Balanitis xerotica obliterans
Chronic inflammatory lymphocyte-mediated skin disorder, involving the foreskin, glans and occasionally the urethra of men. Associated with phimosis, balanitis and urethral stricture disease.
Formally known as lichen sclerosis et atrophicus.
Incidence unknown, about 1 in 300.
Can occur in all ages, with peaks seen between 30 and 50.
The cause is not well defined. Proposed mechanisms include autoimmune causes, post-traumatic, genetic pre-disposition, and contact with urine.
Histology
- Chronic inflammation
- Loss of rete pegs
- Epidermal atrophy
- Hyperkeratosis
- Sclerosis
- Homogenisation of collagen in the upper dermis
- Perivascular dermal infiltration
- Plugging of ostia of eccrine and follicular structures
Gross appearance and presentation
White, scaly plaques.
Atrophic and sclerotic white patches (leukoderma) as disease progresses.
Preputial thickening, cracking and phimosis with bleeding and pain.
Meatal stenosis and stricturing.
Management
Topical steroids (e.g. 0.05 % betamethasone BD for 4 weeks) can be trialled.
Surgery (circumcision) is generally needed especially for bothersome symptoms.
Urethral strictures related to BXO are difficult to manage:
- Prompt management of meatal stenosis only may be curative
- Always found in anterior urethra
- Reconstruction or urethroplasty with penile skin or any skin generally not recommended as BXO is a skin disease and can easily recur – most would use buccal mucosa
BXO is considered to have premalignant potential and is associated with PeIN and penile SCC development – incidence reported as high as 4 – 8 %.