Balanitis Xerotica Obliterans: Conservative Treatment
Options.
Introduction. Balanitis Xerotica Obliterans was
first described by Stühmer in 1928 in Germany.1 Balanitis 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.25 Depasquale 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.30
31 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
n 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]
- Freeman C, Laymon CW.
Balanitis
xerotica obliterans. Arch Dermat Syph (Chicago)
1941;44;(4):547-559.
- Laymon CW, Freeman C.
Relationship of
Balanitis xerotica obliterans to lichen sclerosus et
atrophicus. Arch Derm Syph (Chicago) 1944: 49;
57-59.
- Catterall RD, Oakes
JK. Treatment of balanitis xerotica obiterans with
hydrocortisone injections. Br J Ven Dis
1962;38:75.
- Poynter JH. Levy J.
Balanitis xerotica obliterans: effective treatment with
topical and sublesional corticosteroids. Br J Urol
1967;39(4):420-5.
- McKay DL Jr, Fuqua F,
Weinberg AG. Balanitis xerotica
obliterans in children. J Urol
1975;114(5):773-5.
- Pasieczny TAH. The treatment of
balanitis xerotica obliterans with testosterone propionate
ointment. Acta Derm Venerol (Stockholm)
1977;57:275-277.
- Rickwood AMK,
Hemalatha V, Batcup G, Spitz L. Phimosis in
Boys. Brit J Urol 1980; 52:147-150.
- Rosemberg SK, Jacobs
H. Continuous wave carbon dioxide treatment of balanitis
xerotica obliterans. Urology 1982;19(5):539-41.
- Ratz JL. Carbon dioxide laser
treatment of balanitis xerotica obliterans. J Am
Acad Dermatol 1984;10:925-28.
- Rosemberg SK. Carbon dioxide
laser treatment of external genital lesions.
Urology 1985;25(6):555-8.
- Bale PM, Lochhead
A, Martin HC, Gollow I. Balanitis xerotica
obliterans in children. Pediatr Pathol
1987;7(5-6):617-27.
- Windahl T, Hellsten
S. Carbon
dioxide laser treatment of lichen sclerosus et
atrophicus. J Urol 1993;150:868-70.
- Jørgensen
ET, Svensson Å. The treatment
of phimosis in boys, with a potent topical steroid
(clobetasol propionate 0,05%) cream. Acta
Dermato-Venereologica (Stockholm)
1993;73(1):55-56.
- Hinchliffe SA,
Ciftci AO, Khine MM, et al. Composition of
the inflammatory infiltrate in pediatric penile lichen
sclerosus et atrophicus (balanitis xerotica obliterans): a
prospective, comparative immunophenotyping study.
Pediatr Pathol 1994;14(2):223-33.
- Meuli M, Briner J,
Hanimann B, Sacher P. Lichen sclerosus
et atrophicus causing phimosis in boys: a prospective study
with 5-year followup after complete circumcision. J
Urol 1994:152(3):987-9.
- Meffert JJ, Davis
BM, Grimwood RE. Lichen
Sclerosus. J Am Acad Dermatol
1995;32(3):393-416.
- Hrebinko RL. Circumferential
laser vaporization for severe meatal stenosis secondary to
balanitis xerotica obliterans. J Urol
1996;156(5):1735-6.
- Jorgensen ET,
Svensson A. Problems with the penis and prepuce in
children: Lichen sclerosus should be treated with
corticosteroids to reduce need for surgery. BMJ
1996;313:692. (link to www.bmj.com)
- Kartamaa M, Reitamo
S. Treatment of
lichen sclerosus with carbon dioxide laser
vaporization. Br J Dermatol 1997;136:356-9.
- Parsad D, R. Saini
R. Oral Stanozolol in Lichen Sclerosus et
Atrophicus. J Am Acad Dermatol 1998; 38( 2) part
1: 278-9. (link to www.vulvarpain.icom.ca)
- Dahlman-Ghozlan K,
Hedblad MA, von Krogh G. Penile
lichen sclerosus et atrophicus treated with clobetasol
dipropionate 0.05% cream: a retrospective clinical and
histopathological study. J Am Acad Dermatol
1999;40(3):451-7.
- Shankar KR,
Rickwood AM. The incidence
of phimosis in boys.BJU Int
1999;84(1):101-2.
- Neuhaus IM,
Skidmore RA. Balanitis xerotica obliterans and its
differential diagnosis. J Am Board Fam Pract
1999; 12(6):473-476.
- Shelley, WB,
Shelley ED, Gruenwald MA, et al. Long-term
antibiotic therapy for balanitis xerotica obliterans.
J Am Acad Dermatol 1999;40:69-72.
- Rickwood AMK.
Medical indications for circumcision. BJU Int 1999:
83 Suppl 1, 45-51.
- Depasquale I, Park
AJ, Bracka A. The treatment of
balanitis xerotica obliterans. BJU Int
2000;86(4):459-465.
- Rickwood AMK, Kenny
SE, Donnell SC. Towards
evidence based circumcision of English boys: survey of
trends in practice. BMJ 2000;321:792-793.
- Dalton JD. BXO
does not require treatment by circumcision. (letter)
BMJ 2000; rapid response pages.
- Kiss A, Csontai A,
Pirot L, et al. The response of
balanitis xerotica obliterans to local steroid application
compared with placebo in children. J Urol
2001;165(1):219-20.
- Neill SM, Tatnall
FM, Cox NH. Guidelines for the
management of lichen sclerosus. Br J Dermatol
2002;147:640-9.
- Finkbeiner AE. Balanitis xerotica obliterans: a
form of lichen sclerosus. South Med J
2003;96(1):7-8.
- Kizer WS, Prairie
T, Morey AF. Balanitis xerotica
obliterans: epidemiologic distribution in an equal access
health care system. South Med J
2003;96(1):9-11.
- Dewan PA. Treating Phimosis. Med J Aust
2003;178 (4):148-150.
- Assmann T, Becker-Wegerich
P, Grewe M, et al. Tacrolimus ointment
for the treatment of vulvar lichen sclerosis. J Am
Acad Dermatol 2003;48(6):935-7.
- Gargollo PC, Kozakewich HP,
Bauer SB, et al. Balanitis
xerotica obliterans in boys. J Urol
2005;174:1409-12.
- Vincent MV, MacKinnon E. The response of clinical balanitis
xerotica obliterans to the application of topical
steroid-based creams. J Pediatr Surg
2005;40(4):709–12.
- Ebert AK, Vogt T, Rösch
WH. [Topical therapy of balanitis
xerotica obliterans in childhood: Long-term clinical
results and an overview.] Urologe A.
2007;46(12):1682-6.
- Pugliese JM, Morey AF,
Peterson AC. Lichen sclerosus:
review of the literature and current recommendations for
management. J Urol 2007;178:2268-76.
doi:10.1016/j.juro.2007.08.024
- Poindexter G, Morrell DS. Anogenital pruritus: lichen
sclerosus in children. Pediatr Ann
2007;36(12):785-91.
Medical Photographs
Family Practice offers a
photograph of BXO. (link to www.familypractice.com)