Balanitis xerotica obliterans

Infobox_Disease
Name = Balanitis xerotica obliterans


Caption =
DiseasesDB = 31995
ICD10 = ICD10|N|48|0|n|40 Leukoplakia of penis
ICD9 =
ICDO =
OMIM =
MedlinePlus =
eMedicineSubj = derm
eMedicineTopic = 46
MeshID =

Balanitis xerotica obliterans (BXO) is a dermatological (skin) condition affecting the male genitalia. It was first described by Stuhmer in 1928, though earlier reports describe what may have been the same condition. cite journal | author=Freeman C, Laymon CW | title=Balanitis xerotica obliterans | journal=Arch Dermat Syph | year=1941 | month= | volume=44 | issue=4 | pages=547–59 | id= | url=http://www.cirp.org/library/treatment/BXO/freeman1/ | format=Reprint:The CIRP Circumcision Reference Library | accessdate=2006-10-01] BXO commonly occurs on the foreskin and glans penis. cite web | author=Keogh GC. | title=Balanitis xerotica obliterans | url=http://www.emedicine.com/DERM/topic46.htm | publisher=eMedicine.com | accessdate=2005-08-15]
Atrophic white patches appear on the affected area, cite journal | author = Buechner S | title = Common skin disorders of the penis | journal = BJU Int | volume = 90 | issue = 5 | pages = 498–506 | year = 2002 | month = Sep | pmid = 12175386 | doi = 10.1046/j.1464-410X.2002.02962.x] and commonly, a whitish ring of indurated (hardened) tissue usually forms near the tip that may prevent retraction.

Epidemiology

The true prevalence of BXO is controversial and unclear. One study calculated a rate of 0.6% of boys affected by their 15th birthday. cite journal | author = Shankar K, Rickwood A | title = The incidence of phimosis in boys | journal = BJU Int | volume = 84 | issue = 1 | pages = 101–2 | year = 1999 | month = Jul | pmid = 10444134 | doi = 10.1046/j.1464-410x.1999.00147.x] Another reported a rate of 0.07%. cite journal | author = Kizer W, Prarie T, Morey A | title = Balanitis xerotica obliterans: epidemiologic distribution in an equal access health care system | journal = South Med J | volume = 96 | issue = 1 | pages = 9–11 | year = 2003 | month = Jan | pmid = 12602705 | doi = 10.1097/00007611-200301000-00004] However, a review noted that "with a high degree of suspicion and histologic examination, the condition will prove to be much more frequent than one generally believes." cite journal | author = Das S, Tunuguntla H | title = Balanitis xerotica obliterans--a review | journal = World J Urol | volume = 18 | issue = 6 | pages = 382–7 | year = 2000 | month = Dec | pmid = 11204255 | doi = 10.1007/PL00007083] Another suggested that "more cases would be diagnosed during infancy if all dried foreskin were examined systematically." cite journal | author = Garat J, Chéchile G, Algaba F, Santaularia J | title = Balanitis xerotica obliterans in children | journal = J Urol | volume = 136 | issue = 2 | pages = 436–7 | year = 1986 | month = Aug | pmid = 3735511] Another remarked that the condition "may be misdiagnosed or ignored in the young boy." cite journal | author = McKay D, Fuqua F, Weinberg A | title = Balanitis xerotica obliterans in children | journal = J Urol | volume = 114 | issue = 5 | pages = 773–5 | year = 1975 | month = Nov | pmid = 1237636] Yet another commented that "its true incidence is not appreciated because most cases are cured by circumcision, and unfortunately many surgeons still fail to send their circumcision specimens for histology." cite journal | author=Depasquale I, Park AJ, Bracka A. | title=The treatment of balanitis xerotica obliterans | journal=BJU Int | year=2000 | month= | volume=86 | issue=4 | pages=459–65 | id= | url=http://www.cirp.org/library/treatment/BXO/depasquale1/ | format=Reprint:The CIRP Circumcision Reference Library | accessdate=2006-10-01 | doi=10.1046/j.1464-410X.2000.00772.x] Another remarked that the "extent of asymptomatic disease in this series would suggest the true prevalence of LS in men might be much higher than published work suggests." cite journal | author=Riddell I, Edwards A, Sherrard J. | title=Clinical features of lichen sclerosus in men attending a department of genitourinary medicine | journal=Sex Trans Infect | year=2000 | month=Aug | volume=76 | issue=4 | pages=311–3 | id= | url=http://sextrans.bmjjournals.com/cgi/content/full/76/4/311 | doi=10.1136/sti.76.4.311 | pmid=11026891]

According to some authors, the disease most frequently affects middle-aged men. However, a large study reported that the age distribution was similar from 2 to 90 years of age, except for men in their twenties, who were at twice the risk. The same study found that black and Hispanic men had approximately twice the risk of white men. The authors suggested possible reasons for this, including access to health care, differences in neonatal circumcision rates, and climate differences.

Mallon "et al." found that BXO was related to circumcision status. Adjusting for age, lack of circumcision was associated with an odds ratio of 53.55. The finding was statistically significant.cite journal | author = Mallon E, Hawkins D, Dinneen M, Francics N, Fearfield L, Newson R, Bunker C | title = Circumcision and genital dermatoses | journal = Arch Dermatol | volume = 136 | issue = 3 | pages = 350–4 | year = 2000 | month = Mar | pmid = 10724196 | doi = 10.1001/archderm.136.3.350] However, BXO has also been noted to occur after late circumcision, especially when performed for phimosis.

Etiology

The etiology of BXO is uncertain. However, some possibilities have been suggested.

Some studies have shown that patients with BXO also show signs of suffering from autoimmune disorders.cite journal | author = Azurdia R, Luzzi G, Byren I, Welsh K, Wojnarowska F, Marren P, Edwards A | title = Lichen sclerosus in adult men: a study of HLA associations and susceptibility to autoimmune disease | journal = Br J Dermatol | volume = 140 | issue = 1 | pages = 79–83 | year = 1999 | month = Jan | pmid = 10215772 | doi = 10.1046/j.1365-2133.1999.02611.x] cite journal | author = Meyrick Thomas R, Ridley C, Black M | title = The association of lichen sclerosus et atrophicus and autoimmune-related disease in males | journal = Br J Dermatol | volume = 109 | issue = 6 | pages = 661–4 | year = 1983 | month = Dec | pmid = 6652042 | doi = 10.1111/j.1365-2133.1983.tb00546.x] cite journal | author = Harrington C, Dunsmore I | title = An investigation into the incidence of auto-immune disorders in patients with lichen sclerosus and atrophicus | journal = Br J Dermatol | volume = 104 | issue = 5 | pages = 563–6 | year = 1981 | month = May | pmid = 7236515 | doi = 10.1111/j.1365-2133.1981.tb08172.x] However, this finding is not repeated in every study.

Infection from "human papilloma virus (serotype 16 in particular), spirochetes and atypical mycobacteria" has also been suggested as a cause. Additional suggestions include "pemphigus vulgaris and chronic nonspecific bacterial balanitis". cite journal | author=Edwards S. | title=Balanitis and balanoposthitis: a review | journal=Genitourin Med | year= 1996 | month= | volume=72 | issue=3 | pages=155–9 | id= | url=http://www.circs.org/library/edwards/ | format=Reprint:The CIRP Circumcision Reference Library]

Relationship to phimosis

BXO is a common cause of pathological phimosis.

Kiss "et al." report that 40% of boys with phimosis suffered from BXO. cite journal | author = Kiss A, Király L, Kutasy B, Merksz M | title = High incidence of balanitis xerotica obliterans in boys with phimosis: prospective 10-year study | journal = Pediatr Dermatol | volume = 22 | issue = 4 | pages = 305–8 | year = 2005 | month = Jul-Aug | pmid = 16060864 | doi = 10.1111/j.1525-1470.2005.22404.x] Shankar and Rickwood reported BXO in 84% of phimosis patients. Evans reported BXO in 10.5% of phimosis patients. cite journal | author = Evans D | title = Retrospective study of male lichen sclerosus and outcome in Leicester: 1995-9 inclusive: experience of a genitourinary medicine clinic | journal = Sex Transm Infect | volume = 76 | issue = 6 | pages = 495 | year = 2000 | pmid = 11221136 | url=http://sti.bmjjournals.com/cgi/content/full/76/6/495 | doi = 10.1136/sti.76.6.495] Clemmensen "et al." reported BXO in 14.2% of phimosis patients. cite journal | author = Clemmensen O, Krogh J, Petri M | title = The histologic spectrum of prepuces from patients with phimosis | journal = Am J Dermatopathol | volume = 10 | issue = 2 | pages = 104–8 | year = 1988 | month = Apr | pmid = 3239715] Bale reported that BXO was found in 19% of circumcisions performed for diseases of the prepuce and penis. cite journal | author = Bale P, Lochhead A, Martin H, Gollow I | title = Balanitis xerotica obliterans in children | journal = Pediatr Pathol | volume = 7 | issue = 5-6 | pages = 617–27 | year = 1987 | pmid = 3449818] Mattioli observed BXO in 60% of patients with acquired phimosis and 30% of patients with congenital phimosis. cite journal | author = Mattioli G, Repetto P, Carlini C, Granata C, Gambini C, Jasonni V | title = Lichen sclerosus et atrophicus in children with phimosis and hypospadias | journal = Pediatr Surg Int | volume = 18 | issue = 4 | pages = 273–5 | year = 2002 | month = May | pmid = 12021978 | doi = 10.1007/s003830100699] Rickwood reported BXO in 20 of 21 patients circumcised for pathological phimosis. cite journal | author=Rickwood AMK, Hemalatha V, Batcup G, Spitz L. | title=Phimosis in boys | journal=Brit J Urol | year=1980 | month= | volume=52 | issue= | pages=147–50 | id= | url=http://www.cirp.org/library/treatment/phimosis/rickwood/ | format=Reprint:The CIRP Circumcision Reference Library | accessdate= ]

Relationship to lichen sclerosus

Many researchers regard BXO as lichen sclerosus et atrophicus (LSA) of the penis, LSA is also known as lichen sclerosus (LS). Lately BXO was coded as part of LSA by Medical literature search tool Medline. cite journal | author = Finkbeiner A | title = Balanitis xerotica obliterans: a form of lichen sclerosus | journal = South Med J | volume = 96 | issue = 1 | pages = 7–8 | year = 2003 | month = Jan | pmid = 12602704 | url=http://www.smajournalonline.com/pt/re/smj/fulltext.00007611-200301000-00003.htm | doi = 10.1097/01.SMJ.0000047973.46602.E8] cite journal | author=Laymon CW, Freeman C. | title=Relationship of balanitis xerotica obliterans to lichen sclerosus et atrophicus | journal=Arch Dermat Syph | year=1944 | month= | volume=49 | issue= | pages=57–9 | id= | url=http://www.cirp.org/library/treatment/BXO/laymon1/ | format=Reprint:The CIRP Circumcision Reference Library | accessdate= ] cite journal | author = Neill S, Tatnall F, Cox N | title = Guidelines for the management of lichen sclerosus | journal = Br J Dermatol | volume = 147 | issue = 4 | pages = 640–9 | year = 2002 | month = Oct | pmid = 12366407 | doi = 10.1046/j.1365-2133.2002.05012.x] However, Mallon "et al." suggest that BXO "may be a consequence of other fibrosing dermatoses, such as lichen planus and cicatricial pemphigoid." When occurring on the male genitals, the term 'BXO' is traditionally used.

Prevention

There is no known means of preventing BXO. However, one study reports that the data "suggest that circumcision prevents or protects against common infective penile dermatoses."

Prognosis

BXO is chronic and often progressive. Please see the following section on treatment.

The condition may cause pain, irritation, and disturbance of sexual function.

In later stages, a meatal stricture may occur, causing urinary retention. This may result in bladder or kidney damage.

The coronal sulcus and frenulum may be destroyed.

Phimosis or paraphimosis may occur.

Several studies indicate that BXO may play a pre-cancerous role, cite journal | author = Velazquez E, Cubilla A | title = Lichen sclerosus in 68 patients with squamous cell carcinoma of the penis: frequent atypias and correlation with special carcinoma variants suggests a precancerous role | journal = Am J Surg Pathol | volume = 27 | issue = 11 | pages = 1448–53 | year = 2003 | month = Nov | pmid = 14576478 | doi = 10.1097/00000478-200307000-00015] cite journal | author = Cubilla A, Velazquez E, Young R | title = Pseudohyperplastic squamous cell carcinoma of the penis associated with lichen sclerosus. An extremely well-differentiated, nonverruciform neoplasm that preferentially affects the foreskin and is frequently misdiagnosed: a report of 10 cases of a distinctive clinicopathologic entity | journal = Am J Surg Pathol | volume = 28 | issue = 7 | pages = 895–900 | year = 2004 | month = Jul | pmid = 15223959] cite journal | author = Perceau G, Derancourt C, Clavel C, Durlach A, Pluot M, Lardennois B, Bernard P | title = Lichen sclerosus is frequently present in penile squamous cell carcinomas but is not always associated with oncogenic human papillomavirus | journal = Br J Dermatol | volume = 148 | issue = 5 | pages = 934–8 | year = 2003 | month = May | pmid = 12786823 | doi = 10.1046/j.1365-2133.2003.05326.x] cite journal | author = Powell J, Robson A, Cranston D, Wojnarowska F, Turner R | title = High incidence of lichen sclerosus in patients with squamous cell carcinoma of the penis | journal = Br J Dermatol | volume = 145 | issue = 1 | pages = 85–9 | year = 2001 | month = Jul | pmid = 11453912 | doi = 10.1046/j.1365-2133.2001.04287.x] cite journal | author = Micali G, Nasca M, Innocenzi D | title = Lichen sclerosus of the glans is significantly associated with penile carcinoma | journal = Sex Transm Infect | volume = 77 | issue = 3 | pages = 226 | year = 2001 | month = Jun | pmid = 11402247 | url=http://sti.bmjjournals.com/cgi/content/full/77/3/226 | doi = 10.1136/sti.77.3.226] resulting in squamous cell carcinoma of the penis, a form of penile cancer.

Diagnosis

Neuhaus and Skidmore report that "Tzanck smear and cutaneous biopsy, along with a rapid protein reagin test, will provide a definitive diagnosis." cite journal | author = Neuhaus I, Skidmore R | title = Balanitis xerotica obliterans and its differential diagnosis | journal = J Am Board Fam Pract | volume = 12 | issue = 6 | pages = 473–6 | year = 1999 | month = Nov-Dec | pmid = 10612365]

Depasquale "et al." note that many surgeons do not send circumcision specimens for histology. They caution that this practice "is becoming medicolegally indefensible in a litigation-conscious society, where the clinical sequelae of BXO are often misinterpreted by the patient as surgical errors."

Treatment

Therapy focuses on prevention of disease progression.

Shelley reported some success with long-term antibiotic therapy. However, relapses were seen upon stopping treatment. cite journal | author = Shelley W, Shelley E, Grunenwald M, Anders T, Ramnath A | title = Long-term antibiotic therapy for balanitis xerotica obliterans | journal = J Am Acad Dermatol | volume = 40 | issue = 1 | pages = 69–72 | year = 1999 | month = Jan | pmid = 9922014 | doi = 10.1016/S0190-9622(99)70529-3]

Some success has been reported with topical steroids, cite journal | author = Kiss A, Csontai A, Pirót L, Nyirády P, Merksz M, Király L | title = The response of balanitis xerotica obliterans to local steroid application compared with placebo in children | journal = J Urol | volume = 165 | issue = 1 | pages = 219–20 | year = 2001 | month = Jan | pmid = 11125410 | doi = 10.1097/00005392-200101000-00062] when scarring is minimal, cite journal | author = Vincent M, Mackinnon E | title = The response of clinical balanitis xerotica obliterans to the application of topical steroid-based creams | journal = J Pediatr Surg | volume = 40 | issue = 4 | pages = 709–12 | year = 2005 | month = Apr | pmid = 15852285 | doi = 10.1016/j.jpedsurg.2004.12.001] though some have found this ineffectual. cite journal | author = Wright J | title = The treatment of childhood phimosis with topical steroid | journal = Aust N Z J Surg | volume = 64 | issue = 5 | pages = 327–8 | year = 1994 | month = May | pmid = 8179528 | doi = 10.1111/j.1445-2197.1994.tb02220.x]

Moderate therapeutic results have been reported using etretinate. cite journal | author = Neuhofer J, Fritsch P | title = Treatment of localized scleroderma and lichen sclerosus with etretinate | journal = Acta Derm Venereol | volume = 64 | issue = 2 | pages = 171–4 | year = 1984 | pmid = 6203311]

Some success has been reported in the use of carbon dioxide laser therapy. cite journal | author = Kartamaa M, Reitamo S | title = Treatment of lichen sclerosus with carbon dioxide laser vaporization | journal = Br J Dermatol | volume = 136 | issue = 3 | pages = 356–9 | year = 1997 | month = Mar | pmid = 9115915 | doi = 10.1111/j.1365-2133.1997.tb14943.x] cite journal | author = Peterson C, Lane J, Ratz J | title = Successful carbon dioxide laser therapy for refractory anogenital lichen sclerosus | journal = Dermatol Surg | volume = 30 | issue = 8 | pages = 1148–51 | year = 2004 | month = Aug | pmid = 15274708 | doi = 10.1111/j.1524-4725.2004.30343.x]

Many authors report that circumcision is the treatment of choice, cite journal | author = Meuli M, Briner J, Hanimann B, Sacher P | title = Lichen sclerosus et atrophicus causing phimosis in boys: a prospective study with 5-year followup after complete circumcision | journal = J Urol | volume = 152 | issue = 3 | pages = 987–9 | year = 1994 | month = Sep | pmid = 8051779] with modifications if necessary. cite journal | author = Campus G, Ena P, Scuderi N | title = Surgical treatment of balanitis xerotica obliterans | journal = Plast Reconstr Surg | volume = 73 | issue = 4 | pages = 652–7 | year = 1984 | month = Apr | pmid = 6538689 | doi = 10.1097/00006534-198404000-00024] Pasieczny suggests testosterone ointment, however. cite journal | author=Pasieczny TAH. | title=The treatment of balanitis xerotica obliterans with testosterone propionate ointment | journal=Acta Derm Venerol | year=1977 | month= | volume=57 | issue= | pages=275–7 | id= | url=http://www.cirp.org/library/treatment/BXO/pasieczny1/ | format=Reprint:The CIRP Circumcision Reference Library]

Glansectomy may be required.

Images of BXO

* [http://dermis.multimedica.de/doia/diagnose.asp?zugr=d&lang=e&diagnr=701010&topic=t Atlas of Dermatology]
* [http://www.webpathology.com/case.cfm?case=43 Webpathology.com] (histology of BXO)

ee also

* Penis
* Glans penis
* Foreskin
* Phimosis
* Circumcision

Footnotes