CASE REPORT

Balanoposthitis and Penile Edema: Atypical

Manifestations of Primary Syphilis
Roger Rovira-López, MD, Pablo García-Martínez, MD, Gemma Martín-Ezquerra, MD, PhD,
Ramon M. Pujol, MD, and Daniel López Aventín, MD

Abstract: The typical finding in primary syphilis stage is a unique,

painless chancre with indurated borders. We report a case of primary syph-
ilis presenting as erosive and crusted balanoposthitis with an underlying
chancre, penile edema, and bilateral inguinal lymphadenopathy in a hetero-
sexual man.
CASE REPORT
A previously healthy, 46-year-old heterosexual man pre-
sented to the emergency department with a 10-day history of pain-
less penile shaft edema, along with diffuse swelling and crusted
erosions over the entire glans penis and prepuce (Figs. 1 and 2).
Examination also revealed an indurated ulceration on the glans,
underneath the crusts. Bilateral voluminous tender inguinal lymph-
adenopathy was palpable. The rest of the physical examination
showed no abnormalities. He referred last unprotected sexual
intercourse with a woman 2 months earlier. Bacteriological
and mycological cultures from the glans resulted positive for
Staphylococcus aureus and Haemophilus parainfluenzae, but
negative for Candida albicans. Polymerase chain reaction (PCR)
for herpes simplex virus DNA was negative. A multiplex PCR
assay for the simultaneous detection of Chlamydia trachomatis,
Neisseria gonorrhoeae, Trichomonas vaginalis, and Mycoplasma
genitalium in urethral swab specimen resulted negative. Sero-
logical testing for syphilis was performed: a rapid plasma re- FIGURE 1. Prominent penile edema and erosive and
agin test gave a result of 1:8 and specific immunoglobulin crusted balanoposthitis.
M enzyme immunoassay against Treponema pallidum yielded
values of 4.56 U/mL (reference range, 0.1–1.5 U/mL). HIV serol- wide range of causes, but infection is the most commonly reported
ogy was negative. Histopathological examination from a non- etiology.1 Syphilitic balanoposthitis is a rare manifestation of
ulcerated zone of the glans penis revealed a psoriasiform epithelial syphilis. Follmann was the first to describe 3 cases of primary
hyperplasia covered with a parakeratotic and multilocular serous
exudative horny layer, vascular dilatation, and a dense and diffuse
infiltrate of numerous plasma cells, lymphocytes, and histiocytes
in the upper subepithelial connective tissue (Fig. 3). A real-time
PCR for detection of T. pallidum was performed in formalin-
fixed and paraffin-embedded skin biopsy and resulted positive.
Primary syphilis presenting as balanoposthitis with associated
underlying chancre, penile edema, and bilateral inguinal lymph
nodes enlargement was diagnosed. The presence of S. aureus
was considered a secondary infection and H. parainfluenzae
as a mucosal commensal. Treatment with a single intramuscu-
lar injection of 2.4 million units of benzathine-penicillin and
topical 2% fusidic acid ointment led to the resolution of all clin-
ical manifestations within 3 weeks.
Balanitis is defined as inflammation of the glans penis,
which often involves the prepuce (balanoposthitis). There are a

From the Department of Dermatology, Hospital del Mar–Parc de Salut

Mar, Barcelona, Catalonia, Spain.
Conflicts of interest and source of funding: None declared.
Correspondence: Roger Rovira-López, MD, Department of Dermatology,
Hospital del Mar–Parc de Salut Mar Passeig Marítim, 25–29, 08003
Barcelona, Catalonia, Spain. E-mail: RRovira@parcdesalutmar.cat.
Received for publication May 19, 2015, and accepted June 13, 2015. FIGURE 2. Detail of the glans penis and foreskin. Note the erosive
DOI: 10.1097/OLQ.0000000000000322 erythema, whitish macules of the glans and prepuce, adherent
Copyright © 2015 American Sexually Transmitted Diseases Association crusts on the glans, and an indurated ulceration compatible with a
All rights reserved. chancre on the left side of the glans.

524 Sexually Transmitted Diseases • Volume 42, Number 9, September 2015

Copyright © 2015 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
AQ1
FIGURE 3. Biopsy from the glans penis showing elongation of rete
ridges, vascular dilatation, and a dense and diffuse infiltrate of
numerous plasma cells, lymphocytes, and histiocytes in the upper
subepithelial connective tissue (hematoxylin-eosin, original
magnification 100).
syphilis presenting as erosive balanitis without a chancre.2–4
Since then, around 10 cases have been published in the medical
literature.3–8 Clinical features of the syphilitic balanitis or balano-
posthitis are variable, including an edematous and dark erythem-
atous balanitis and the presence of erosions, crusts, or coalescent
smooth white/pink papules and plaques on the surface of the
glans.3,4,6,7 Diffuse cardboard-like induration of the glans penis
may be present.3,4 In syphilitic balanitis of Follmann, a chancre
may be present before, concomitant with (as was the case in our
patient), or after the balanitis. However, it may also be absent in
some cases.3,4,7 In only one case, balanitis and penile edema oc-
curred simultaneously with a cutaneous eruption on his buttocks,
lower abdomen, scrotum, thighs, and soles representing an unusual
manifestation of secondary syphilis.8 The pathogenesis of syphi-
litic balanitis of Follmann was discussed by Lejman and Starzycki.7
A massive intraepidermal accumulation of T. pallidum secondary
to an active penetration of the spirochetes through the walls of
capillaries and the epidermal basal membrane would cause a dif-
fuse inflammation of the glans penis. Inguinal lymphadenopathy
is usually present and must lead to a suspicion of primary syphilis.3,4
Diagnosis of syphilitic balanoposthitis requires the exclusion of
other infectious (C. albicans, groups B and D streptococci, anaer-
obes, herpes simplex virus) and noninfectious (lichen sclerosus
et atrophicus, lichen planus, Zoon balanitis, psoriasis, Reiter
Sexually Transmitted Diseases • Volume 42, Number 9, September 2015
Copyright © 2015 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Balanoposthitis and Penile Edema
syndrome, eczema, fixed drug eruption, erythroplasia of Queyrat)
causes of balanoposthitis.1,3,4 In addition, acute penile edema can
be caused by infection, filariasis, vigorous sexual intercourse, irri-
tant or allergic contact dermatitis, injury, paraphimosis, adverse
drug reaction, or insect bite.8,9 The presence of S. aureus in a pre-
viously reported patient was considered by the authors as a sec-
ondary infection,3 as it was in the present case.
Syphilitic balanitis and balanoposthitis may be the unique
clinical expression of primary syphilis. Serological tests for
syphilis should be performed in any case of balanitis, especially
when the glans penis is indurated and inguinal lymphadenopathy
is present.3 Demonstration of T. pallidum by direct detection
methods (dark-field examination, PCR, immunohistochemistry,
or Warthin-Starry argentic staining depending on local expertise
and availability of each laboratory) provides definitive diagnosis of
syphilitic infection.10 Treatment of syphilitic balanitis of Follmann
is identical to that of primary syphilis consisting of a single dose
of 2.4 million units of benzathine-penicillin administered intra-
muscularly.4 Finally, although a very uncommon condition, syph-
ilitic balanitis should be considered in the differential diagnosis
of balanitis attending to the recrudescence of syphilis during the
last years.
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