Abstract

Balanitis is the inflammation of the glans penis while balanoposthitis involves both the glans penis and prepuce and occurs only in uncircumcised males. Balanitis is more common in uncircumcised males due to the occlusive effect of the foreskin, which facilitates smegma retention and bacterial and fungal overgrowth. Therefore, balanitis is rare after circumcision and severe balanitis is even rarer. Circumcision is clearly indicated in recurrent balanoposthitis. On the other hand, in patients with recurrent balanoposthitis, the presence of diabetes should be ruled out.

Diabetes mellitus is a frequent predisposing factor for candida balanoposthitis. In addition, male genital lichen sclerosus has been associated with diabetes mellitus and in progressive stages leads to phimosis. Circumcision is also indicated in the treatment of lichen sclerosus when associated with phimosis.

Candida albicans stands as the primary culprit in cases of acute infectious balanoposthitis, with aerobic bacteria constituting the second most common etiological factor. Among these bacteria, streptococci particularly groups B and D and staphylococci, notably S. aureus, are prevalent. Mixed infections may also occur. The typical clinical manifestations involve erythema and edema accompanied by itching and/or pain. In instances of painful, erosive streptococcal balanoposthitis, severe balanopreputial edema with purulent exudate can be observed.

Staphylococcus haemolyticus, a prominent member of coagulase-negative staphylococci found in the skin microbiota, is known to cause infections in the male urogenital tract, such as urinary tract infections, chronic prostatitis, and epididymo-orchitis. However, it has not been linked to balanitis.

Enterococcus faecalis is part of the normal gastrointestinal microflora and is also a frequent cause of urinary tract infections in both genders and of chronic prostatitis. Enterococcus has been associated with mild balanoposthitis in adults and Enterococcus faecalis has been reported to cause balanoposthitis in young children, but we had also not found its association with severe balanitis in circumcised adults.

We comment the case of a healthy, non-diabetic, circumcised adult male patient with severe, erosive, and painful balanitis due to S. haemolyticus and another case of severe, extensive, and painful balanitis due to E. faecalis in a diabetic, circumcised adult male. In both cases, fungal culture on Sabouraud dextrose agar was negative.

Keywords: Balanitis; Balanoposthitis circumcision; Coagulase-negative staphylococci; Staphylococcus haemolyticus; Enterococci; Enterococcus faecalis