Balanitis xerotica obliterans
Balanitis Xerotica Obliterans (BXO) is also known as Lichen Sclerosus et Atrophicus (LSA). First described in Germany by Stühmer in 1928, it is a skin disease of unknown etiology and occurs in both males and females. BXO is the name traditionally used when the disease afflicts the male sexual organs, while LSA is the name applied when the disease appears in a female or a male in other than the genital organs. An older name for BXO is kraurosis glandii et praeputii penis.
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.
Affecting only 6 in 1000 males (0.6%), BXO is a rare disease which can affect males at any age. As rare as it may be, BXO is a relatively serious disease. It can cause urethral stricture and retention of urine. Malignant tumors have been reported to develop from BXO, albeit very rarely. Meffert et al. (1995) provide a recent review of the literature. A person with BXO or suspected BXO should be under the care of a medical doctor.
Freeman & Laymon (1941) provide a detailed classic description of the disease: 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. Immunophenotyping may be useful in differential diagnosis. Histologic examination of cutaneous biopsy gives a definite diagnosis. The presence of BXO must be confirmed in order to consider the choice of treatment modality. If the biopsy rules out BXO as a cause of non-retractile foreskin, then conservative treatment is most likely possible. If, on the other hand, a biopsy confirms the presence of BXO, the choice of treatment modality is more difficult.
Conventional vs. conservative treatment
Conventional medical wisdom has stated that BXO is an absolute indication for circumcision, however, this treatment modality dates from a time when the prepuce was considered to have no value for the individual. In more recent times, this is no longer the case, as the function and value of the prepuce are now being recognized, and males may wish for treatment that preserves the integrity of their organs; protection of the individual from unnecessarily radical surgery is always a doctor's prerogative. Fortunately, thanks to advances in modern medicine, researchers have reported some success with conservative therapies for BXO that spare the patient from surgery and preserve the prepuce.
Corticosteroids have been used with varying degrees of success. Pasieczny (1977) reports successful treatment with topical testosterone propionate ointment. Several authorities report success with clobetasol propionate. Shelley and colleagues (1999) report successful treatment with antibiotics. While Depasquale and colleagues (2000) recommend radical circumcision, they also suggest mometasone or clobetasol cream as a non-surgical alternative. Dewan (2001) reports that BXO is successfully treated with topical steroid ointment during the early stages. Finkbeiner (2003) reports that tacrolimus ointment is effective for treatment of LSA in women. Clinical experience has shown it to be effective against BXO in boys. Ebert et al. (2007) report safety and good results with the use with Tacrolimus ointment.
Rosemberg et al. (1982) Carbon dioxide (CO2) laser surgery has been used with reported good results. A carbon dioxide laser is used to vaporize the lesions. Circumcision is the conventional radical surgical treatment but sacrifices the prepuce.
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. (1999) hypothesize spirochete infection. More research is needed. Now, however, there is a good possibility of successful treatment without radical circumcision. The trend today seems to be for greater use of medical treatment and less use of radical surgery in the treatment of BXO.
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- Shelley, WB, Shelley ED, Gruenwald MA, et al. Long-term antibiotic therapy for balanitis xerotica obliterans. J Am Acad Dermatol 1999;40:69-72.
- 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.
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- Finkbeiner AE. Balanitis xerotica obliterans: a form of lichen sclerosus. South Med J 2003;96(1):7-8.
- 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.
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- Dalton JD. BXO does not require treatment by circumcision (letter). BMJ. 2000; rapid response pages.