Balanitis; vulvitis — expanded notes
Definitions and causes
Balanitis is inflammation of the glans; balanoposthitis affects glans and foreskin. Vulvitis is inflammation of vulvar skin and mucosa. Causes include infection, irritant/allergic contact dermatitis, inflammatory dermatoses, moisture, occlusion, diabetes and immunosuppression.
Infectious causes
- Candida may cause erythema, soreness, itch, fissures and satellite papules/pustules; recurrent disease should prompt consideration of diabetes or immunosuppression.
- Bacterial infection may cause malodour, purulent discharge, erosions and tenderness.
- STIs including HSV, syphilis, HPV, gonorrhoea, chlamydia and trichomoniasis may cause genital lesions or associated symptoms; test according to presentation and exposure.
Inflammatory dermatoses
Eczema and contact dermatitis cause erythema, itch, soreness and fissuring. Psoriasis may present as well-demarcated erythematous plaques with little scale in moist genital skin. Lichen sclerosus causes porcelain-white atrophic plaques, fissures and scarring; in males it may lead to phimosis and meatal stenosis, and in females may cause architectural change and increased vulvar squamous cell carcinoma risk. Lichen planus may cause erosive painful mucosal disease.
Assessment
Take a sensitive, confidential history of symptoms, sexual exposure, products, hygiene practices, antibiotics, diabetes, pregnancy and recurrence. Examine the full genital and perianal region. Consider swabs, fungal microscopy/culture, STI NAATs and glucose/HbA1c where appropriate. Biopsy persistent, atypical, ulcerated, indurated, pigmented or treatment-resistant lesions.
Management
Remove irritants and avoid over-washing; use bland emollients and gentle drying. Treat proven or strongly suspected infection with organism-appropriate therapy. Use topical corticosteroids or calcineurin inhibitors for inflammatory dermatoses with site-appropriate potency and duration. Lichen sclerosus requires appropriate potent topical corticosteroid regimens and follow-up. Address diabetes, moisture, phimosis and other predisposing factors. Urgent review is needed for urinary retention, paraphimosis, necrosis, severe pain, fever or rapidly progressive swelling.