The most important symptoms of balanoposthitis in sub-Saharan Africa include redness and swelling of the glans and foreskin, accompanied by pain and tenderness. Patients often experience a foul-smelling discharge under the foreskin. Persistent itching and irritation are common, along with difficulty retracting the foreskin (phimosis). In severe cases, ulceration or sores may develop on the affected areas. Painful urination (dysuria) can also occur if the inflammation spreads to the urethral opening.

Clinical findings of balanoposthitis in sub-Saharan Africa include redness and swelling of the glans and foreskin, pain and tenderness, foul-smelling discharge, itching and irritation, and ulceration or sores. Patients may also experience dysuria, difficulty retracting the foreskin (phimosis), and systemic symptoms like fever if a secondary infection is present.

The differential diagnoses of balanoposthitis in sub-Saharan Africa include:

1. The most important differential diagnosis, squamous cell carcinoma of the penis.
2. Balanitis
3. Fixed drug eruption: history of consumption of certain medications prior.
4. Lichen planus
5. Stevens-Johnson Syndrome

 The relevant investigations for balanoposthitis in sub-Saharan Africa include:

1. Clinical Examination

   - Detailed medical history

   - Physical examination of the genital area

2. Microbiological Tests

   Mostly clinical diagnosis and does not require laboratory investigation except in treatment failure.

- Gram Stain and Culture: To identify bacterial infections

   - Viral Testing: For HSV and HP

   - Parasitic Testing: For parasites like Schistosoma haematobium

3. STI Screening:

   - Tests for gonorrhoea, chlamydia, syphilis, and HIV

4. Urinalysis:

   - To check for urinary tract infections and other urinary abnormalities

5. Blood Tests:

   - Complete blood count (CBC)

   - Blood glucose levels (to rule out diabetes)

   - HIV testing

6. Skin Swabs and Biopsies:

   - For persistent or severe cases to rule out dermatological conditions or malignancies

7. Serological Tests:

   - Tests for syphilis (RPR or VDRL) and HIV

8. Allergy Testing: If allergic reactions are suspected as a cause. Most times specific history taking identifies the allergens.

9. Histopathology:

   - For chronic or atypical cases to rule out malignancies or specific dermatological conditions

These investigations help in identifying the underlying cause of balanoposthitis and guide appropriate treatment and management strategies.

Initial empirical management of balanoposthitis in sub-Saharan Africa includes maintaining proper genital hygiene by genital cleaning with water and mild soap (avoid irritants like soap, perfumes, etc) sitz baths and topical antimicrobials therapy. treatment require improved hygiene and better access to medical care. Failure to resolve should prompt further evaluation and specific therapy.

For infections, prescribe appropriate antibiotics or antifungals based on microbiological tests. Treat underlying conditions like diabetes to reduce recurrence. Educate patients on safe sex practices to prevent STI-related cases. Ensure regular follow-up monitor response to treatment and manage any complications.

Flowchart of syndromic treatment of balanitis/balanoposthitis. (adapted from the revised balanitis/balanoposthitis flowchart of the Primary Health Care Standard Treatment Guidelines and Essential Drugs List, 2015) 23

Source: Flowchart of syndromic treatment of balanitis/balanoposthitis. (adapted... | Download Scientific Diagram (researchgate.net)

Follow-up for balanoposthitis involves regular appointments to monitor treatment response and assess for complications. Patients should report any persistent or worsening symptoms. Conduct physical exams during visits and repeat tests if needed. Reinforce education on hygiene, safe sex, and managing underlying conditions.

To prevent and control balanoposthitis:

1. Maintain regular genital hygiene with water and mild soap.
2. Use condoms to reduce the risk of STIs and ensure both partners are tested and treated if necessary.
3. Control blood sugar levels in diabetic patients.
4. Avoid irritants and use hypoallergenic products.
5. Educate about genital hygiene and safe sex practices.
6. Seek prompt medical treatment for symptoms.
7. Consider circumcision in recurrent cases after consulting a healthcare provider.