Balanitis xerotica obliterans
Encyclopedia
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.
of BXO is controversial and unclear. One study calculated a rate of 0.6% of boys are affected by their 15th birthdays.
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
.
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
".
.
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.
(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.
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-cancer
ous role,
resulting in squamous cell carcinoma
of the penis, a form of penile cancer.
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."
Shelley reported some success with long-term antibiotic
therapy. However, relapses were seen upon stopping treatment.
Some success has been reported with topical steroid
s, when scar
ring 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.
Dermatology
Dermatology is the branch of medicine dealing with the skin and its diseases, a unique specialty with both medical and surgical aspects. A dermatologist takes care of diseases, in the widest sense, and some cosmetic problems of the skin, scalp, hair, and nails....
(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
Foreskin
In male human anatomy, the foreskin is a generally retractable double-layered fold of skin and mucous membrane that covers the glans penis and protects the urinary meatus when the penis is not erect...
and glans penis
Glans penis
The glans penis is the sensitive bulbous structure at the distal end of the penis. The glans penis is anatomically homologous to the clitoral glans of the female...
.
Atrophic
Atrophy
Atrophy is the partial or complete wasting away of a part of the body. Causes of atrophy include mutations , poor nourishment, poor circulation, loss of hormonal support, loss of nerve supply to the target organ, disuse or lack of exercise or disease intrinsic to the tissue itself...
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 prevalencePrevalence
In epidemiology, the prevalence of a health-related state in a statistical population is defined as the total number of cases of the risk factor in the population at a given time, or the total number of cases in the population, divided by the number of individuals in the population...
of BXO is controversial and unclear. One study calculated a rate of 0.6% of boys are affected by their 15th birthdays.
Another reported a rate of 0.07%.
However, a review noted that "with a high degree of suspicion and histologic
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...
examination, the condition will prove to be much more frequent than one generally believes."
Another suggested that "more cases would be diagnosed
Medical diagnosis
Medical diagnosis refers both to the process of attempting to determine or identify a possible disease or disorder , and to the opinion reached by this process...
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
Circumcision
Male circumcision is the surgical removal of some or all of the foreskin from the penis. The word "circumcision" comes from Latin and ....
, and unfortunately many surgeons still fail to send their circumcision specimens for histology."
Another remarked that the "extent of asymptomatic
Asymptomatic
In medicine, a disease is considered asymptomatic if a patient is a carrier for a disease or infection but experiences no symptoms. A condition might be asymptomatic if it fails to show the noticeable symptoms with which it is usually associated. Asymptomatic infections are also called subclinical...
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
Black people
The term black people is used in systems of racial classification for humans of a dark skinned phenotype, relative to other racial groups.Different societies apply different criteria regarding who is classified as "black", and often social variables such as class, socio-economic status also plays a...
and Hispanic
Hispanic
Hispanic is a term that originally denoted a relationship to Hispania, which is to say the Iberian Peninsula: Andorra, Gibraltar, Portugal and Spain. During the Modern Era, Hispanic sometimes takes on a more limited meaning, particularly in the United States, where the term means a person of ...
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
Odds ratio
The odds ratio is a measure of effect size, describing the strength of association or non-independence between two binary data values. It is used as a descriptive statistic, and plays an important role in logistic regression...
of 53.55. The finding was statistically significant
Statistical significance
In statistics, a result is called statistically significant if it is unlikely to have occurred by chance. The phrase test of significance was coined by Ronald Fisher....
.
However, BXO has also been noted to occur after late circumcision, especially when performed for phimosis
Phimosis
Phimosis , from the Greek phimos ), is a condition where, in men, the foreskin cannot be fully retracted over the glans penis...
.
Etiology
The etiologyEtiology
Etiology is the study of causation, or origination. The word is derived from the Greek , aitiologia, "giving a reason for" ....
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
Autoimmunity
Autoimmunity is the failure of an organism to recognize its own constituent parts as self, which allows an immune response against its own cells and tissues. Any disease that results from such an aberrant immune response is termed an autoimmune disease...
disorders.
However, this finding is not repeated in every study.
Infection from "human papilloma virus (serotype 16 in particular), spirochetes
Spirochaete
Spirochaetes belong to a phylum of distinctive Gram-negative bacteria, which have long, helically coiled cells...
and atypical mycobacteria
Mycobacterium
Mycobacterium is a genus of Actinobacteria, given its own family, the Mycobacteriaceae. The genus includes pathogens known to cause serious diseases in mammals, including tuberculosis and leprosy...
" has also been suggested as a cause. Additional suggestions include "pemphigus vulgaris
Pemphigus
Pemphigus is a rare group of blistering autoimmune diseases that affect the skin and mucous membranes.In pemphigus, autoantibodies form against desmoglein. Desmoglein forms the "glue" that attaches adjacent epidermal cells via attachment points called desmosomes...
and chronic nonspecific bacterial balanitis
Balanitis
Balanitis is inflammation of the glans penis . When the foreskin is also affected, it is termed balanoposthitis....
".
Relationship to phimosis
BXO is a common cause of pathological phimosisPhimosis
Phimosis , from the Greek phimos ), is a condition where, in men, the foreskin cannot be fully retracted over the glans penis...
.
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 sclerosusLichen sclerosus
Lichen sclerosus is an uncommon disease of unknown cause that results in white patches on the skin, which may cause scarring on and around genital skin....
(LS). Lately BXO was coded as part of LSA by Medical literature search tool Medline
MEDLINE
MEDLINE is a bibliographic database of life sciences and biomedical information. It includes bibliographic information for articles from academic journals covering medicine, nursing, pharmacy, dentistry, veterinary medicine, and health care...
.
However, Mallon et al. suggest that BXO "may be a consequence of other fibrosing dermatoses, such as lichen planus
Lichen planus
Lichen planus is a chronic mucocutaneous disease that affects the skin, tongue, and oral mucosa. The disease presents itself in the form of papules, lesions, or rashes. Lichen planus does not involve lichens, the fungus/algae symbionts that often grow on tree trunks; the name refers to the dry and...
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
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
, irritation
Irritation
Irritation or exacerbation, in biology and physiology, is a state of inflammation or painful reaction to allergy or cell-lining damage. A stimulus or agent which induces the state of irritation is an irritant...
, and disturbance of sexual function
Sexual intercourse
Sexual intercourse, also known as copulation or coitus, commonly refers to the act in which a male's penis enters a female's vagina for the purposes of sexual pleasure or reproduction. The entities may be of opposite sexes, or they may be hermaphroditic, as is the case with snails...
.
In later stages, a meatal
Urinary meatus
The urinary meatus is an orifice of the urethra. It is the point at which urine and, in males, semen exits the urethra. The meatus features varying degrees of sensitivity to the touch among males and females....
stricture
Stenosis
A stenosis is an abnormal narrowing in a blood vessel or other tubular organ or structure.It is also sometimes called a stricture ....
may occur, causing urinary retention
Urinary retention
Urinary retention, also known as ischuria, is a lack of ability to urinate. It is a common complication of benign prostatic hyperplasia , although it can also be caused by nerve dysfunction, constipation, infection, or medications...
. This may result in bladder
Urinary bladder
The urinary bladder is the organ that collects urine excreted by the kidneys before disposal by urination. A hollow muscular, and distensible organ, the bladder sits on the pelvic floor...
or kidney
Kidney
The kidneys, organs with several functions, serve essential regulatory roles in most animals, including vertebrates and some invertebrates. They are essential in the urinary system and also serve homeostatic functions such as the regulation of electrolytes, maintenance of acid–base balance, and...
damage.
The coronal sulcus and frenulum
Frenulum
A frenulum is a small fold of tissue that secures or restricts the motion of a mobile organ in the body.-In human anatomy:...
may be destroyed.
Phimosis
Phimosis
Phimosis , from the Greek phimos ), is a condition where, in men, the foreskin cannot be fully retracted over the glans penis...
or paraphimosis
Paraphimosis
Paraphimosis is an uncommon medical condition where the foreskin becomes trapped behind the glans penis, and cannot be reduced...
may occur.
Several studies indicate that BXO may play a pre-cancer
Cancer
Cancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...
ous role,
resulting in squamous cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma , occasionally rendered as "squamous-cell carcinoma", is a histologically distinct form of cancer. It arises from the uncontrolled multiplication of malignant cells deriving from epithelium, or showing particular cytological or tissue architectural characteristics of...
of the penis, a form of penile cancer.
Diagnosis
Neuhaus and Skidmore report that "Tzanck smear and cutaneousSkin
-Dermis:The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many Mechanoreceptors that provide the sense of touch and heat...
biopsy
Biopsy
A biopsy is a medical test involving sampling of cells or tissues for examination. It is the medical removal of tissue from a living subject to determine the presence or extent of a disease. The tissue is generally examined under a microscope by a pathologist, and can also be analyzed chemically...
, 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
Antibiotic
An antibacterial is a compound or substance that kills or slows down the growth of bacteria.The term is often used synonymously with the term antibiotic; today, however, with increased knowledge of the causative agents of various infectious diseases, antibiotic has come to denote a broader range of...
therapy. However, relapses were seen upon stopping treatment.
Some success has been reported with topical steroid
Steroid
A steroid is a type of organic compound that contains a characteristic arrangement of four cycloalkane rings that are joined to each other. Examples of steroids include the dietary fat cholesterol, the sex hormones estradiol and testosterone, and the anti-inflammatory drug dexamethasone.The core...
s, when scar
Scar
Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...
ring is minimal,
though some have found this ineffectual.
Moderate therapeutic results have been reported using etretinate
Etretinate
Etretinate is a medication developed by Hoffmann–La Roche that was approved by the FDA in 1986 to treat severe psoriasis...
.
Some success has been reported in the use of carbon dioxide
Carbon dioxide
Carbon dioxide is a naturally occurring chemical compound composed of two oxygen atoms covalently bonded to a single carbon atom...
laser therapy.
Many authors report that circumcision is the treatment of choice,
with modifications if necessary.
Pasieczny suggests testosterone
Testosterone
Testosterone is a steroid hormone from the androgen group and is found in mammals, reptiles, birds, and other vertebrates. In mammals, testosterone is primarily secreted in the testes of males and the ovaries of females, although small amounts are also secreted by the adrenal glands...
ointment, however.
Glansectomy may be required.