Surgical management is reserved for cases with progressive phimosis or where conservative management has not been successful. The underlying benefit of performing a circumcision is to remove the urine exposed warm, moist environment provided by the foreskin aiding the development of BXO.
Circumcision is recommended when BXO is restricted to the foreskin with or without the involvement of the external urethral meatus. In the presence of a urethral stricture, surgical procedures vary depending on the location of the stricture, the length and previous treatments.
Therefore, urethral dilatation, urethrotomy and urethroplasty are all recognised treatments for the management of this disease [17,18]. Long-term monitoring of the foreskin is required in patients managed conservatively as progressive phimosis and adhesions between the inner prepuce and the glans may lead to a less favourable cosmetic result following circumcision. Patients need to be educated with regards to BXO once diagnosis is confirmed and following circumcision, monitoring of the penile shaft skin and urethral meatus is required [19].
Good cosmetic and functional outcomes are dependent on the severity and the extent of the disease. Early diagnosis in primary care will enable timely conservative management under specialist dermatologist teams [20]. Arch F Dermat u Syph ; Phimosis in boys. Br J Urol ; 52 2 The treatment of balanitis xerotica obliterans. BJU Int ; 86 4 Balanitis xerotica obliterans in children. Balanitis xerotica obliterans: epidemiologic distribution in an equal access health care system.
South Med J ; 96 1 Lichen sclerosus et atrophicus. A histological, immunohistochemical and electron microscopic study. Arch Dermatol Res ; 8 Composition of the inflammatory infiltrate in pediatric penile lichen sclerosus et atrophicus balanitis xerotica obliterans : a prospective, comparative immunophenotyping study.
Pediatric Pathology ; 14 2 Male Genital Lichen Sclerosus. Indian Journal of Dermatology ; 60 2 Lichen sclerosus associated with urinary contamina-tion. Referring specialty, the anatomical location of the BXO and duration of symptoms were noted. Previous management including surgical procedures was documented and any change in urinary or sexual function secondary to the disease process was recorded. This was compared to function following plastic surgery management.
Twenty-three patients aged between four and 78 mean age 38 [ Figure 1 ] were referred from six different specialties. The remaining patients were referred from the General Surgery, Genitourinary Medicine and other Plastic Surgery units.
In the group of 23 there were seven patients who had BXO affecting between three and five areas of their genitalia, indicating severe progressive disease. Reconstructive surgery with excision of the affected area and skin grafting or urethroplasty was performed for these patients and they are still being followed in the clinic.
To date there is no recurrence of the disease and the patients have reported subjective improvement in their urinary and sexual function from before surgery. A patient in our study who had BXO affecting his meatus and urethra had undergone two optical urethrotomies and four urethral dilatations over a period of 12 years [ Figure 2 ]. Due to the spread of the disease he needed to perform intermittent self-catheterisation twice a week to maintain a reasonable urinary flow for nearly ten years.
We performed distal urethrotomy of the dense stricture to allow urethroscopy which also showed skip lesions of BXO in the posterior urethra. The patient underwent excision of the distal stricture and two-stage urethral reconstruction using a buccal mucosa graft [ Figure 3 ]. Subsequently he was able to pass urine normally without the need for the self-catheterisation. At two years post procedure he remains disease-free.
In order to assess the progression of the disease, we recorded the anatomical location of the affected area. Patients were recorded as having BXO affecting the foreskin, glans, meatus, penile shaft, urethra and scrotum or any combination of these.
Thirty percent had previous medical treatment in the form of steroid creams, anti-fungal cream, antibiotics or self-catheterisation. Sixty-one percent of patients had previously undergone circumcision a proportion of these were unrelated to the diagnosis of BXO. Forty-seven percent of patients had alteration of their urinary function due to the disease. Symptoms included reduced flow, hesitancy and pain. Forty-eight percent had problems with sexual function and described fissuring, painful intercourse, bleeding, erectile dysfunction and discharge.
Fifty-two percent of the procedures performed in our department were examination under anaesthesia EUA and circumcision [ Figure 5 ]. This correlates with the proportion of patients diagnosed with BXO affecting only the glans or foreskin.
However, four patients underwent a two-stage urethroplasty with buccal mucosal reconstruction, two patients had urethral tubularisations and one had an optical urethrotomy.
The remainder had excision of the affected skin and grafting [an example shown in Figure 6 ] or meatal reconstruction. Patients were followed up for an average of two years and five months prior to discharge. BXO involving glans and corona a3-d3 excised and resurfaced with split skin graft a4-d4.
When looking at the effectiveness of medical therapy for the treatment of BXO our results show limited success. Many cases eventually required surgical treatment. Of the seven patients treated with steroid creams, anti-fungal or antibiotics three had disease confined to the foreskin and glans but with evidence of adhesions or scarring.
The remaining four patients had advanced disease that had spread to the penile shaft or scrotum. A literature review conducted by Pugliese et al. This was supported by a study looking at a paediatric population using steroid cream which showed resolution in patients with clinically mild BXO that was limited to the prepuce but no reported benefit in those with more severe disease.
For patients with disease confined to their glans or foreskin, circumcision offers cure by eliminating the moist urine-rich environment in which BXO can progress. The top of the foreskin will not retract and there can be pale scarred areas around the tip of the foreskin. It can be extremely painful but present in boys with difficult in voiding. Management is a formal circumcision. Post operatively topical steroids will be applied to decrease the need for further surgery.
Additional procedures are sometimes required to ensure that the urethral opening is clear if it has been blocked by scarring or thickened tissue. Generally young men complain of discomfort. Sometimes the penis is sore and burning. The foreskin becomes tighter and tighter and is unretractable. It can consist of bleeding and occasionally there can be small tears visible at the top of the foreskin.
Young men can find that their ability to void slows gradually over time. BXO on examination, the top of the foreskin is quite tight and cannot be retracted. Generally, the issues can look quite variable. Occasionally the skin over the top of the penis will be very white and shiny. Sometimes the skin can become quite inflamed or on some occasions it can be quite thin and very pale or alternatively quite thick.
It is important to seek medical advice if there are any concerns as it will need to be treated. Since the symptoms of BXO can be so variable, it is important to see a doctor if you notice anything unusual about the penis or your son complains of pain or problems when urinating. BXO is generally diagnosed on clinical examination and the tissue is normally sent for histology if the child is circumcised to confirm this.
In reality, the cause for this condition is unclear. It generally affects men who are uncircumcised. It is extremely rare in those young boys who have been circumcised in the neonatal period.
There is no evidence of any infection and no particular cause has ever been detected. However, we do know that boys who have autoimmune disorders or atopic conditions such as eczema, hay fever or asthma are more likely to develop balanitis xerotica obliterans.
Lichen sclerosis is a chronic inflammatory condition that can affect the skin in different parts of the body. We will treat these problems if they arise. It is thought that long standing untreated BXO can lead to a higher incidence of cancer of the penis. If you have any lumps or non-healing sores in that area, you should ask your doctor to look at them.
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