400–500mg (twice daily for 1 week) (D, 5) for severe cases.
Antibacterial and antifungal combination therapy (topical)
Combined antibacterial and antifungal topical therapy for refractory BP is recommended in individuals with underlying conditions like diabetes (B, 2c).
In conclusion, this is an evidence-based consensus on BP and serves as a significant step toward advancing the evaluation and management of BP in China. These findings will contribute to a global standardization and future consensus in this field.
Funding
This work was supported by grants from the National Natural Science Foundation of China (No. 82273538); the Public Health Research and Development Program of the Shenyang Science and Technology Bureau (No. 22-321-33-12); and National Key R&D Program of China (No. 2023YFC2508200).
Conflicts of interest
None.
References
1.Edwards SK, Bunker CB, van der Snoek EM, van der Meijden WI. 2022 European guideline for the management of balanoposthitis. J Eur Acad Dermatol Venereol 2023;37:1104–1117. doi: 10.1111/jdv.18954.
- Cited Here |
- Google Scholar
2.Morris BJ, Krieger JN. Penile inflammatory skin disorders and the preventive role of circumcision. Int J Prev Med 2017;8:32. doi: 10.4103/ijpvm.IJPVM_377_16.
- Cited Here |
- Google Scholar
3.Jegadish N, Fernandes SD, Narasimhan M, Ramachandran R. A descriptive study of the clinical and etiological profile of balanoposthitis. J Family Med Prim Care 2021;10:2265–2271. doi: 10.4103/jfmpc.jfmpc_2467_20.
- Cited Here |
- Google Scholar
4.Lisboa C, Santos A, Dias C, Azevedo F, Pina-Vaz C, Rodrigues A. Candida balanitis: Risk factors. J Eur Acad Dermatol Venereol 2010;24:820–826. doi: 10.1111/j.1468-3083.2009.03533.x.
- Cited Here |
- Google Scholar
5.Horner PJ, Taylor-Robinson D. Association of Mycoplasma genitalium with balanoposthitis in men with non-gonococcal urethritis. Sex Transm Infect 2011;87:38–40. doi: 10.1136/sti.2010.044487.
- Cited Here |
- Google Scholar
6.Mallon E, Hawkins D, Dinneen M, Francics N, Fearfield L, Newson R, et al. Circumcision and genital dermatoses. Arch Dermatol 2000;136:350–354. doi: 10.1001/archderm.136.3.350.
- Cited Here |
- Google Scholar
7.Li M, Mao JX, Jiang HH, Huang CM, Gao XH, Zhang L. Microbiome profile in patients with adult balanoposthitis: Relationship with redundant prepuce, genital mucosa physical barrier status and inflammation. Acta Derm Venereol 2021;101:adv00466. doi: 10.2340/00015555-3833.
- Cited Here |
- Google Scholar
