Balanitis and balanoposthitis: a review

Balanoposthitis in children: Analysis of treatment diversity and development of a treatment proposal

INTRODUCTION

Balanoposthitis in boys with physiological phimosis is common. Publications on the topic are rare and literature provides no evidence-based guidelines on treatment efficacy. With this study, we aim to analyze treatments currently used, physicians' experience regarding the success and thus derive a treatment proposal.

STUDY DESIGN

An online questionnaire was created to evaluate practice patterns and experience. A case scenario, open questions and multiple-choice questions were used to allow multilayered answers. Pediatricians, pediatric surgeons, pediatric urologists, and family practitioners were invited to participate. Demographic data and answers to multiple choice questions were analyzed descriptively. Free text comments were analyzed quantitively by coding the text entries and identifying relevant themes. The themes were then grouped into categories.

RESULTS

Three-hundred-and-one data sets were analyzed. Predominantly, participants were from Germany and Switzerland, and most were specialized in either pediatrics or pediatric surgery. The analysis revealed a wide variability of treatments. Three main treatment forms were identified: baths, topical antiseptic treatment (wraps, gels), and topical antibiotics. Many participants use combinations of the above. Altogether, 53 treatment varieties and 27 categories were identified, including oral antibiotics and local irrigation. Treatment success was reported to be good for all treatment forms, baths were reported to be the best perceived treatment by the majority of participants.

DISCUSSION

The online questionnaire generated valuable data on the wide variety of treatment used for posthitis. The fact that all treatments are reported to be highly effective suggests that little is necessary to treat the condition or that it might even be self-limiting. Further studies will be needed to prove this conclusion. Until those are available, three main concepts should be considered when choosing a treatment: avoid (traumatizing) manipulation, apply antibiotic stewardship and adhere to families' preferences and feasibility.

CONCLUSION

We propose baths or local antiseptics, depending on the practitioner's and family's choice as the least invasive alternative. A prospective study to back our recommendation is scheduled.

Characteristics of the Skin Microbiome in Selected Dermatological Conditions: A Narrative Review

The skin is the largest and outermost organ of the human body. The microbial diversity of the skin can be influenced by several variable factors such as physiological state, lifestyle, and geographical locations. Recent years have seen increased interest in research aiming at an improved understanding of the relationship between the human microbiota and several diseases. Albeit understudied, interesting correlations between the skin microbiota and several dermatological conditions have been observed. Studies have shown that a decrease or increase in the abundance of certain microbial communities can be implicated in several dermatological pathologies. This narrative review (i) examines the role of the skin microbiota in the maintenance of skin homeostasis and health, (ii) provides examples on how some common skin diseases (acne inversa, candidiasis, psoriasis) are associated with the dysbiosis of microbial communities, and (iii) describes how recent research approaches used in skin microbiome studies may lead to improved, more sensitive diagnostics and individual therapeutics in the foreseeable future.

Penile Inflammatory Skin Disorders and the Preventive Role of Circumcision

Penile inflammatory skin conditions such as balanitis and posthitis are common, especially in uncircumcised males, and feature prominently in medical consultations. We conducted a systematic review of the medical literature on PubMed, EMBASE, and Cohrane databases using keywords "balanitis," "posthitis," "balanoposthitis," "lichen sclerosus," "penile inflammation," and "inflammation penis," along with "circumcision," "circumcised," and "uncircumcised." Balanitis is the most common inflammatory disease of the penis. The accumulation of yeasts and other microorganisms under the foreskin contributes to inflammation of the surrounding penile tissue. The clinical presentation of inflammatory penile conditions includes itching, tenderness, and pain. Penile inflammation is responsible for significant morbidity, including acquired phimosis, balanoposthitis, and lichen sclerosus. Medical treatment can be challenging and a cost burden to the health system. Reducing prevalence is therefore important. While topical antifungal creams can be used, usually accompanied by advice on hygiene, the definitive treatment is circumcision. Data from meta-analyses showed that circumcised males have a 68% lower prevalence of balanitis than uncircumcised males and that balanitis is accompanied by a 3.8-fold increase in risk of penile cancer. Because of the high prevalence and morbidity of penile inflammation, especially in immunocompromised and diabetic patients, circumcision should be more widely adopted globally and is best performed early in infancy.

Characterisation of clinically isolated Streptococcus pyogenes from balanoposthitis patients, with special emphasis on emm89 isolates

PURPOSE

Streptococcus pyogenes causes a variety of diseases, such as pharyngitis and toxic shock syndrome. In addition, this bacterium is a causative agent of balanoposthitis. To reveal the bacteriological characteristics of the isolates from balanoposthitis patients, we analysed 47 isolates. In addition, novel clade genotype emm89 S. pyogenes isolates have been reported to be spreading worldwide recently. Hence, we further analysed eight emm89 isolates.

METHODOLOGY

A drug susceptibility experiment was performed and emm types were determined. More detailed experiments, such as PCR analysis for the presence of virulence-associated genes and MLST analysis, were performed especially using emm89 isolates.

RESULTS

All isolates were sensitive to ampicillin, but 34 % of the isolates were resistant to at least one antibiotic. The emm types of the isolates varied, with emm89 and emm11 being the most prevalent, but the emm1 type was not detected. The analysis of emm89 isolates revealed that drug susceptibilities varied. All isolates were negative for the hasABC gene and produced active NADase that are characteristics of novel clade genotype emm89 S. pyogenes. MLST analysis demonstrated that six isolates were of the ST101 type, the most predominant type reported thus far, but two isolates were of the ST646 type. According to the PCR analysis used to determine the presence of streptococcal pyrogenic exotoxin-related genes, the six ST101 isolates were further classified into four groups.

CONCLUSION

These results suggest that balanoposthitis is caused by a variety of types of S. pyogenes, with novel clade genotype emm89 isolates playing a role in balanoposthitis infections in Japan.

Safe and pragmatic use of sodium-glucose co-transporter 2 inhibitors in type 2 diabetes mellitus: South Asian Federation of Endocrine Societies consensus statement

Diabetes prevalence shows a continuous increasing trend in South Asia. Although well-established treatment modalities exist for type 2 diabetes mellitus (T2DM) management, they are limited by their side effect profile. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) with their novel insulin-independent renal action provide improved glycemic control, supplemented by reduction in weight and blood pressure, and cardiovascular safety. Based on the clinical outcomes with SGLT2i in patients with T2DM, treatment strategies that make a "good clinical sense" are desirable. Considering the peculiar lifestyle, body types, dietary patterns (long duration religious fasts), and the hot climate of the South Asian population, a unanimous decision was taken to design specific, customized guidelines for T2DM treatment strategies in these regions. The panel met for a discussion three times so as to get a consensus for the guidelines, and only unanimous consensus was included. After careful consideration of the quality and strength of the available evidence, the executive summary of this consensus statement was developed based on the American Association of Clinical Endocrinologists/American College of Endocrinology protocol.

Pseudoepitheliomatous, Keratotic and Micaceous Balanitis: A Case Report

Pseudoepitheliomatous, keratotic and micaceous balanitis (KPMB) is a rare condition affecting glans penis of elderly men. It is characterized by thick hyperkeratotic plaque with micaceous scaling often leading to phimosis. Here we are reporting a rare case of pseudoepitheliomatous, keratotic, and micaceous balanitis in 50-year-old man who has undergone circumcision 16 years back. Till date only a handful cases have been reported in world literature.

Newborn male circumcision

The circumcision of newborn males in Canada has become a less frequent practice over the past few decades. This change has been significantly influenced by past recommendations from the Canadian Paediatric Society and the American Academy of Pediatrics, who both affirmed that the procedure was not medically indicated. Recent evidence suggesting the potential benefit of circumcision in preventing urinary tract infection and some sexually transmitted infections, including HIV, has prompted the Canadian Paediatric Society to review the current medical literature in this regard. While there may be a benefit for some boys in high-risk populations and circumstances where the procedure could be considered for disease reduction or treatment, the Canadian Paediatric Society does not recommend the routine circumcision of every newborn male.

Opportunistic yeast pathogens: reservoirs, virulence mechanisms, and therapeutic strategies

Life-threatening invasive fungal infections are becoming increasingly common, at least in part due to the prevalence of medical interventions resulting in immunosuppression. Opportunistic fungal pathogens of humans exploit hosts that are immunocompromised, whether by immunosuppression or genetic predisposition, with infections originating from either commensal or environmental sources. Fungal pathogens are armed with an arsenal of traits that promote pathogenesis, including the ability to survive host physiological conditions and to switch between different morphological states. Despite the profound impact of fungal pathogens on human health worldwide, diagnostic strategies remain crude and treatment options are limited, with resistance to antifungal drugs on the rise. This review will focus on the global burden of fungal infections, the reservoirs of these pathogens, the traits of opportunistic yeast that lead to pathogenesis, host genetic susceptibilities, and the challenges that must be overcome to combat antifungal drug resistance and improve clinical outcome.

Phenotypic Detection of Genitourinary Candidiasis among Sexually Transmitted Disease Clinic Attendees in Ladoke Akintola University Teaching Hospital, Osogbo, Nigeria

The management of genitourinary candidiasis (GC) is fraught with challenges, especially, in an era of increasing antifungal resistance. This descriptive cross-sectional study conducted between May 2013 and January 2014 determined the prevalence and characteristics of GC and the species of Candida among 369 attendees of a Sexually Transmitted Disease (STD) clinic of Ladoke Akintola University Teaching Hospital, Osogbo, Nigeria. Appropriate urogenital specimen collected from each attendee was examined by microscopy and culture for Candida, with preliminary species identification by CHROMAgar Candida and confirmation by Analytical Profile Index (API) 20C AUX. The age range of attendees was 1-80 years, mean age was 36.32 ± 11.34 years, and male to female ratio was 1 to 3. The prevalence of genitourinary candidiasis was 47.4%, with 4.9% in males and 42.5% in females (p < 0.0001). The age groups 31-45 and 16-30 have the highest prevalence of 23.3% and 16.8%, respectively. The species of Candida recovered include Candida glabrata 46.9%, Candida albicans 33.7%, Candida dubliniensis 9.7%, Candida tropicalis 5.7%, Candida krusei 1.7%, Candida lusitaniae 1.7%, and Candida utilis 0.6%. This study reported non-C. albicans Candida, especially C. glabrata, as the most frequently isolated species in GC, contrary to previous studies in this environment and elsewhere.

A 'snip' in time: what is the best age to circumcise?

BACKGROUND

Circumcision is a common procedure, but regional and societal attitudes differ on whether there is a need for a male to be circumcised and, if so, at what age. This is an important issue for many parents, but also pediatricians, other doctors, policy makers, public health authorities, medical bodies, and males themselves.

DISCUSSION

We show here that infancy is an optimal time for clinical circumcision because an infant's low mobility facilitates the use of local anesthesia, sutures are not required, healing is quick, cosmetic outcome is usually excellent, costs are minimal, and complications are uncommon. The benefits of infant circumcision include prevention of urinary tract infections (a cause of renal scarring), reduction in risk of inflammatory foreskin conditions such as balanoposthitis, foreskin injuries, phimosis and paraphimosis. When the boy later becomes sexually active he has substantial protection against risk of HIV and other viral sexually transmitted infections such as genital herpes and oncogenic human papillomavirus, as well as penile cancer. The risk of cervical cancer in his female partner(s) is also reduced. Circumcision in adolescence or adulthood may evoke a fear of pain, penile damage or reduced sexual pleasure, even though unfounded. Time off work or school will be needed, cost is much greater, as are risks of complications, healing is slower, and stitches or tissue glue must be used.

SUMMARY

Infant circumcision is safe, simple, convenient and cost-effective. The available evidence strongly supports infancy as the optimal time for circumcision.

Etiology and clinical and epidemiological profile of erosive and ulcerative affections of genitals

The authors present data on clinical characteristics of the course of erosive and ulcerative affections on the skin of genitals in patients who consulted a dermatovenerologist. The authors analyzed factors contributing to the onset of this pathology and having an effect on the severity of its course. They also studied the composition of microbial associations present in the discharge from lesion foci. The authors demonstrated the prevalence of a mixed infection as well as opportunistic microflora in most patients suffering from erosive and ulcerative affections on the skin of genitals.

Barriers to mucosal transmission of immunodeficiency viruses

Lentiviruses such as HIV have a daunting challenge in gaining access to a new host predominantly through the penile, rectal, or vaginal/cervical mucosal tissue after sexual exposure. Multiple mechanisms have evolved to help prevent such infections, including anatomical barriers, innate inhibitors, and adaptive immune responses. For lentiviruses, it appears that in naive or even conventionally vaccinated hosts, typical adaptive immune responses are generally too little and too late to prevent infection. Nevertheless, a combination of anatomical barriers and innate immune responses may limit transmission, especially in patients without predisposing conditions such as mucosal lesions or preexisting sexually transmitted infections. Furthermore, when infection does occur, most often the primary viremia of the acute infection can be traced back genetically to a single founder virus. Unfortunately, even a single virion can establish an infection that will ultimately lead to the demise of the host. This review seeks to describe the biology of and barriers to establishment of systemic, disseminated productive infection with HIV after sexual exposure and to discuss the possible mechanisms leading to infection by a single viral variant. Understanding the initial events of infection, before systemic spread, could provide insights into strategies for reducing acquisition or ameliorating clinical outcome.

Candida infections of the genitourinary tract

All humans are colonized with Candida species, mostly Candida albicans, yet some develop diseases due to Candida, among which genitourinary manifestations are extremely common. The forms of genitourinary candidiasis are distinct from each other and affect different populations. While vulvovaginal candidiasis affects mostly healthy women, candiduria occurs typically in elderly, hospitalized, or immunocompromised patients and in neonates. Despite its high incidence and clinical relevance, genitourinary candidiasis is understudied, and therefore, important questions about pathogenesis and treatment guidelines remain to be resolved. In this review, we summarize the current knowledge about genitourinary candidiasis.

Genital colonisation and infection with candida in heterosexual and homosexual males

OBJECTIVES

To determine the penile, perianal, and oropharyngeal candidal colonisation rates among homosexual and heterosexual males attending an STD clinic. To determine the prevalence of balanitis and candidal balanitis in the two groups.

SUBJECTS

252 heterosexual and 210 homosexual male patients attending consecutively the STD clinic in Coventry, England.

DESIGN

A prospective study recording sexual behaviour, relevant history, symptoms, and examination. Specimens for candida culture were collected from the glans penis, perianal area, and oropharynx.

RESULTS

Among the 462 men studied, penile, perianal, and oropharyngeal colonisation rates were 74 (16%), 70 (15%), and 116 (25%) respectively. On examination, 47 (10%) were found to have balanitis. Of the 74 patients with penile colonisation, 26 (37%) were symptomatic and 20 (27%) had balanitis. The 223 heterosexual and the 196 homosexual males who had sexual intercourse within 3 months had comparable colonisation rates of candida on the penis, perianal area, and oropharynx. Balanitis was seen in 31 heterosexuals (14%) and candidal balanitis in 16 (7%); the incidence was significantly less in homosexuals where balanitis was seen in 12 (6%) and candidal balanitis in four (2%).

CONCLUSIONS

Itching or burning sensations after sex were the most common symptoms associated with penile colonisation with candida and were present in more than one third. Candidal balanitis was commoner in those who had vaginal than those who had anal intercourse within 3 months.

Balanitis and balanoposthitis: a review

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