Balanitis xerotica obliterans: Difference between revisions

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{{Infobox_Disease |
__NOTOC__
  Name          = Balanitis xerotica obliterans |
  Image          = |
  Caption        = |
  DiseasesDB    = 31995 |
  ICD10          = {{ICD10|N|48|0|n|40}} [[Leukoplakia]] of penis |
  ICD9          = <!-- {{ICD9|xxx}} --> |
  ICDO          = |
  OMIM          = |
  MedlinePlus    = |
  eMedicineSubj  = derm |
  eMedicineTopic = 46 |
  MeshID        = |
}}
{{SI}}
{{SI}}
{{SCC}}
{{CMG}}{{AE}}{{VD}}
 
{{EH}}


{{SK}}BXO, Penile lichen sclerosus
==Overview==
==Overview==
Balanitis xerotica obliterans (BXO) is a [[dermatological]] ([[skin]]) condition affecting the [[male]] [[genitalia]]. It was first described by Stuhmer in year 1928. The exact [[pathophysiology]] of balanitis xerotica obliterans is unknown. Balanitis xerotica obliterans (BXO) commonly occurs on [[foreskin]] and [[glans penis]]. Patients with [[BXO]] usually present with [[Atrophy|atrophic]] white patches with [[Indura|indurated]] (hardened) whitish ring near the tip of [[penis]]. Definitive diagnosis is provided by [[cutaneous]] [[biopsy]]. [[Prognosis]] is usually good with treatment. Treatment options for balanitis xerotica obliterans (BXO) include both medical and surgical modalities.


'''Balanitis xerotica obliterans''' (BXO) is a [[dermatology|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.<!--
==Historical Perspective==
  --><ref name="freeman1941">{{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}}</ref>
In 1928, Stuhmer for the first time in medical literature has described  [[lichen sclerosus]] on [[penis]] as balanitits xerotica obliterans.<ref name="pmid22085120" />
BXO commonly occurs on the [[foreskin]] and [[glans penis]].<!--
  --><ref name="keogh2005">{{cite web | author=Keogh GC. | title=Balanitis xerotica obliterans | url=http://www.emedicine.com/DERM/topic46.htm | publisher=eMedicine.com | accessdate=2005-08-15}}</ref>
[[Atrophy|Atrophic]] white patches appear on the affected area,<!--
  --><ref name="buechner2002">{{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 | id = PMID 12175386}}</ref>
and commonly, a whitish ring of indurated (hardened) tissue usually forms near the tip that may prevent retraction.<ref name="keogh2005" />


==Epidemiology==
==Classification==
The true [[prevalence]] of BXO is controversial and unclear. One study calculated a rate of 0.6% of boys affected by their 15th birthday.<!--
There is no established classification system for balanitits xerotica obliterans.
  --><ref name="shankar1999">{{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 | id = PMID 10444134}}</ref>
==Pathophysiology==
Another reported a rate of 0.07%.<!--
The exact pathophysiology of balanitits xerotica obliterans is unknown. Studies have shown that multiple factors were associated with development of [[Balanitis xerotica obliterans|BXO]]. These include:<ref name="pmid8491994" /><ref name="pmid10215772" /><ref name="pmid78687092" /><ref name="pmid9006371" /><ref name="pmid9349358" /><ref name="pmid20885159" /><ref name="pmid20973765" /><ref name="pmid17854373" />
  --><ref name="kizer2003">{{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 | id = PMID 12602705}}</ref>
{| class="wikitable"
However, a review noted that "with a high degree of suspicion and [[histology|histologic]] examination, the condition will prove to be much more frequent than one generally believes."<!--
! colspan="3" |Factors associated with pathogenesis of BXO
  --><ref name="das2000">{{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 | id = PMID 11204255}}</ref>
|-
Another suggested that "more cases would be [[diagnosis|diagnosed]] during infancy if all dried foreskin were examined systematically."<!--
|[[Circumcise|Uncircumcised Penis]]
  --><ref name="garat1986">{{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 | id = PMID 3735511}}</ref>
| colspan="2" |Accumulation of secretions and [[epithelial]] debris between the [[foreskin]] and [[coronal sulcus]] leads to chronic [[irritation]] and [[sub-clinical]] [[trauma]]. <ref name="pmid8491994">{{cite journal| author=Schempp C, Bocklage H, Lange R, Kölmel HW, Orfanos CE, Gollnick H| title=Further evidence for Borrelia burgdorferi infection in morphea and lichen sclerosus et atrophicus confirmed by DNA amplification. | journal=J Invest Dermatol | year= 1993 | volume= 100 | issue= 5 | pages= 717-20 | pmid=8491994 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8491994  }}</ref>
Another remarked that the condition "may be misdiagnosed or ignored in the young boy."<!--
|-
  --><ref name="mckay1975">{{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 | id = PMID 1237636}}</ref>
|[[Autoimmune diseases]]
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."<!--
| colspan="2" |
  --><ref name="depasquale2000">{{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 }}</ref>
* Patients with [[BXO]], were found to have other associated [[autoimmune]] conditions, which include: [[diabetes mellitus]], [[vitiligo]][[alopecia areata|aandlopecia areata]].<ref name="pmid78687092">{{cite journal| author=Meffert JJ, Davis BM, Grimwood RE| title=Lichen sclerosus. | journal=J Am Acad Dermatol | year= 1995 | volume= 32 | issue= 3 | pages= 393-416; quiz 417-8 | pmid=7868709 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7868709  }}</ref>
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."<!--
* Some studies have shown a close association between [[BXO]] and HLA DQ7 with DR11 and DR12.<ref name="pmid10215772">{{cite journal| author=Azurdia RM, Luzzi GA, Byren I, Welsh K, Wojnarowska F, Marren P et al.| title=Lichen sclerosus in adult men: a study of HLA associations and susceptibility to autoimmune disease. | journal=Br J Dermatol | year= 1999 | volume= 140 | issue= 1 | pages= 79-83 | pmid=10215772 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10215772  }}</ref>
  --><ref name="riddell2000">{{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}}</ref>
|-
| rowspan="2" |[[Infection|Infections]]
|[[Human papillomavirus|Human papillomavirus (HPV)]]
|Several studies have implicated [[human papillomavirus]] as a causative agent in [[pathogenesis]] of BXO. [[HPV]] 16, 18, 33 and 51 have been found to be closely associated with development of BXO. Though recent studies have reported lack of clinical correlation between BXO and [[Human papillomavirus|HPV]] as they both have unrelated transcriptosome.
|-
| colspan="2" |Several studies have reported association of various [[infectious]] organisms with development of balanitis xerotica obliterans, which include:
* [[Borrelia|Borrelia burgdoferi]]<ref name="pmid9006371">{{cite journal| author=Fujiwara H, Fujiwara K, Hashimoto K, Mehregan AH, Schaumburg-Lever G, Lange R et al.| title=Detection of Borrelia burgdorferi DNA (B garinii or B afzelii) in morphea and lichen sclerosus et atrophicus tissues of German and Japanese but not of US patients. | journal=Arch Dermatol | year= 1997 | volume= 133 | issue= 1 | pages= 41-4 | pmid=9006371 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9006371  }}</ref>
* [[HCV]]<ref name="pmid9349358">{{cite journal| author=Boulinguez S, Bernard P, Lacour JP, Nicot T, Bedane C, Ortonne JP et al.| title=Bullous lichen sclerosus with chronic hepatitis C virus infection. | journal=Br J Dermatol | year= 1997 | volume= 137 | issue= 3 | pages= 474-5 | pmid=9349358 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9349358  }}</ref>
* [[Epstein-Barr virus]]<ref name="pmid20885159">{{cite journal| author=Aidé S, Lattario FR, Almeida G, do Val IC, da Costa Carvalho M| title=Epstein-Barr virus and human papillomavirus infection in vulvar lichen sclerosus. | journal=J Low Genit Tract Dis | year= 2010 | volume= 14 | issue= 4 | pages= 319-22 | pmid=20885159 | doi=10.1097/LGT.0b013e3181d734f1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20885159  }}</ref>
|-
|[[Genetics]]
| colspan="2" |
* In females, 12% of patients were found to have a family history of [[lichen]] [[sclerosis]]
* In males, there is no evidence familial predisposition
|-
| colspan="2" |[[Environmental factor|Environmental factors]]
|
[[Trauma]], old scars, [[Skin graft|skin grafts]], [[sunburn]] and [[radiation]] were found to be associated with BXO.<ref name="pmid20973765">{{cite journal| author=Bjekić M, Šipetić S, Marinković J| title=Risk factors for genital lichen sclerosus in men. | journal=Br J Dermatol | year= 2011 | volume= 164 | issue= 2 | pages= 325-9 | pmid=20973765 | doi=10.1111/j.1365-2133.2010.10091.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20973765  }}</ref> Some studies have proposed that post-micturation dribbling or micro-incontinence play a central role in development of BXO.<ref name="pmid17854373">{{cite journal| author=Bunker CB| title=Male genital lichen sclerosus and tacrolimus. | journal=Br J Dermatol | year= 2007 | volume= 157 | issue= 5 | pages= 1079-80 | pmid=17854373 | doi=10.1111/j.1365-2133.2007.08179.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17854373  }}</ref>


According to some authors, the disease most frequently affects middle-aged men.<ref name="keogh2005" /> 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.<ref name="kizer2003" /> The same study found that [[black people|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 [[statistical significance|statistically significant]].<ref name="mallon2000">{{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 | id = PMID 10724196}}</ref>
=== Histopathology ===
However, BXO has also been noted to occur after late circumcision, especially when performed for [[phimosis]].<ref name="freeman1941" /><ref name="mallon2000" /><ref name="kizer2003" />
Histopatholgy findings in [[BXO]] include the following:<ref name="pmid22085120">{{cite journal| author=Clouston D, Hall A, Lawrentschuk N| title=Penile lichen sclerosus (balanitis xerotica obliterans). | journal=BJU Int | year= 2011 | volume= 108 Suppl 2 | issue= | pages= 14-9 | pmid=22085120 | doi=10.1111/j.1464-410X.2011.10699.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22085120  }}</ref>


==Etiology==
==== Early stage of BXO ====
The etiology of BXO is uncertain. However, some possibilities have been suggested.
* Moderately heavy [[lymphocytic]] infiltrate found in basal [[epidermis]] and superficial [[dermis]] in early stages of the [[Lesion|lesion.]]


Some studies have shown that patients with BXO also show signs of suffering from [[autoimmunity|autoimmune]] disorders.<ref name="azurdia1999">{{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 | id = PMID 10215772}}</ref><!--
==== Late stages of BXO ====
  --><ref name="meyrickthomas1983">{{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 | id = PMID 6652042}}</ref><!--
* [[Epidermis]] becomes [[Atrophy|atrophic]] with surface [[hyperkeratosis]] <nowiki/>and thickened basement membrane
  --><ref name="harrington1981">{{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 | id = PMID 7236515}}</ref>
* Broad zone of subepidermal [[oedema]] with homogenization of [[collagen]], which becomes sclerotic over time
However, this finding is not repeated in every study.<ref name="meyrickthomas1983" />
* In few cases, [[epidermis]] is detached from [[dermis]] resulting in formation of [[haemorrhagic]] bullae


Infection from "[[human papilloma virus]] (serotype 16 in particular), [[spirochaete|spirochetes]] and atypical [[mycobacterium|mycobacteria]]" has also been suggested as a cause.<ref name="kizer2003" /> Additional suggestions include "[[pemphigus|pemphigus vulgaris]] and chronic nonspecific bacterial [[balanitis]]".<!--
==Epidemiology and Demographics==
  --><ref name="edwards1996">{{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}}</ref>


===Relationship to phimosis===
==== Incidence ====
BXO is a common cause of pathological [[phimosis]].<ref name="keogh2005" /><ref name="buechner2002" />
There are no comprehensive studies studying the [[incidence]] and [[prevalence]] in general population. A recent study conducted in an unselected cohort of 153,432 patients presenting to an outpatient clinic in Brookes Army Medical Center in the United States reported the incidence of BXO at 0.07%.  


Kiss ''et al.'' report that 40% of boys with phimosis suffered from BXO.<!--
==== Age ====
  --><ref name="kiss2005">{{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 | id = PMID 16060864}}</ref>
[[Balanitis xerotica obliterans|BXO]] commonly affects middle age group, with men in their twenties were found to be at twice the risk on comparison with other age groups.<ref name="pmid12602705">{{cite journal| author=Kizer WS, Prarie T, Morey AF| title=Balanitis xerotica obliterans: epidemiologic distribution in an equal access health care system. | journal=South Med J | year= 2003 | volume= 96 | issue= 1 | pages= 9-11 | pmid=12602705 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12602705  }}</ref>
Shankar and Rickwood reported BXO in 84% of phimosis patients.<ref name="shankar1999" /> Evans reported BXO in 10.5% of phimosis patients.<!--
  --><ref name="evans2000">{{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 | id = PMID 11221136 | url=http://sti.bmjjournals.com/cgi/content/full/76/6/495}}</ref>
Clemmensen ''et al.'' reported BXO in 14.2% of phimosis patients.<!--
  --><ref name="clemmensen1988">{{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 | id = PMID 3239715}}</ref>
Bale reported that BXO was found in 19% of circumcisions performed for diseases of the prepuce and penis.<!--
  --><ref name="bale1987">{{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 | id = PMID 3449818}}</ref>
Mattioli observed BXO in 60% of patients with acquired phimosis and 30% of patients with congenital phimosis.<!--
  --><ref name="mattioli2002">{{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 | id = PMID 12021978}}</ref>
Rickwood reported BXO in 20 of 21 patients circumcised for pathological phimosis.<!--
  --><ref name="rickwood1980">{{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= }}</ref>


===Relationship to lichen sclerosus===
==== Race ====
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|Medline]].<!--
On comparison with white men, BXO is more [[Prevalence|prevalent]] in black and hispanic men.<ref name="pmid126027052">{{cite journal| author=Kizer WS, Prarie T, Morey AF| title=Balanitis xerotica obliterans: epidemiologic distribution in an equal access health care system. | journal=South Med J | year= 2003 | volume= 96 | issue= 1 | pages= 9-11 | pmid=12602705 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12602705  }}</ref>
  --><ref name="finkbeiner2003">{{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 | id = PMID 12602704 | url=http://www.smajournalonline.com/pt/re/smj/fulltext.00007611-200301000-00003.htm}}</ref><!--
  --><ref name="laymon1944">{{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= }}</ref><!--
  --><ref name="neill2002">{{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 | id = PMID 12366407}}</ref>
However, Mallon ''et al.'' suggest that BXO "may be a consequence of other fibrosing [[dermatosis|dermatoses]], such as [[lichen planus]] and cicatricial pemphigoid."<ref name="mallon2000" /> When occurring on the male genitals, the term 'BXO' is traditionally used.<ref name="keogh2005" />


==Prevention==
==Screening==
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."<ref name="mallon2000" />
There are no established screening guidelines for [[BXO]].
==Natural History, Complications, and Prognosis==
===Natural history===
If left untreated, [[Balanitis xerotica obliterans|BXO]] may involve the penile [[skin]], [[scrotum]], and entire [[urethra]] leading to the complications such as [[phimosis]] and [[urinary retention]].<ref name="pmid10971272">{{cite journal| author=Depasquale I, Park AJ, Bracka A| title=The treatment of balanitis xerotica obliterans. | journal=BJU Int | year= 2000 | volume= 86 | issue= 4 | pages= 459-65 | pmid=10971272 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10971272  }}</ref>


==Prognosis==
===Complications===
BXO is chronic and often progressive.<ref name="keogh2005" /> Please see the following section on treatment.
Complication of BXO include:<ref name="pmid20854400">{{cite journal| author=Neill SM, Lewis FM, Tatnall FM, Cox NH, British Association of Dermatologists| title=British Association of Dermatologists' guidelines for the management of lichen sclerosus 2010. | journal=Br J Dermatol | year= 2010 | volume= 163 | issue= 4 | pages= 672-82 | pmid=20854400 | doi=10.1111/j.1365-2133.2010.09997.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20854400  }} </ref><ref name="pmid10570372">{{cite journal| author=Nasca MR, Innocenzi D, Micali G| title=Penile cancer among patients with genital lichen sclerosus. | journal=J Am Acad Dermatol | year= 1999 | volume= 41 | issue= 6 | pages= 911-4 | pmid=10570372 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10570372  }} </ref><ref name="pmid14576478">{{cite journal| author=Velazquez EF, Cubilla AL| 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 | year= 2003 | volume= 27 | issue= 11 | pages= 1448-53 | pmid=14576478 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14576478  }} </ref><ref name="pmid18047520">{{cite journal| author=Prowse DM, Ktori EN, Chandrasekaran D, Prapa A, Baithun S| title=Human papillomavirus-associated increase in p16INK4A expression in penile lichen sclerosus and squamous cell carcinoma. | journal=Br J Dermatol | year= 2008 | volume= 158 | issue= 2 | pages= 261-5 | pmid=18047520 | doi=10.1111/j.1365-2133.2007.08305.x | pmc=2268980 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18047520  }} </ref><ref name="pmid12786863">{{cite journal| author=Thami GP, Kaur S| title=Genital lichen sclerosus, squamous cell carcinoma and circumcision. | journal=Br J Dermatol | year= 2003 | volume= 148 | issue= 5 | pages= 1083-4 | pmid=12786863 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12786863  }} </ref><ref name="pmid19126024">{{cite journal| author=Ranjan N, Singh SK| title=Malignant transformation of penile lichen sclerosus: exactly how common is it? | journal=Int J Dermatol | year= 2008 | volume= 47 | issue= 12 | pages= 1308-9 | pmid=19126024 | doi=10.1111/j.1365-4632.2008.03866.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19126024  }} </ref>
 
* [[Phimosis]]
The condition may cause [[Pain and nociception|pain]], [[irritation]], and disturbance of [[sex|sexual function]].<ref name="edwards1996" />
* Painful [[erection]]
 
* Reduced urinary flow
In later stages, a [[meatus|meatal]] [[stenosis|stricture]] may occur, causing [[urinary retention]].<ref name="freeman1941" /><ref name="keogh2005" /> This may result in [[Urinary bladder|bladder]] or [[kidney]] damage.<ref name="keogh2005" />
* [[Urinary retention]]
 
* Risk of malignant transformation into [[squamous cell carcinoma]] (long-term prospective studies are needed to determine the real risk of [[malignant transformation]])
The coronal sulcus and [[frenulum]] may be destroyed.<ref name="keogh2005" />
 
[[Phimosis]] or [[paraphimosis]] may occur.<ref name="keogh2005" />


Several studies indicate that BXO may play a pre-[[cancer|cancerous]] role,<!--
===Prognosis===
  --><ref name="velazquez2003">{{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 | id = PMID 14576478}}</ref><!--
  --><ref name="cubilla2004">{{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 | id = PMID 15223959}}</ref><!--
  --><ref name="perceau2003">{{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 | id = PMID 12786823}}</ref><!--
  --><ref name="powell2001">{{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 | id = PMID 11453912}}</ref><!--
  --><ref name="micali2001">{{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 | id = PMID 11402247 | url=http://sti.bmjjournals.com/cgi/content/full/77/3/226}}</ref>
resulting in [[squamous cell carcinoma]] of the penis, a form of [[penile cancer]].


[[Prognosis]] is usually good with treatment.<ref name="pmid220851205">{{cite journal| author=Clouston D, Hall A, Lawrentschuk N| title=Penile lichen sclerosus (balanitis xerotica obliterans). | journal=BJU Int | year= 2011 | volume= 108 Suppl 2 | issue=  | pages= 14-9 | pmid=22085120 | doi=10.1111/j.1464-410X.2011.10699.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22085120  }}</ref>
==Diagnosis==
==Diagnosis==
Neuhaus and Skidmore report that "[[Tzanck smear]] and [[skin|cutaneous]] [[biopsy]], along with a rapid protein reagin test, will provide a definitive diagnosis."<!--
  --><ref name="neuhaus1999">{{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 | id = PMID 10612365}}</ref>


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."<ref name="depasquale2000" />
===History and symptoms===
Patients with BXO could be asymptomatic or symptomatic presenting with:<ref name="pmid220851203">{{cite journal| author=Clouston D, Hall A, Lawrentschuk N| title=Penile lichen sclerosus (balanitis xerotica obliterans). | journal=BJU Int | year= 2011 | volume= 108 Suppl 2 | issue=  | pages= 14-9 | pmid=22085120 | doi=10.1111/j.1464-410X.2011.10699.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22085120  }}</ref>
====More common symptoms====
* Whitening or reddening of [[Penis|penile]] region
* Difficulty in retracting [[foreskin]]
* Painful [[erection]]
* Reduced urinary flow
* [[Urinary retention]]


==Treatment==
====Less common symptoms====
Therapy focuses on prevention of disease progression.<ref name="neuhaus1999" />
* Burning sensation ([[Paresthesia|paraesthesia]]) 
* Purple rash in the genitial region([[purpura]])
* Small red or purple clusters, often spidery in appearance, on penis([[telangiectases]])
*[[Itching]]([[pruritus]]) of the genitalia
*Discomfort in urination(dysuria)


Shelley reported some success with long-term [[antibiotic]] therapy. However, relapses were seen upon stopping treatment.<!--
===Physical examination===
  --><ref name="shelley1999">{{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 | id = PMID 9922014}}</ref>
Physical examination findings include:<ref name="pmid220851204">{{cite journal| author=Clouston D, Hall A, Lawrentschuk N| title=Penile lichen sclerosus (balanitis xerotica obliterans). | journal=BJU Int | year= 2011 | volume= 108 Suppl 2 | issue= | pages= 14-9 | pmid=22085120 | doi=10.1111/j.1464-410X.2011.10699.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22085120  }}</ref>
 
* Whitening or reddening of [[glans penis]], [[foreskin]](prepuce) and [[coronal sulcus]]
Some success has been reported with topical [[steroid]]s,<!--
* [[Induration]] of [[glans]] and [[foreskin]]
  --><ref name="kiss2001">{{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 | id = PMID 11125410}}</ref> when [[scar|scarring]] is minimal,<!--
* [[Phimosis]]
  --><ref name="vincent2005">{{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 | id = PMID 15852285}}</ref>
* [[Purpura]]
though some have found this ineffectual.<!--
* [[Telangiectases]]
  --><ref name="wright1994">{{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 | id = PMID 8179528}}</ref>
 
Moderate therapeutic results have been reported using [[etretinate]].<!--
  --><ref name="neuhofer1984">{{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 | id = PMID 6203311}}</ref>


Some success has been reported in the use of [[carbon dioxide]] [[laser therapy]].<!--
===Laboratory findings===
  --><ref name="kartamaa1997">{{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 | id = PMID 9115915}}</ref><!--
  --><ref name="peterson2004">{{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 | id = PMID 15274708}}</ref>


Many authors report that circumcision is the treatment of choice,<ref name="depasquale2000" /><ref name="keogh2005" /><!--
[[Skin|Cutaneous]] [[biopsy]] will provide a definitive diagnosis of BXO.<ref name="pmid112042552">{{cite journal| author=Das S, Tunuguntla HS| title=Balanitis xerotica obliterans--a review. | journal=World J Urol | year= 2000 | volume= 18 | issue= 6 | pages= 382-7 | pmid=11204255 | doi=10.1007/PL00007083 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11204255  }}</ref>
  --><ref name="meuli1994">{{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 | id = PMID 8051779}}</ref>
{| class="wikitable"
with modifications if necessary.<!--
|-
  --><ref name="campus1984">{{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 | id = PMID 6538689}}</ref>
|Cutaneous biopsy
Pasieczny suggests [[testosterone]] ointment, however.<!--
|
  --><ref name="pasieczny1977">{{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}}</ref>
* [[Epidermis]]: Thickened [[epidermis]] which then becomes atrophic with follicular hyperkeratosis.
* [[Dermal|Dermis]]: [[Dermal]] hyalinisation with loss of [[Elastin|elastin fibers]] and underlying perivascular [[lymphocytic]] infiltrate
|}


Glansectomy may be required.<ref name="depasquale2000" />
==Treatment ==


==Images of BXO==
Treatment of BXO include both [[Surgery|surgical]] and [[medical]] modalities, these include:<ref name="pmid220851202">{{cite journal| author=Clouston D, Hall A, Lawrentschuk N| title=Penile lichen sclerosus (balanitis xerotica obliterans). | journal=BJU Int | year= 2011 | volume= 108 Suppl 2 | issue=  | pages= 14-9 | pmid=22085120 | doi=10.1111/j.1464-410X.2011.10699.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22085120  }}</ref><ref name="pmid21396563">{{cite journal| author=Sagi L, Trau H| title=The Koebner phenomenon. | journal=Clin Dermatol | year= 2011 | volume= 29 | issue= 2 | pages= 231-6 | pmid=21396563 | doi=10.1016/j.clindermatol.2010.09.014 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21396563  }}</ref><ref name="pmid11204255">{{cite journal| author=Das S, Tunuguntla HS| title=Balanitis xerotica obliterans--a review. | journal=World J Urol | year= 2000 | volume= 18 | issue= 6 | pages= 382-7 | pmid=11204255 | doi=10.1007/PL00007083 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11204255  }} </ref><ref name="pmid8863582">{{cite journal| author=Hrebinko RL| title=Circumferential laser vaporization for severe meatal stenosis secondary to balanitis xerotica obliterans. | journal=J Urol | year= 1996 | volume= 156 | issue= 5 | pages= 1735-6 | pmid=8863582 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8863582  }} </ref><ref name="pmid9043588">{{cite journal| author=Rudolph R, Walther P| title=Full-thickness skin grafts from eyelids to penis, plus split-thickness grafts in chronic balanitis xerotica obliterans. | journal=Ann Plast Surg | year= 1997 | volume= 38 | issue= 2 | pages= 173-6 | pmid=9043588 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9043588  }} </ref><ref name="pmid8863582">{{cite journal| author=Hrebinko RL| title=Circumferential laser vaporization for severe meatal stenosis secondary to balanitis xerotica obliterans. | journal=J Urol | year= 1996 | volume= 156 | issue= 5 | pages= 1735-6 | pmid=8863582 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8863582  }} </ref><ref name="pmid17180441">{{cite journal| author=Singh I, Ansari MS| title=Extensive balanitis xerotica obliterans (BXO) involving the anterior urethra and scrotum. | journal=Int Urol Nephrol | year= 2006 | volume= 38 | issue= 3-4 | pages= 505-6 | pmid=17180441 | doi=10.1007/s11255-006-0100-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17180441  }} </ref><ref name="pmid21210959">{{cite journal| author=Garaffa G, Shabbir M, Christopher N, Minhas S, Ralph DJ| title=The surgical management of lichen sclerosus of the glans penis: our experience and review of the literature. | journal=J Sex Med | year= 2011 | volume= 8 | issue= 4 | pages= 1246-53 | pmid=21210959 | doi=10.1111/j.1743-6109.2010.02165.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21210959  }} </ref>
* [http://dermis.multimedica.de/doia/diagnose.asp?zugr=d&lang=e&diagnr=701010&topic=t Atlas of Dermatology]
{| class="wikitable" | rowspan="10" colspan="3"
* [http://www.webpathology.com/case.cfm?case=43 Webpathology.com] (histology of BXO)
! colspan="3" |Management of BXO
|-
!Medical
!Drug dosage
!Effectiveness
|-
|[[Topical steroid|Topical steroids]]
|* [[Betamethasone|Betamethasone diproprionate]] 0.05% or [[Clobetasol|clobetasol proprionate]] 0.05% [[Cream (pharmaceutical)|cream]] or [[ointment]] applied once or twice daily
* After 6–8 weeks, reduce the application of the [[topical steroid]] to every second day
* After 12–16 weeks to assess response to treatment ([[Mometasone (topical)|mometasone aceponate]] 0.1% cream can be substituted if there is a good response)
* No improvement by 6 months, then use of the potent [[topical steroid]] should be abandoned
|Studies have shown that 50% of patients respond to topical [[steroid]] application
|-
| rowspan="2" colspan="1" |Topical [[calcineurin]] inhibitors
| rowspan="1" colspan="1"|[[Tacrolimus]] ointment 0.1% twice daily
| rowspan="2" colspan="1"|Shouldn't be used as first-line therapy
|-
| rowspan="1" colspan="1"|[[Pimecrolimus]] cream 1% twice daily
|-
| rowspan="2" colspan="1"| [[Tricyclic antidepressant]] or [[gabapentin]]
| rowspan="2" colspan="2" | Can be used in cases where [[Balanitis xerotica obliterans|BXO]] is associated with penile [[dysesthesia]]
|-
|
|-
| colspan="3"|
'''Surgery'''<br>
* Surgical treatment often involves [[Circumcise|circumcision]]. Trial of [[steroids]] is usually prescribed before subjecting patients for [[surgery]]. [[Phimosis]] is an indication for [[surgery]]. In patients with severe [[Balanitis xerotica obliterans|BXO]] may require an extensive [[surgery]] after careful evaluation of disease control, function and cosmesis.
* Some cases may require meatoplasty, extensive [[urethroplasty]] and reconstructions
* Patients who undergo [[surgery]] should be follow up as the disease as tendency to recur (BXO as high tendency to recur due to [[koebner phenomenon]])
* Patients should be advice for regular [[genital]] self-examination and should be advice to return if the lesions reoccur
|-
| colspan="3" |
'''Prospective therapies'''
|-
| colspan="3" |Intralesional [[corticosteroids]],  [[intravenous]] [[procaine]], [[topical]] [[estrogen]] and [[retinoid]] creams, oral [[vitamin E]], [[radiation therapy]] and CO2 laser are currently being studied for their role in treating BXO.
|}


==See also==
===Prevention ===
* [[Penis]]
There are no established preventive measures for preventing BXO. Studies have shown that [[Circumcise|circumcision]] in males can help in reducing the risk of having BXO.<ref name="pmid2789094532">{{cite journal| author=Dayal S, Sahu P| title=Zoon balanitis: A comprehensive review. | journal=Indian J Sex Transm Dis | year= 2016 | volume= 37 | issue= 2 | pages= 129-138 | pmid=27890945 | doi=10.4103/0253-7184.192128 | pmc=5111296 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27890945  }}</ref>
* [[Glans penis]]
* [[Foreskin]]
* [[Phimosis]]
* [[Circumcision]]


==References==
==References==
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Vishal Devarkonda, M.B.B.S[2]

Synonyms and keywords:BXO, Penile lichen sclerosus

Overview

Balanitis xerotica obliterans (BXO) is a dermatological (skin) condition affecting the male genitalia. It was first described by Stuhmer in year 1928. The exact pathophysiology of balanitis xerotica obliterans is unknown. Balanitis xerotica obliterans (BXO) commonly occurs on foreskin and glans penis. Patients with BXO usually present with atrophic white patches with indurated (hardened) whitish ring near the tip of penis. Definitive diagnosis is provided by cutaneous biopsy. Prognosis is usually good with treatment. Treatment options for balanitis xerotica obliterans (BXO) include both medical and surgical modalities.

Historical Perspective

In 1928, Stuhmer for the first time in medical literature has described lichen sclerosus on penis as balanitits xerotica obliterans.[1]

Classification

There is no established classification system for balanitits xerotica obliterans.

Pathophysiology

The exact pathophysiology of balanitits xerotica obliterans is unknown. Studies have shown that multiple factors were associated with development of BXO. These include:[2][3][4][5][6][7][8][9]

Factors associated with pathogenesis of BXO
Uncircumcised Penis Accumulation of secretions and epithelial debris between the foreskin and coronal sulcus leads to chronic irritation and sub-clinical trauma. [2]
Autoimmune diseases
Infections Human papillomavirus (HPV) Several studies have implicated human papillomavirus as a causative agent in pathogenesis of BXO. HPV 16, 18, 33 and 51 have been found to be closely associated with development of BXO. Though recent studies have reported lack of clinical correlation between BXO and HPV as they both have unrelated transcriptosome.
Several studies have reported association of various infectious organisms with development of balanitis xerotica obliterans, which include:
Genetics
  • In females, 12% of patients were found to have a family history of lichen sclerosis
  • In males, there is no evidence familial predisposition
Environmental factors

Trauma, old scars, skin grafts, sunburn and radiation were found to be associated with BXO.[8] Some studies have proposed that post-micturation dribbling or micro-incontinence play a central role in development of BXO.[9]

Histopathology

Histopatholgy findings in BXO include the following:[1]

Early stage of BXO

Late stages of BXO

Epidemiology and Demographics

Incidence

There are no comprehensive studies studying the incidence and prevalence in general population. A recent study conducted in an unselected cohort of 153,432 patients presenting to an outpatient clinic in Brookes Army Medical Center in the United States reported the incidence of BXO at 0.07%.

Age

BXO commonly affects middle age group, with men in their twenties were found to be at twice the risk on comparison with other age groups.[10]

Race

On comparison with white men, BXO is more prevalent in black and hispanic men.[11]

Screening

There are no established screening guidelines for BXO.

Natural History, Complications, and Prognosis

Natural history

If left untreated, BXO may involve the penile skin, scrotum, and entire urethra leading to the complications such as phimosis and urinary retention.[12]

Complications

Complication of BXO include:[13][14][15][16][17][18]

Prognosis

Prognosis is usually good with treatment.[19]

Diagnosis

History and symptoms

Patients with BXO could be asymptomatic or symptomatic presenting with:[20]

More common symptoms

Less common symptoms

Physical examination

Physical examination findings include:[21]

Laboratory findings

Cutaneous biopsy will provide a definitive diagnosis of BXO.[22]

Cutaneous biopsy

Treatment

Treatment of BXO include both surgical and medical modalities, these include:[23][24][25][26][27][26][28][29]

Management of BXO
Medical Drug dosage Effectiveness
Topical steroids * Betamethasone diproprionate 0.05% or clobetasol proprionate 0.05% cream or ointment applied once or twice daily
  • After 6–8 weeks, reduce the application of the topical steroid to every second day
  • After 12–16 weeks to assess response to treatment (mometasone aceponate 0.1% cream can be substituted if there is a good response)
  • No improvement by 6 months, then use of the potent topical steroid should be abandoned
 Studies have shown that 50% of patients respond to topical steroid application
Topical calcineurin inhibitors Tacrolimus ointment 0.1% twice daily Shouldn't be used as first-line therapy
Pimecrolimus cream 1% twice daily
Tricyclic antidepressant or gabapentin Can be used in cases where BXO is associated with penile dysesthesia

Surgery

  • Surgical treatment often involves circumcision. Trial of steroids is usually prescribed before subjecting patients for surgery. Phimosis is an indication for surgery. In patients with severe BXO may require an extensive surgery after careful evaluation of disease control, function and cosmesis.
  • Some cases may require meatoplasty, extensive urethroplasty and reconstructions
  • Patients who undergo surgery should be follow up as the disease as tendency to recur (BXO as high tendency to recur due to koebner phenomenon)
  • Patients should be advice for regular genital self-examination and should be advice to return if the lesions reoccur

Prospective therapies

Intralesional corticosteroids, intravenous procaine, topical estrogen and retinoid creams, oral vitamin E, radiation therapy and CO2 laser are currently being studied for their role in treating BXO.

Prevention

There are no established preventive measures for preventing BXO. Studies have shown that circumcision in males can help in reducing the risk of having BXO.[30]

References

  1. ↑ 1.0 1.1 Clouston D, Hall A, Lawrentschuk N (2011). "Penile lichen sclerosus (balanitis xerotica obliterans)". BJU Int. 108 Suppl 2: 14–9. doi:10.1111/j.1464-410X.2011.10699.x. PMID 22085120.
  2. ↑ 2.0 2.1 Schempp C, Bocklage H, Lange R, Kölmel HW, Orfanos CE, Gollnick H (1993). "Further evidence for Borrelia burgdorferi infection in morphea and lichen sclerosus et atrophicus confirmed by DNA amplification". J Invest Dermatol. 100 (5): 717–20. PMID 8491994.
  3. ↑ 3.0 3.1 Azurdia RM, Luzzi GA, Byren I, Welsh K, Wojnarowska F, Marren P; et al. (1999). "Lichen sclerosus in adult men: a study of HLA associations and susceptibility to autoimmune disease". Br J Dermatol. 140 (1): 79–83. PMID 10215772.
  4. ↑ 4.0 4.1 Meffert JJ, Davis BM, Grimwood RE (1995). "Lichen sclerosus". J Am Acad Dermatol. 32 (3): 393–416, quiz 417-8. PMID 7868709.
  5. ↑ 5.0 5.1 Fujiwara H, Fujiwara K, Hashimoto K, Mehregan AH, Schaumburg-Lever G, Lange R; et al. (1997). "Detection of Borrelia burgdorferi DNA (B garinii or B afzelii) in morphea and lichen sclerosus et atrophicus tissues of German and Japanese but not of US patients". Arch Dermatol. 133 (1): 41–4. PMID 9006371.
  6. ↑ 6.0 6.1 Boulinguez S, Bernard P, Lacour JP, Nicot T, Bedane C, Ortonne JP; et al. (1997). "Bullous lichen sclerosus with chronic hepatitis C virus infection". Br J Dermatol. 137 (3): 474–5. PMID 9349358.
  7. ↑ 7.0 7.1 Aidé S, Lattario FR, Almeida G, do Val IC, da Costa Carvalho M (2010). "Epstein-Barr virus and human papillomavirus infection in vulvar lichen sclerosus". J Low Genit Tract Dis. 14 (4): 319–22. doi:10.1097/LGT.0b013e3181d734f1. PMID 20885159.
  8. ↑ 8.0 8.1 Bjekić M, Šipetić S, Marinković J (2011). "Risk factors for genital lichen sclerosus in men". Br J Dermatol. 164 (2): 325–9. doi:10.1111/j.1365-2133.2010.10091.x. PMID 20973765.
  9. ↑ 9.0 9.1 Bunker CB (2007). "Male genital lichen sclerosus and tacrolimus". Br J Dermatol. 157 (5): 1079–80. doi:10.1111/j.1365-2133.2007.08179.x. PMID 17854373.
  10. ↑ Kizer WS, Prarie T, Morey AF (2003). "Balanitis xerotica obliterans: epidemiologic distribution in an equal access health care system". South Med J. 96 (1): 9–11. PMID 12602705.
  11. ↑ Kizer WS, Prarie T, Morey AF (2003). "Balanitis xerotica obliterans: epidemiologic distribution in an equal access health care system". South Med J. 96 (1): 9–11. PMID 12602705.
  12. ↑ Depasquale I, Park AJ, Bracka A (2000). "The treatment of balanitis xerotica obliterans". BJU Int. 86 (4): 459–65. PMID 10971272.
  13. ↑ Neill SM, Lewis FM, Tatnall FM, Cox NH, British Association of Dermatologists (2010). "British Association of Dermatologists' guidelines for the management of lichen sclerosus 2010". Br J Dermatol. 163 (4): 672–82. doi:10.1111/j.1365-2133.2010.09997.x. PMID 20854400.
  14. ↑ Nasca MR, Innocenzi D, Micali G (1999). "Penile cancer among patients with genital lichen sclerosus". J Am Acad Dermatol. 41 (6): 911–4. PMID 10570372.
  15. ↑ Velazquez EF, Cubilla AL (2003). "Lichen sclerosus in 68 patients with squamous cell carcinoma of the penis: frequent atypias and correlation with special carcinoma variants suggests a precancerous role". Am J Surg Pathol. 27 (11): 1448–53. PMID 14576478.
  16. ↑ Prowse DM, Ktori EN, Chandrasekaran D, Prapa A, Baithun S (2008). "Human papillomavirus-associated increase in p16INK4A expression in penile lichen sclerosus and squamous cell carcinoma". Br J Dermatol. 158 (2): 261–5. doi:10.1111/j.1365-2133.2007.08305.x. PMC 2268980. PMID 18047520.
  17. ↑ Thami GP, Kaur S (2003). "Genital lichen sclerosus, squamous cell carcinoma and circumcision". Br J Dermatol. 148 (5): 1083–4. PMID 12786863.
  18. ↑ Ranjan N, Singh SK (2008). "Malignant transformation of penile lichen sclerosus: exactly how common is it?". Int J Dermatol. 47 (12): 1308–9. doi:10.1111/j.1365-4632.2008.03866.x. PMID 19126024.
  19. ↑ Clouston D, Hall A, Lawrentschuk N (2011). "Penile lichen sclerosus (balanitis xerotica obliterans)". BJU Int. 108 Suppl 2: 14–9. doi:10.1111/j.1464-410X.2011.10699.x. PMID 22085120.
  20. ↑ Clouston D, Hall A, Lawrentschuk N (2011). "Penile lichen sclerosus (balanitis xerotica obliterans)". BJU Int. 108 Suppl 2: 14–9. doi:10.1111/j.1464-410X.2011.10699.x. PMID 22085120.
  21. ↑ Clouston D, Hall A, Lawrentschuk N (2011). "Penile lichen sclerosus (balanitis xerotica obliterans)". BJU Int. 108 Suppl 2: 14–9. doi:10.1111/j.1464-410X.2011.10699.x. PMID 22085120.
  22. ↑ Das S, Tunuguntla HS (2000). "Balanitis xerotica obliterans--a review". World J Urol. 18 (6): 382–7. doi:10.1007/PL00007083. PMID 11204255.
  23. ↑ Clouston D, Hall A, Lawrentschuk N (2011). "Penile lichen sclerosus (balanitis xerotica obliterans)". BJU Int. 108 Suppl 2: 14–9. doi:10.1111/j.1464-410X.2011.10699.x. PMID 22085120.
  24. ↑ Sagi L, Trau H (2011). "The Koebner phenomenon". Clin Dermatol. 29 (2): 231–6. doi:10.1016/j.clindermatol.2010.09.014. PMID 21396563.
  25. ↑ Das S, Tunuguntla HS (2000). "Balanitis xerotica obliterans--a review". World J Urol. 18 (6): 382–7. doi:10.1007/PL00007083. PMID 11204255.
  26. ↑ 26.0 26.1 Hrebinko RL (1996). "Circumferential laser vaporization for severe meatal stenosis secondary to balanitis xerotica obliterans". J Urol. 156 (5): 1735–6. PMID 8863582.
  27. ↑ Rudolph R, Walther P (1997). "Full-thickness skin grafts from eyelids to penis, plus split-thickness grafts in chronic balanitis xerotica obliterans". Ann Plast Surg. 38 (2): 173–6. PMID 9043588.
  28. ↑ Singh I, Ansari MS (2006). "Extensive balanitis xerotica obliterans (BXO) involving the anterior urethra and scrotum". Int Urol Nephrol. 38 (3–4): 505–6. doi:10.1007/s11255-006-0100-8. PMID 17180441.
  29. ↑ Garaffa G, Shabbir M, Christopher N, Minhas S, Ralph DJ (2011). "The surgical management of lichen sclerosus of the glans penis: our experience and review of the literature". J Sex Med. 8 (4): 1246–53. doi:10.1111/j.1743-6109.2010.02165.x. PMID 21210959.
  30. ↑ Dayal S, Sahu P (2016). "Zoon balanitis: A comprehensive review". Indian J Sex Transm Dis. 37 (2): 129–138. doi:10.4103/0253-7184.192128. PMC 5111296. PMID 27890945.

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