Difference between revisions of "Balanitis"

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'''Balanitis''' is an inflammation of the [[glans]] (AKA ''balanus''), but is not necessarily an infection. Balanitis may occur together with [[posthitis]] (inflammation of the [[foreskin]], AKA ''posthe''), when it is known as balanoposthitis.<ref name="edwards1996">{{REFjournal
+
{{GraphicWarning}}
 +
[[File:Inflammation of the glans penis and the preputial mucosa.jpg|thumb|Inflammation of the [[glans penis]] and the [[preputial mucosa]] of a [[circumcised]] penis (''balanitis'')]]
 +
'''Balanitis''' is an inflammation of the [[glans]] (AKA ''balanus''), but is not necessarily an [[infection]]. Balanitis may occur together with <b>[[posthitis]]</b> (inflammation of the [[foreskin]], AKA ''posthe''), when it is known as '''balanoposthitis'''.<ref name="edwards1996">{{REFjournal
 
  |last=Edwards
 
  |last=Edwards
 
  |first=Sarah
 
  |first=Sarah
 +
|init=S
 
  |author-link=
 
  |author-link=
 
  |title=Balanitis and balanoposthitis: a review
 
  |title=Balanitis and balanoposthitis: a review
Line 15: Line 18:
 
  |DOI=10.1136/sti.72.3.155
 
  |DOI=10.1136/sti.72.3.155
 
  |accessdate=2019-10-07
 
  |accessdate=2019-10-07
−
}}</ref> Balanitis xerotica obliterans (BXO) is a separate and distinct condition. For more information on BXO, see [[Balanitis xerotica obliterans]]. Balanitis can occur in both circumcised and intact (non-circumcised) males.
+
|format=PDF
 +
}}</ref> Balanitis xerotica obliterans (BXO) is a separate and distinct condition. For more information on BXO, see [[Balanitis xerotica obliterans]]. Balanitis can occur in both [[circumcised]] and [[intact]] (non-circumcised) males.
  
−
It has many causes, including fungal, yeast, virus, or bacterial infection, environmental irritants, excess sugar in urine, and others.
+
It has many causes, including fungal, yeast, virus, or bacterial infection, environmental irritants, excess sugar in [[urine]], and others.
−
The treatment of balanoposthitis requires accurate diagnosis of the cause of the balanoposthitis because different treatments are required for different causes. Abdennader ''et al''. (1996) observe that such dermatological conditions as psoriasis, lichen planus, lichen sclerosus, fixed drug eruptions, and bullous diseases are ''not'' balanitis.<ref>{{REFjournal
+
The treatment of balanoposthitis requires accurate diagnosis of the cause of the balanoposthitis because different treatments are required for different causes. Abdennader et al. (1996) observe that such dermatological conditions as psoriasis, lichen planus, lichen sclerosus, fixed drug eruptions, and bullous diseases are ''not'' balanitis.<ref>{{REFjournal
 
  |last=Abdennader
 
  |last=Abdennader
−
  |first=S
+
  |init=S
 
  |author-link=
 
  |author-link=
 
  |last2=Casin
 
  |last2=Casin
−
  |first2=I.
+
  |init2=I
 
  |last3=Janier
 
  |last3=Janier
−
  |first3=M.
+
  |init3=M
 
  |last4=Morel
 
  |last4=Morel
−
  |first4=P.
+
  |init4=P
 
  |title=Balanitis and balanoposthitis: a review
 
  |title=Balanitis and balanoposthitis: a review
 
  |journal=Genitourin Med
 
  |journal=Genitourin Med
Line 41: Line 45:
 
  |accessdate=2019-10-07
 
  |accessdate=2019-10-07
 
}}</ref>
 
}}</ref>
−
 
−
One can’t properly treat balanoposthitis until one knows what is causing it.  Different causes require different treatments.  When one knows the cause, then an appropriate treatment can be selected.<ref name="edwards1996" />
 
−
 
−
Diagnosis requires an accurate history, and such tests as biopsy and a swab with a culture.<ref name="edwards1996" /> In the absence of a diagnosis, any prescription for treatment is a guess and is likely to fail.
 
  
 
==Childhood==
 
==Childhood==
  
−
The foreskin is protective of the glans penis in childhood.<ref>{{REFjournal
+
The [[foreskin]] is protective of the [[glans penis]] in childhood.<ref>{{GairdnerDM 1949}}</ref> [[Robert S. Van Howe|Van Howe]] (1997) reported data collected in his pediatric practice on 468 boys up to 18 years of age. Among boys less than three years of age, [[circumcised]] boys were significantly more likely to have a reddened meatus or balanitis.<ref>{{REFjournal
−
|last=Gairdner
 
−
|first=Douglas
 
−
|author-link=Douglas Gairdner
 
−
|title=The fate of the foreskin: a study of circumcision
 
−
|journal=Brit Med J
 
−
|date=1949-12-24
 
−
|volume=2
 
−
|issue=
 
−
|pages=1433-7
 
−
|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2051968/pdf/brmedj03656-0009.pdf
 
−
|quote=
 
−
|pubmedID=15408299
 
−
|pubmedCID=2051968
 
−
|DOI=10.1136/bmj.2.4642.1433
 
−
|accessdate=2019-10-12
 
−
}}</ref> Van Howe (1997) reported data collected in his pediatric practice on 468 boys up to 18 years of age. Among boys less than three years of age, circumcised boys were significantly more likely to have a reddened meatus or balanitis.<ref>{{REFjournal
 
 
  |last=Van Howe
 
  |last=Van Howe
−
  |first=RS
+
  |init=RS
−
  |author-link=Robert Van Howe
+
  |author-link=Robert S. Van Howe
 
  |title=Variability in penile appearance and penile findings: a prospective study
 
  |title=Variability in penile appearance and penile findings: a prospective study
 
  |journal=Brit J Urol
 
  |journal=Brit J Urol
Line 80: Line 64:
 
  |DOI=10.1046/j.1464-410x.1997.00467.x
 
  |DOI=10.1046/j.1464-410x.1997.00467.x
 
  |accessdate=2019-10-01
 
  |accessdate=2019-10-01
−
}}</ref> Boys who have been circumcised are likely to experience balanitis caused by exposure to ammoniacal diapers (nappies).<ref>{{REFjournal
+
}}</ref> Infant boys who have been [[circumcised]] are likely to experience balanitis caused by exposure to ammoniacal diapers (nappies).<ref>{{REFjournal
 
  |last=Simpson
 
  |last=Simpson
−
  |first=E.
+
  |init=E
 
  |author-link=
 
  |author-link=
 
  |last2=Baraclough
 
  |last2=Baraclough
−
  |first2=P.
+
  |init2=P
 
  |title=The management of the paediatric foreskin
 
  |title=The management of the paediatric foreskin
 
  |journal=Australian Family Physician
 
  |journal=Australian Family Physician
Line 98: Line 82:
 
  |DOI=
 
  |DOI=
 
  |accessdate=2019-07-10
 
  |accessdate=2019-07-10
−
}}</ref> Hsieh ''et al''. (2006), working in Taiwan, where boys are not circumcised, examined 2,149 elementary pre-adolescent schoolboys. Hsieh ''et al''. found ''only'' one case of balanitis in the intact 2,149 boys,<ref>{{REFjournal
+
}}</ref> Hsieh et al. (2006), working in Taiwan, where boys are not [[circumcised]], examined 2,149 elementary pre-adolescent schoolboys. Hsieh et al. found ''only'' one case of balanitis in the 2,149 [[intact]] boys,<ref>{{REFjournal
 
  |last=Hsieh
 
  |last=Hsieh
−
  |first=T.F.
+
  |init=TF
 
  |author-link=
 
  |author-link=
 
  |last2=Chang
 
  |last2=Chang
−
  |first2=C.H.
+
  |init2=CH
 
  |last3=Chang
 
  |last3=Chang
−
  |first3=S.S.
+
  |init3=SS
 
  |title=Foreskin development before adolescence in 2149 schoolboys
 
  |title=Foreskin development before adolescence in 2149 schoolboys
 
  |journal=Int J Urol
 
  |journal=Int J Urol
Line 114: Line 98:
 
  |url=https://onlinelibrary.wiley.com/doi/full/10.1111/j.1442-2042.2006.01449.x
 
  |url=https://onlinelibrary.wiley.com/doi/full/10.1111/j.1442-2042.2006.01449.x
 
  |quote=
 
  |quote=
−
  |pubmedID=   16882064
+
  |pubmedID=16882064
 
  |pubmedCID=
 
  |pubmedCID=
 
  |DOI=10.1111/j.1442-2042.2006.01449.x
 
  |DOI=10.1111/j.1442-2042.2006.01449.x
 
  |accessdate=2019-10-09
 
  |accessdate=2019-10-09
−
}}</ref> which suggests a protective effect for the foreskin.
+
}}</ref> which suggests a protective effect for the [[foreskin]].
 +
 
 +
A boy's [[foreskin]] should not be retracted until the boy does it for himself.<ref name="Wright1994">{{REFjournal
 +
|last=Wright
 +
|init=JE
 +
|title=Further to the "Further Fate of the Foreskin"
 +
|journal=Med J Aust
 +
|volume=160
 +
|issue=
 +
|pages=134-135
 +
|url=http://www.cirp.org/library/normal/wright2/
 +
|quote=
 +
|pubmedID=8295581
 +
|pubmedCID=
 +
|DOI=
 +
|date=1994-02-07
 +
|accessdate=2024-11-05
 +
}}</ref>
  
 
==Excessive washing and non-specific dermatitis==
 
==Excessive washing and non-specific dermatitis==
  
−
Birley ''et al''. (1993) report excessive washing, especially with the use of soap, will dry the oils out of tissues and cause a balanitis like inflammation. The use of soap (including body wash, shower gel, and shampoo) should be avoided.<ref name="Birley1991" >{{REFjournal
+
Birley et al. (1993) report excessive washing, especially with the use of soap, will dry the oils out of tissues and cause a balanitis like inflammation. The use of soap (including body wash, shower gel, and shampoo) should be avoided.<ref name="Birley1991" >{{REFjournal
 
  |last=Birley
 
  |last=Birley
−
  |first=H.D.L.
+
  |init=HDL
 
  |author-link=
 
  |author-link=
 
  |last2=Wasker
 
  |last2=Wasker
−
  |first2=M.M.
+
  |init2=MM
 
  |last3=Luzzi
 
  |last3=Luzzi
−
  |first3=G.A.
+
  |init3=GA
 
  |etal=yes
 
  |etal=yes
 
  |title=Clinical Features and management of recurrent balanitis; association with atopy and genital washing
 
  |title=Clinical Features and management of recurrent balanitis; association with atopy and genital washing
Line 143: Line 144:
 
  |DOI=10.1136/sti.69.5.400
 
  |DOI=10.1136/sti.69.5.400
 
  |accessdate=2019-10-07
 
  |accessdate=2019-10-07
−
}}</ref> Although it is commonly believed that the human [[foreskin]] is the source of infection so must be constantly washed to prevent infection, that is not true. Fleiss, Hodges & Van Howe (1998) report the foreskin has both protective and immunological functions that help to prevent disease.<ref name="Fleiss1997">{{REFjournal
+
}}</ref> Although it is commonly believed that the human [[foreskin]] is the source of infection so must be constantly washed to prevent infection, that is not true. [[Paul M. Fleiss|Fleiss]], [[Frederick M. Hodges| Hodges]] & [[Robert S. Van Howe|Van Howe]] (1998) reported the foreskin has both [[Immunological and protective function of the foreskin| protective and immunological functions]] that help to prevent disease.<ref name="Fleiss1997">{{FleissP HodgesF VanHoweRS 1998}}</ref>  Washing removes the protective substances and leaves the [[penis]] prone to [[infection]], so washing should be limited and soap should not be used.
−
  |last=Fleiss
+
 
−
  |first=Paul M.
+
Balanoposthitis is ''not'' usually an indication for circumcision.
−
  |author-link=Paul M. Fleiss
+
 
−
  |last2=Hodges
+
==Yeast infections and diabetic males==
−
  |first2=G.M.
+
 
−
  |last3=Van Howe
+
Diabetic males who have high sugar in their [[urine]] may have recurrent yeast infections. Verma & Molina (2011) report that balanoposthitis caused by yeast infection is prevalent in [[India]] where [[circumcised]] men are rare and the rate of diabetes is high.<ref name="verma2011">{{REFjournal
−
  |first3=R.S.
+
  |last=Verma
−
  |title=Immunological functions of the human prepuce
+
  |first=Shyam B.
−
  |journal=Sex Trans Inf
+
|init=SB
−
  |date=1998-10-01
+
  |author-link=
−
  |volume=74
+
  |last2=Molina
−
  |issue=5
+
  |first2=Uwe
−
  |pages=364-7
+
|init2=U
−
  |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758142/pdf/v074p00364.pdf
+
  |author2-link=
 +
  |etal=no
 +
  |title=Looking through the cracks of diabetic candidal balanoposthitis!
 +
  |journal=Int J Gen Med
 +
|location=
 +
  |date=2011-07-07
 +
  |volume=4
 +
  |issue=
 +
  |pages=511-3
 +
  |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3150172/
 +
|archived=
 +
|quote=
 +
|pubmedID=21845057
 +
|pubmedCID=3150172
 +
|DOI=10.2147/IJGM.S17875
 +
|accessdate=2020-06-23
 +
}}</ref> Better control of sugar levels is indicated.  Recurrent yeast infections that are not responsive to better management of diabetes may be relieved by [[Adolescent and adult circumcision| circumcision]].
 +
 
 +
Yeast infections may cause adult-onset [[phimosis]]. Yeast infections may usually be successfully treated by application of topical clotrimazole.<ref>{{REFjournal
 +
|last=Crowley
 +
|first=
 +
|init=PD
 +
|author-link=
 +
|last2=Galagher
 +
|first2=HC
 +
|init2=
 +
|author2-link=
 +
|etal=no
 +
|title=Clotrimazole as a pharmaceutical: past, present and future
 +
|trans-title=
 +
|language=
 +
|journal=J Appl Microbiol
 +
|location=
 +
|date=2014-09
 +
|volume=117
 +
|issue=3
 +
|article=
 +
|page=
 +
|pages=611-7
 +
|url=https://sfamjournals.onlinelibrary.wiley.com/doi/full/10.1111/jam.12554
 +
|archived=
 
  |quote=
 
  |quote=
−
  |pubmedID=10195034
+
  |pubmedID=24863842
−
  |pubmedCID=1758142
+
  |pubmedCID=
−
  |DOI=10.1136/sti.74.5.364
+
  |DOI=10.1111/jam.12554
−
  |accessdate=2019-10-07
+
  |accessdate=2021-05-31
−
}}</ref> Washing removes the protective substances and leaves the [[penis]] prone to infection, so washing should be limited and soap should not be used.
+
}}</ref>
 +
==Diagnosis and treatment==
 +
Balanitis has many possible instigators. Diagnosis requires an accurate history, and such tests as biopsy and a swab with a culture.<ref name="edwards1996" /> In the absence of a diagnosis, any prescription for treatment is a guess and is likely to fail.
  
−
Balanoposthitis is ''not'' an indication for circumcision.
+
One can’t properly treat balanoposthitis until one knows what is causing it.  Different causes require different treatments.  When one knows the cause, then an appropriate treatment can be selected.<ref name="edwards1996" />
  
−
==Diabetic males==
+
{{SEEALSO}}
  
−
Diabetic males who have high sugar in their urine may have recurrent yeast infections. Better control of sugar levels is indicated.  Recurrent yeast infections that are not responsive to better management of diabetes may be relieved by [[circumcision]].
+
* [[Immunological and protective function of the foreskin]]
 +
* [[Issues with American urologists and the practice of male circumcision]]
 +
* [[Penis]]
 +
* [[Preputial sac]]
 +
* [[Regret men]]
 +
* [[Smegma]]  
  
 
{{LINKS}}
 
{{LINKS}}
−
 
 
* {{REFweb
 
* {{REFweb
 
  |url=http://www.cirp.org/library/disease/balanitis/
 
  |url=http://www.cirp.org/library/disease/balanitis/
 
  |title=Balanitis
 
  |title=Balanitis
−
|last=
+
  |publisher=[[CIRP]]
−
|first=
 
−
  |publisher=
 
−
|website=Circumcision Information Reference Library
 
 
  |date=2008-02-14
 
  |date=2008-02-14
 
  |accessdate=2019-10-07
 
  |accessdate=2019-10-07
−
|format=
 
−
|quote=
 
 
}}
 
}}
−
 
 
* {{REFweb
 
* {{REFweb
 
  |url=https://web.archive.org/web/20041030063437/http://www.bashh.org/guidelines/2002/balanitis_0901b.pdf
 
  |url=https://web.archive.org/web/20041030063437/http://www.bashh.org/guidelines/2002/balanitis_0901b.pdf
 +
|archived=yes
 
  |title=2001 National Guideline on the Management of Balanitis
 
  |title=2001 National Guideline on the Management of Balanitis
 
  |last=Clinical Effectiveness Group
 
  |last=Clinical Effectiveness Group
−
|first=
 
−
|publisher=
 
 
  |website=Wayback Machine
 
  |website=Wayback Machine
 
  |date=2001
 
  |date=2001
 
  |accessdate=2019-10-07
 
  |accessdate=2019-10-07
−
  |format=
+
  |format=PDF
−
|quote=
 
 
}}
 
}}
−
 
 
* {{REFweb
 
* {{REFweb
 
  |url=https://www.nhs.uk/conditions/balanitis/
 
  |url=https://www.nhs.uk/conditions/balanitis/
 
  |title=Balanitis
 
  |title=Balanitis
−
|trans-title=
 
−
|language=
 
−
|last=
 
−
|first=
 
−
|author-link=
 
 
  |publisher=National Health Service
 
  |publisher=National Health Service
−
|website=
 
 
  |date=2017-05-31
 
  |date=2017-05-31
 
  |accessdate=2020-01-10
 
  |accessdate=2020-01-10
−
|format=
 
−
|quote=
 
 
}}
 
}}
  
Line 218: Line 248:
 
  |url=https://www.doctorsopposingcircumcision.org/for-professionals/alleged-medical-benefits/phimosis-balantis/
 
  |url=https://www.doctorsopposingcircumcision.org/for-professionals/alleged-medical-benefits/phimosis-balantis/
 
  |title=Phimosis and Balanitis
 
  |title=Phimosis and Balanitis
−
|last=
+
  |publisher=[[Doctors Opposing Circumcision (D.o.C.)]]
−
|first=
 
−
  |publisher=Doctors Opposing Circumcision
 
−
|website=Doctors Opposing Circumcision
 
 
  |date=2019
 
  |date=2019
 
  |accessdate=2019-10-07
 
  |accessdate=2019-10-07
Line 230: Line 257:
 
{{REF}}
 
{{REF}}
  
−
[[Category:Disease]]
+
[[Category:Medical condition]]
−
[[Category:Medical conditions]]
+
[[Category:Medical term]]
−
[[Category:Penile disorders]]
+
[[Category:Penile disorder]]
 +
[[Category:Penile illness]]
  
 
[[Category:From Intactipedia]]
 
[[Category:From Intactipedia]]

Latest revision as of 23:02, 5 November 2024

IntactiWikiGraphicWarning.png

Inflammation of the glans penis and the preputial mucosa of a circumcised penis (balanitis)

Balanitis is an inflammation of the glans (AKA balanus), but is not necessarily an infection. Balanitis may occur together with posthitis (inflammation of the foreskin, AKA posthe), when it is known as balanoposthitis.[1] Balanitis xerotica obliterans (BXO) is a separate and distinct condition. For more information on BXO, see Balanitis xerotica obliterans. Balanitis can occur in both circumcised and intact (non-circumcised) males.

It has many causes, including fungal, yeast, virus, or bacterial infection, environmental irritants, excess sugar in urine, and others. The treatment of balanoposthitis requires accurate diagnosis of the cause of the balanoposthitis because different treatments are required for different causes. Abdennader et al. (1996) observe that such dermatological conditions as psoriasis, lichen planus, lichen sclerosus, fixed drug eruptions, and bullous diseases are not balanitis.[2]

Childhood

The foreskin is protective of the glans penis in childhood.[3] Van Howe (1997) reported data collected in his pediatric practice on 468 boys up to 18 years of age. Among boys less than three years of age, circumcised boys were significantly more likely to have a reddened meatus or balanitis.[4] Infant boys who have been circumcised are likely to experience balanitis caused by exposure to ammoniacal diapers (nappies).[5] Hsieh et al. (2006), working in Taiwan, where boys are not circumcised, examined 2,149 elementary pre-adolescent schoolboys. Hsieh et al. found only one case of balanitis in the 2,149 intact boys,[6] which suggests a protective effect for the foreskin.

A boy's foreskin should not be retracted until the boy does it for himself.[7]

Excessive washing and non-specific dermatitis

Birley et al. (1993) report excessive washing, especially with the use of soap, will dry the oils out of tissues and cause a balanitis like inflammation. The use of soap (including body wash, shower gel, and shampoo) should be avoided.[8] Although it is commonly believed that the human foreskin is the source of infection so must be constantly washed to prevent infection, that is not true. Fleiss, Hodges & Van Howe (1998) reported the foreskin has both protective and immunological functions that help to prevent disease.[9] Washing removes the protective substances and leaves the penis prone to infection, so washing should be limited and soap should not be used.

Balanoposthitis is not usually an indication for circumcision.

Yeast infections and diabetic males

Diabetic males who have high sugar in their urine may have recurrent yeast infections. Verma & Molina (2011) report that balanoposthitis caused by yeast infection is prevalent in India where circumcised men are rare and the rate of diabetes is high.[10] Better control of sugar levels is indicated. Recurrent yeast infections that are not responsive to better management of diabetes may be relieved by circumcision.

Yeast infections may cause adult-onset phimosis. Yeast infections may usually be successfully treated by application of topical clotrimazole.[11]

Diagnosis and treatment

Balanitis has many possible instigators. Diagnosis requires an accurate history, and such tests as biopsy and a swab with a culture.[1] In the absence of a diagnosis, any prescription for treatment is a guess and is likely to fail.

One can’t properly treat balanoposthitis until one knows what is causing it. Different causes require different treatments. When one knows the cause, then an appropriate treatment can be selected.[1]

See also

External links

References

  1. ↑ a b c REFjournal Edwards S. Balanitis and balanoposthitis: a review PDF. Genitourin Med. 1996; 72: 155-9. PMID. PMC. DOI. Retrieved 7 October 2019.
  2. ↑ REFjournal Abdennader S, Casin I, Janier M, Morel P. Balanitis and balanoposthitis: a review. Genitourin Med. 1996; 72: 434-5. PMID. PMC. DOI. Retrieved 7 October 2019.
  3. ↑ REFjournal Gairdner DMT. The fate of the foreskin: a study of circumcision. British Medical Journal. 1949; 2(4642): 1433-7. PMID. PMC. DOI. Retrieved 28 October 2019.
  4. ↑ REFjournal Van Howe RS. Variability in penile appearance and penile findings: a prospective study. Brit J Urol. 1 November 1997; 80(6): 776-81. PMID. DOI. Retrieved 1 October 2019.
  5. ↑ REFjournal Simpson E, Baraclough P. The management of the paediatric foreskin. Australian Family Physician. 1 May 1998; 27(5): 381-3. PMID. Retrieved 10 July 2019.
  6. ↑ REFjournal Hsieh TF, Chang CH, Chang SS. Foreskin development before adolescence in 2149 schoolboys. Int J Urol. 2006; 13(7): 968-70. PMID. DOI. Retrieved 9 October 2019.
  7. ↑ REFjournal Wright JE. Further to the "Further Fate of the Foreskin". Med J Aust. 7 February 1994; 160: 134-135. PMID. Retrieved 5 November 2024.
  8. ↑ REFjournal Birley HDL, Wasker MM, Luzzi GA, et al. Clinical Features and management of recurrent balanitis; association with atopy and genital washing. Genitourin Med. 1 October 1993; 69(5): 400-3. PMID. PMC. DOI. Retrieved 7 October 2019.
  9. ↑ REFjournal Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Infect. October 1998; 74(5): 364-67. PMID. PMC. DOI. Retrieved 14 January 2022.
  10. ↑ REFjournal Verma SB, Molina U. Looking through the cracks of diabetic candidal balanoposthitis!. Int J Gen Med. 7 July 2011; 4: 511-3. PMID. PMC. DOI. Retrieved 23 June 2020.
  11. ↑ REFjournal Crowley PD, Galagher, HC. Clotrimazole as a pharmaceutical: past, present and future. J Appl Microbiol. September 2014; 117(3): 611-7. PMID. DOI. Retrieved 31 May 2021.
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