Balanitis xerotica obliterans
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 | ||
| 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
- Moderately heavy lymphocytic infiltrate found in basal epidermis and superficial dermis in early stages of the lesion.
Late stages of BXO
- Epidermis becomes atrophic with surface hyperkeratosis and thickened basement membrane
- Broad zone of subepidermal oedema with homogenization of collagen, which becomes sclerotic over time
- In few cases, epidermis is detached from dermis resulting in formation of haemorrhagic bullae
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]
- Phimosis
- Painful erection
- Reduced urinary flow
- Urinary retention
- Risk of malignant transformation into squamous cell carcinoma (long-term prospective studies are needed to determine the real risk of malignant transformation)
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
- Whitening or reddening of penile region
- Difficulty in retracting foreskin
- Painful erection
- Reduced urinary flow
- Urinary retention
Less common symptoms
- Burning sensation (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)
Physical examination
Physical examination findings include:[21]
- Whitening or reddening of glans penis, foreskin(prepuce) and coronal sulcus
- Induration of glans and foreskin
- Phimosis
- Purpura
- Telangiectases
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
|
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
| ||
|
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
- ↑ 1.0 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.
- ↑ 2.0 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.
- ↑ 3.0 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.
- ↑ 4.0 4.1 Meffert JJ, Davis BM, Grimwood RE (1995). "Lichen sclerosus". J Am Acad Dermatol. 32 (3): 393–416, quiz 417-8. PMID 7868709.
- ↑ 5.0 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.
- ↑ 6.0 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.
- ↑ 7.0 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.
- ↑ 8.0 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.
- ↑ 9.0 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.
- ↑ 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.
- ↑ 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.
- ↑ Depasquale I, Park AJ, Bracka A (2000). "The treatment of balanitis xerotica obliterans". BJU Int. 86 (4): 459–65. PMID 10971272.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Thami GP, Kaur S (2003). "Genital lichen sclerosus, squamous cell carcinoma and circumcision". Br J Dermatol. 148 (5): 1083–4. PMID 12786863.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Das S, Tunuguntla HS (2000). "Balanitis xerotica obliterans--a review". World J Urol. 18 (6): 382–7. doi:10.1007/PL00007083. PMID 11204255.
- ↑ 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.
- ↑ Sagi L, Trau H (2011). "The Koebner phenomenon". Clin Dermatol. 29 (2): 231–6. doi:10.1016/j.clindermatol.2010.09.014. PMID 21396563.
- ↑ Das S, Tunuguntla HS (2000). "Balanitis xerotica obliterans--a review". World J Urol. 18 (6): 382–7. doi:10.1007/PL00007083. PMID 11204255.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
Template:WikiDoc Sources<section></section><section><section></section><section></section></section>