Balanitis xerotica obliterans: Difference between revisions

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* 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.  
* 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
* Some cases may require meatoplasty, extensive [[urethroplasty]] and reconstructions

Revision as of 00:34, 15 February 2017

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 sublincal trauma. [2]
Autoimmune diseases
  • Patients with BXO, were found to have other associated autoimmune conditions, which include: diabetes mellitus, vitiligo, alopecia areata.[4]
  • Some studies have shown a close association between BXO and HLA DQ7 with DR11 and DR12.[3]
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, has 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 Centre 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]

  • Itching(pruritus) of the genitalia(rare)
  • Discomfort in urination(dysuria)(rare)

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]

Managements of BXO
Medical Drug dosage Effectiveness
Topical steroids 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 oestrogen and retinoid creams, oral vitamin E, radiation therapy and CO2 laser are currently been studied for there 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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