Balanitis and posthitis:
To paediatric surgeons, the most obvious medical reasons for circumcision are balanitis (inflammation of the glans) and posthitis (inflammation of the foreskin). Both are very painful conditions.
Posthitis is limited to uncircumcised males. Balanitis is seen in 11-13% of uncircumcised men, but in only 2% of those who are circumcised [172, 305]. In uncircumcised diabetic men it is 35% [305].
In boys the incidence of balanitis is twice as high in those who are uncircumcised [190, 244]. In babies, balanitis is caused by soiled diapers, playing and sitting in dirty areas, antibiotic therapy, as well as yeast and other micro-organisms. Balanitis caused by the group A haemolytic variety of Streptococcus is present exclusively in uncircumcised boys [412]. In children, balanoposthitis is most common between age 2 to 5 [168]. About 4% of uncircumcised boys get it [168].
In balanoposthitis the entire front end of the penis becomes red, painful and swollen, often accompanied by a smelly discharge of pus [514]. It tends to be associated with phimosis and inability to clean under the foreskin of young boys because the foreskin is still lightly attached to the penis beneath it [514].
Balanitis is a cause of phimosis, as discussed in the section on Physical Problems. Pathological phimosis can arise from secondary cicatrization of the foreskin orifice due to balanitis xerotica obliterans (BXO). Once thought to be rare, and a disorder presenting in adulthood, BXO is now regarded as common in young boys, in whom treatment by circumcision is advocated to prevent the complications that occur later in life [653]. Thus whereas a rate of 1% has been reported [467], others find an incidence in the UK of 5-6% in uncircumcised boys under 18 and under 15, respectively [221, 257].
A study in Plymouth found BXO in 35% of the 80% of boys aged 3 months to 16 years (mean 6) who had been circumcised following foreskin problems [653]. Histological abnormalities were seen in 85% of those circumcised, chronic inflammation in 47%, and fibrosis in 3% [653]. In this study, overall BXO frequency in the boys referred was 12%. Similarly, a prospective study involving 1,178 boys in Budapest who presented consecutively over the decade 1991-2001 and were then treated by circumcision found by histological examination that BXO incidence was 40%, peaking at age 9-11 (76%), BXO being the cause of the secondary phimosis in all of these [301]. In the study as a whole, 19% of boys had early, 60% intermediate and 21% late form of BXO.
The narrow foreskin opening causes urinary obstruction that can be partial or complete. As well as urethral stenosis, meatal stenosis is seen, making it a significant condition [653]. Indeed, BXO is generally regarded as an indication for circumcision [653]. In one series in Boston of pediatric BXO, amongst 41 patients, 52% had been referred for phimosis, 13% for balanitis and 10% for buried penis [196]. Of these, 46% underwent curative circumcision, 27% also had BXO involvement of the meatus and had not only circumcision, but meatotomy or meatoplasty, and 22% required extensive plastic surgery of the penis, including buccal mucosa grafts, demonstrating a more severe and morbid clinical course.
The incidence of yeast fungi was 44% in uncircumcised boys and 18% in circumcised boys (ages 8 months to 18 years; men 6.4 years), i.e., was 2.4 times higher in the uncircumcised [264]. The yeast species found were, in order of frequency, Malassezia globosa, M. furfur, M. slooffiae, Candida albicans, C. tropicalis, C. parapsilosis. All were present in uncircumcised infants (age <1 year), but none in circumcised. A gradual accumulation then occurred in a portion of the circumcised boys with age so that by age 18 yeast were found in 62.5% of uncircumcised and 37.5% of circumcised boys.
Penile skin diseases also include psoriasis, those arising from penile infections, lichen sclerosis, lichen planus, schorrheic dermatitis, and Zoon balanitis. The various conditions have been extensively reviewed [166, 305] and are either much more common in, or totally confined to, uncircumcised males. For example, all patients with plasma cell (Zoon) balanitis, bowenoid papulosis, and non-specific balanoposthitis were uncircumcised [346]. Mycobacterium smegmatis has been implicated in Zoon balanitis [166]. Typical symptoms of Zoon balanitis include erythrema (in 100%), swelling (in 91%), discharge (in 73%), dysuria (in 13%), bleeding (in 2%) and ulceration (in 1%) [305].
In a study involving men aged 24-70, lesions were on the foreskin and glans of 59%, foreskin only 23% and glans only 18% [313]. ‘The importance of circumcision as the treatment of choice is emphasized’ [313]. In pediatric patients 37% with severe phimosis had lichen sclerosis [476]. Lichen sclerosis has been found in 4–19% of all foreskins, and in older patients progressive Lichen sclerosis or other inflammatory changes lead to phimosis [47]. Phimosis in older men is, moreover, associated with 44-85% of cases of penile cancer [366].
Balanoposthitis:
Balanoposthitis (inflammation of the foreskin and glans) is common in uncircumcised diabetic men, owing to a weakened shrunken penis [172] and such men also have more intercourse problems. Diabetes is common, inherited and rising in incidence, so this, especially when there is a family history of diabetes, may add to considerations about whether to circumcise an infant at birth.
Most cases of inflammatory dermatoses are diagnosed in uncircumcised men (overall odds ratio 3.2). Thus circumcision is protective [346]. The disorders include psoriasis, penile infections, lichen sclerosus, lichen planus, schorrheic dermatitis, and Zoon balanitis (referred to above).
All patients with Zoon balanitis, bowenoid papulosis, and nonspecific balanoposthitis were uncircumcised. Lichen sclerosis is found in 4-19% of all foreskins [156]. It has been seen in 62% of foreskins of Hungarian men circumcised for phimosis [398]. In older patients progressive Lichen sclerosis or other inflammatory changes lead to phimosis [47]. For a more extensive account on diseases of the penis see the references [166, 305].
