Balanitis xerotica obliterans

Editor-in-Chief: Joel Gelman, M.D. [mailto:jgelman@uci.edu], Director of the Center for Reconstructive Urology and Associate Clinical Professor in the Department of Urology at the University of  California, Irvine

Synonyms and keywords: BXO

Overview
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. BXO commonly occurs on the foreskin and glans penis. Atrophic white patches appear on the affected area, 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. Another reported a rate of 0.07%. 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." Another suggested that "more cases would be diagnosed during infancy if all dried foreskin were examined systematically." Another remarked that the condition "may be misdiagnosed or ignored in the young boy." 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." 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."

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. 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. 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".

Relationship to phimosis
BXO is a common cause of pathological phimosis.

Kiss et al. report that 40% of boys with phimosis suffered from BXO. Shankar and Rickwood reported BXO in 84% of phimosis patients. Evans reported BXO in 10.5% of phimosis patients. Clemmensen et al. reported BXO in 14.2% of phimosis patients. Bale reported that BXO was found in 19% of circumcisions performed for diseases of the prepuce and penis. Mattioli observed BXO in 60% of patients with acquired phimosis and 30% of patients with congenital phimosis. Rickwood reported BXO in 20 of 21 patients circumcised for pathological phimosis.

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. 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, 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."

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.

Some success has been reported with topical steroids, when scarring is minimal, though some have found this ineffectual.

Moderate therapeutic results have been reported using etretinate.

Some success has been reported in the use of carbon dioxide laser therapy.

Many authors report that circumcision is the treatment of choice, with modifications if necessary. Pasieczny suggests testosterone ointment, however.

Glansectomy may be required.

Currently, topical steriods are the most commonly used and most effective medication for the treatment of the adverse skin changes associated with BXO. Patients with urethral stricture disease associated with BXO are generally best managed with surgery to relieve the obstruction. Although urethral dilation is a treatment option, this treatment generally offers only temporary relief of the blockage and a complication of dilations can be stricture progression. The best treatment of urethral stricture treatment options are extended meatotomy (an open incision of the urethra) for short strictures and staged tissue transfer urethroplasty, a surgery to reconstruct the urethra using grafts such as buccal mucosa from inside the cheek.

Images of BXO

 * Atlas of Dermatology
 * Webpathology.com (histology of BXO)