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CASE REPORT
Ahead of print publication  

An unusual cause of multiple penile ulcers and balanoposthitis in a young male


 Department of General Surgery, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission10-Sep-2021
Date of Decision13-May-2022
Date of Acceptance14-May-2022
Date of Web Publication17-Sep-2022

Correspondence Address:
Shrihari Chandrasekaran,
Department of General Surgery, Pondicherry Institute of Medical Sciences, Puducherry - 605 014
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrsm.jcrsm_68_21

  Abstract 


Balanoposthitis is a common inflammatory condition of the glans and prepuce among sexually active men in sexually transmitted diseases clinics. The common causes of this condition are infective, most commonly candidal, followed by bacterial and inflammatory. Among young uncircumcised men who are not sexually active, balanoposthitis may be the first clinical sign of underlying Type II diabetes mellitus (DM). Here, we present one such patient who presented with balanoposthitis and penile cellulitis. On initial workup, he was found to be a diabetic with poor control (HbA1c 11%), and on further investigations, he was found to have Staphylococcal balanoposthitis. He was initially managed with intravenous antibiotics, insulin therapy, and a dorsal slit of the prepuce, followed by circumcision, insulin, and oral hypoglycemic agents. DM should be suspected in all uncircumcised males presenting with balanoposthitis in the absence of positive contact history.

Keywords: Balanoposthitis, circumcision, dorsal slit, penile cellulitis, Type II diabetes mellitus



How to cite this URL:
Chandrasekaran S, Palaniappan NK, Raju Mandapati JJ. An unusual cause of multiple penile ulcers and balanoposthitis in a young male. J Curr Res Sci Med [Epub ahead of print] [cited 2022 Oct 4]. Available from: https://www.jcrsmed.org/preprintarticle.asp?id=356215




  Introduction Top


Balanoposthitis is an inflammatory condition of the male glans and prepuce. It is a common condition among male patients in sexually transmitted disease clinics. Uncircumcised preputial skin, poor hygiene, buildup of smegma, and a tight foreskin are considered the risk factors for this condition. Uncircumcised males with diabetes mellitus (DM) are those with the highest risk. Candida species are the most common cause of this condition, especially in patients with underlying predisposing factors such as DM and other immunosuppressed states. Bacteria such as Streptococci, Staphylococci, Treponema pallidum, and Chlamydia trachomatis form the second most common cause of this condition, followed by viral and parasitic agents.[1] Inflammatory etiologies include contact dermatitis, reactive arthritis, and lichen sclerosus. Acquired balanoposthitis may be the first clinical sign of underlying DM in adults.[2] Here, we present a case of bacterial balanoposthitis in a young male who was detected to have DM with poor control. Hence, DM should be suspected in all uncircumcised males presenting with balanoposthitis in the absence of positive contact history.


  Case Report Top


A 27-year-old male came with complaints of pain and swelling over his penis for 4 days. It was sudden in onset and increased in size over 4 days, associated with fever and chills, whitish discharge from the prepuce, and difficulty in micturition. There was no history of sexual contact earlier. He had no comorbidities previously. On examination, preputial skin was edematous, tender and underlying glans showed multiple circinate ulcers on its surface associated with pus discharge and redness surrounding it [Figure 1]. The testes and scrotum were normal. He was catheterized and his urine was sent for culture. His blood sugar on admission was 205 mg% with an HbA1c of 11%. His urine routine showed sugars 2+, white blood cells 2/hpf, and red blood cells 5/hpf. His viral markers were nonreactive and his urine culture showed no growth. An emergency dorsal slit was done under a penile block. A pus swab was taken which showed heavy growth of Staphylococcus aureus. Dermatologist's opinion was sought and they suspected herpes genitalis. Tzanck smear was negative for herpes infection. He was treated empirically with a broad-spectrum antibiotic and antiviral initially and was changed to the appropriate antibiotic after the culture report showed heavy growth of S. aureus. Given his elevated sugars, he was started on insulin Mixtard 30/70 (8-0-8 U s/c) and sustained release metformin at a dose of 1 gram twice daily. He was advised to return after a week for circumcision. The inflammation and discharge reduced drastically 1 week later, and circumcision was done [Figure 2]. The circumcised skin showed inflammatory changes on biopsy.
Figure 1: Inflamed preputial skin with the glans showing multiple circinate ulcers on its surface with pus discharge

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Figure 2: Postcircumcision image with the glans showing healed ulcers

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  Discussion Top


Bacterial balanoposthitis should be suspected in the presence of intense erythema along with transudative or exudative preputial discharge. The common aerobic bacteria are Streptococcus pyogenes and S. aureus. Mild cases can receive therapy with topical antibiotics such as mupirocin 2% cream TID for 7–14 days. In severe cases or when phimosis prevents topical treatment, therapy should commence with oral antibiotics such as cephalexin or erythromycin for 1 week. Cases with concomitant Group A streptococcal pharyngitis are treatable as pharyngitis with beta-lactam.[3] Diabetes is related to balanoposthitis and acquired phimosis. Bromage et al. found that 26% of patients with balanitis were found to have Type II DM. The diagnosis of DM was made for the first time in 8% of these patients which means that balanoposthitis in a healthy male is a cutaneous marker of DM. Another 15% of males had impaired glycemic control.[4]

In India, diabetes-related balanoposthitis is more problematic than sexually transmitted balanoposthitis. The presentation may be more severe in patients with underlying DM than those without, with edema and fissuring of the foreskin, which may become nonretractile.[3] Phimosis with preputial fissures may be a specific sign of undiagnosed DM.[5] It can be explained by the accumulation of advanced glycation end products in the foreskin.[2] Balanoposthitis should be viewed as a manifestation of an immunocompromised state, which can occur at any age and need not be limited to sexually active men.[6] Diabetes has a growing impact on urological practice with an increased incidence of erectile dysfunction, voiding dysfunction, and urinary tract infections among diabetics than nondiabetics.[7]

Drivsholm et al., in their study, found that the incidence of balanitis was 12% among those patients who were newly diagnosed with Type II DM.[8] It is important to recognize this condition by appropriate blood glucose testing to promptly initiate treatment to avoid late and long-term complications.[6] Meta-analysis has shown that circumcision can decrease the prevalence of inflammatory conditions of the glans penis by 68%.[9] If phimosis is the presenting complaint severe enough to cause urinary obstruction, the patient should be urgently catheterized. If unable to place a catheter, the patient may require more invasive interventions such as a dorsal slit as done in our case. Circumcision can be deferred until preputial edema has subsided.[10] HIV should be ruled out in every case not responding to therapy/having an atypical presentation.


  Conclusion Top


Balanoposthitis may be the first clinical sign of DM in males. Appropriate blood glucose testing should be carried out when assessing men with balanoposthitis. Treatment with dorsal slit and appropriate antibiotic during the acute phase and circumcision of the involved foreskin after the inflammatory process has subsided, along with adequate glycemic control form the cornerstones of the management of these patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his image and other clinical information to be reported in the journal. The patient understood that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lisboa C, Ferreira A, Resende C, Rodrigues AG. Infectious balanoposthitis: Management, clinical and laboratory features. Int J Dermatol 2009;48:121-4.  Back to cited text no. 1
    
2.
Verma SB, Wollina U. Looking through the cracks of diabetic candidal balanoposthitis! Int J Gen Med 2011;4:511-3.  Back to cited text no. 2
    
3.
Pandya I, Shinojia M, Vadukul D, Marfatia YS. Approach to balanitis/balanoposthitis: Current guidelines. Indian J Sex Transm Dis AIDS 2014;35:155-7.  Back to cited text no. 3
    
4.
Bromage SJ, Crump A, Pearce I. Phimosis as a presenting feature of diabetes. BJU Int 2008;101:338-40.  Back to cited text no. 4
    
5.
Huang YC, Huang YK, Chen CS, Shindel AW, Wu CF, Lin JH, et al. Phimosis with preputial fissures as a predictor of undiagnosed type 2 diabetes in adults. Acta Derm Venereol 2016;96:377-80.  Back to cited text no. 5
    
6.
Saoji V, Achliya A. Balanoposthitis as a cutaneous marker of diabetes mellitus in an apparently healthy male. Our Dermatol Online 2015;6:289-91.  Back to cited text no. 6
    
7.
Goldstraw MA, Kirby MG, Bhardwa J, Kirby RS. Diabetes and the urologist: A growing problem. BJU Int 2007;99:513-7.  Back to cited text no. 7
    
8.
Drivsholm T, de Fine Olivarius N, Nielsen AB, Siersma V. Symptoms, signs and complications in newly diagnosed type 2 diabetic patients, and their relationship to glycaemia, blood pressure and weight. Diabetologia 2005;48:210-4.  Back to cited text no. 8
    
9.
Edwards SK, Bunker CB, Ziller F, van der Meijden WI. 2013 European guideline for the management of balanoposthitis. Int J STD AIDS 2014;25:615-26.  Back to cited text no. 9
    
10.
Thiruchelvam N, Nayak P, Mostafid H. Emergency dorsal slit for balanitis with retention. J R Soc Med 2004;97:205-6.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

 
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