Introduction. Balanitis Xerotica Obliterans was first described by Stühmer in 1928 in Germany.1Balanitis Xerotica Obliterans (BXO) and Lichen Sclerosus et Atrophicus (LSA) are two names for the same disease.2-3,21,32 BXO/LSA is a skin disease of unknown etiology.2 It occurs in both males and females. LSA is the name applied when the disease appears in a female or a male in other than the genital organs. BXO is the name traditionally used when the disease afflicts the male sexual organs. An older name is kraurosis glandii et praeputii penis.2,6 This page is limited to information about the disease in males when it affects the genital organs. For information on the disease in females see Lichen Sclerosus.
BXO is a rare disease that affects only 6 of 1000 males (.6 of 1 percent).21 It can affect males of any age.21 The traditional treatment has been radical circumcision.16 However, many conservative treatment options are now available.
Diagnosis.Freeman and Laymon (1941) provide a detailed classic description of the disease:2 BXO is usually distinguished by a ring of hardened tissue with a whitish color at the tip of the foreskin. The hardening of the tissue prevents retraction of the foreskin.23 Immunophenotyping may be useful in differential diagnosis.15 Histologic examination of cutaneous biopsy gives a definite diagnosis.7,8,23,27 If the biopsy rules out BXO as a cause of non-retractile foreskin, then conservative treatment is most likely possible. On the other hand, if the biopsy confirms the presence of BXO, the choice of treatment modality is more difficult.
BXO is a relatively serious disease. It can cause urethral stricture and retention of urine.2 Malignant tumors have (rarely) been reported to develop from BXO.2,23 Meffert et al. provide a recent review of the literature.17 A person with BXO or suspected BXO should be under the care of a medical doctor.
Conventional vs. Conservative treatment. Conventional medical wisdom has stated that BXO is an absolute indication for circumcision.16 However, that treatment modality dates from a time when the prepuce was considered to have no value for the individual. Clearly this is no longer the case. The function and value of the prepuce is now recognized, and protection of the individual from unnecessarily radical surgery is always a doctor's prerogative. Fortunately, researchers have reported some success with conservative therapies for BXO that preserve the prepuce.
Medical treatment. Corticosteroids have been used with varying degrees of success.4,5. Pasieczny reports successful treatment with topical testosterone propionate ointment.7,26 Several authorities report success with clobetasol propionate.14,19,22,24 Shelley and colleagues report successful treatment with antibiotics.25Depasquale and colleagues, however, recommend radical circumcision, but also suggest mometasone or clobetasol cream as a medical treatment.27 Dewan reports that BXO is successfully treated with topical steroid ointment during the early stages.3031 Assmann et al. report that tacrolimus ointment is effective for treatment of LSA in women.32 Clinical experience has shown it to be effective against BXO in boys. Ebert et al. report safety and good results with the use with Tacrolimus ointment.38
Surgical treatment. Carbon dioxide (CO2) laser surgery has been used with reported good results.9,10,11,13,20 A carbon dioxide laser is used to vaporize the lesions. Circumcision is the conventional radical surgical treatment but sacrifices the prepuce.8,23,24,26,27
Conclusion. There still seems to a wide range of opinion on the best treatment modalities for BXO. The cause is still unknown, although Shelley et al. hypothesize spirochete infection.24 More research is needed. Now, however, there is a good possibility of successful treatment without radical circumcision.29
The trend today seems to be for greater use of medical treatment and less use of radical surgery in the treatment of BXO.
Library holdings are indexed in approximate chronological order of publication.
Library holdings
Stühmer A. Balanitis xerotica obiterans und ihre Beziehungen zur 'Kraurosis glandi et praeputii penis'. Arch Dermatol Syph (Berlin) 1928;156:613. DOI: 10.1007/BF01828558 [Abstract]
Family Practice offers a photograph of BXO. (link to www.familypractice.com)
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Diagnosis. Freeman and Laymon (1941) provide a detailed classic description of the disease:2 BXO is usually distinguished by a ring of hardened tissue with a whitish color at the tip of the foreskin. The hardening of the tissue prevents retraction of the foreskin.23 Immunophenotyping may be useful in differential diagnosis.15 Histologic examination of cutaneous biopsy gives a definite diagnosis.7,8,23,27 If the biopsy rules out BXO as a cause of non-retractile foreskin, then conservative treatment is most likely possible. On the other hand, if the biopsy confirms the presence of BXO, the choice of treatment modality is more difficult.