timphoto-
I believe the medical problem you are experiencing is balanoposthisis.
Could you please tell us what other medical conditions you may have
(ie diabetes). Has your doctor tested your blood sugar to exlude the
possibility of diabetes?
Additionally, I will post a very good review of balanoposthisis below.
You should consider being seen by a urologist. As the article
mentions, the fact that your condition has not improved may be
suggestive of a more serious condition. Perhaps you have a gram
negative infection which needs to be treated with oral antibiotics. I
would also suggest a complete work-up for sexually transmitted
infections. Lastly, as the article mentions, a biopsy to rule-out
squamous cell carcinoma may be necessary. I hope you find the
following information helpful and I hope you will consider
following-up with a urologist and consider a second opinion from
another dermatologist.
Diseases of the foreskin, penis, and urethra.
Lundquist ST - Emerg Med Clin North Am - 01-AUG-2001; 19(3): 529-46
Balanitis is an acute or chronic inflammation of the superficial
cutaneous layers of the glans penis, often involving the distal
foreskin (posthitis). The combination, called balanoposthitis (Fig. 1)
, occurs in all ages, but predominantly in children between ages 2 and
5[40] and in diabetics. It is a fairly common condition, reportedly
diagnosed in 6% of uncircumcised children presenting to their
pediatrician,[20] and 11% of uncircumcised males presenting for care
at a genitourinary clinic.[6] Although the causes are varied,
balanoposthitis can be classified into one of two categories: irritant
and infectious. The majority of authors feel that irritant
balanoposthitis is the most common form,[6] and that the bulk of these
cases are related to poor hygiene. As a result of infection or poor
hygiene, the glans penis and prepuce become inflamed, causing adherent
foreskin and smegma accumulation. Products such as soap, bubble bath,
fabric softeners, and laundry detergent have been implicated as
external irritants that initiate and/or worsen the condition.[40] The
presenting complaints in the emergency department are usually
pruritis, penile discomfort, and swelling. Examination of these
patients reveals redness and swelling of the glans as well as a
discharge from the preputial-glanular sulcus. Urethral discharge is
not typically present. Treatment for irritant balanoposthitis includes
sitz baths, gentle cleansing with foreskin retraction, and, on
occasion, 0.5% hydrocortisone cream.[40] Adequate drying must be
assured after cleansing. If secondary infection is present, antibiotic
treatment may be needed. Candidal infections are felt to be the most
common infectious cause of balanoposthitis and may be concomitant with
irritant balanoposthitis. The symptoms of candidal infection are
similar to those of irritant balanoposthitis, with burning, itching,
and pain of the glans. On physical exam, the glans has generalized
erythema with eroded white plaques and a whitish discharge[12] (Fig.
2) . Again, initial treatment is aimed at improved hygiene with the
addition of a topical antifungal agent such as lotrimin cream (1%) or
miconazole cream (2%).[43]
Less common infectious causes of balanoposthitis include anaerobic,
streptococcal, and sexually transmitted infections. A recalcitrant
case of irritant balanoposthitis may actually be caused by an
anaerobic infection. A short course of erythromycin or penicillin is
recommended to kill anaerobic microbes.[40] Streptococcal infections
have a fiery red appearance with a thin purulent exudate within the
preputial-glanular sulcus. Rapid antigen tests or cultures should be
obtained, and penicillin is the treatment of choice.[40] A detailed
history and physical examination of sexually active males may reveal
other infectious etiologies such as syphilis, herpes, and human
papilloma virus.
Balanoposthitis occurring in specific clinical situations should
heighten the clinician's suspicion for severe systemic disease.
Candidal balanoposthitis diagnosed in an otherwise healthy patient
should be evaluated for diabetes or other immunocompromising
illnesses.[43] Balanoposthitis has been reported as the source of
fever in neutropenic patients.[26] Persistent balanoposthitis despite
aggressive treatment suggests squamous cell carcinoma of the penis and
should be referred to a urologist for evaluation and biopsy.[43]
Finally, if the symptoms of balanoposthitis occur in a sexually active
male with urethral discharge, N. gonorrhea and C. trachomatis should
be considered and excluded.
Complications from acute balanoposthitis treated with appropriate
measures are rare. Chronic balanoposthitis can develop in individuals
that are not treated, inadequately treated, or adequately treated but
continue to have poor genital hygiene. These patients are at risk for
developing phimosis and/or paraphimosis.
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