Balanitis Xerotics Obliterans BXO

Balanitis Xerotics Obliterans BXO

Balanitis xerotica obliterans (BXO) is also known as lichen sclerosis atrophicus of the male genitalia is a chronic inflammatory process which affects the foreskin but can also extend onto the glans and external urethral meatus. 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.

Symptoms of BXO

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.

The symptoms of BXO can appear as:

• A hard, scaly or whitish lump that forms around the urethral opening (also known as the meatus)
• Inflammation of the glans or foreskin
• Tightening of the foreskin that may prevent it from retracting or from returning back over the glans
• Bleeding or tears on the foreskin
• Pain or difficulty passing urine
• Weak flow of urine
• Urine spraying rather than flowing out steadily
• Itchiness, burning or soreness around the glans and foreskin
• Discharge from the penis

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.

Causes of BXO

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.

Although we don’t fully understand the causes of BXO, some scientists believe that it could be associated with other types of autoimmune conditions such as vitiligo. Autoimmune disorders cause inflammation because the immune system mistakenly starts to attack the body’s own tissues. We don’t know why this happens and it isn’t yet possible to predict who will be affected. 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.

You may hear the term lichen sclerosis used to refer to your son’s condition. Lichen sclerosis is a chronic inflammatory condition that can affect the skin in different parts of the body. When it affects the male genitalia, it is known as balanitis xerotica obliterans or BXO.

Lichen sclerosis is not an infection so there is no risk that it will spread to other people. The condition is chronic and progressive, which means that it is a long term condition that will gradually get worse if it is left untreated. Lichen sclerosis causes inflammation that can make the penis sore and red. The opening of the urethra may become narrowed or blocked and an ulcer can eventually form. The skin of the glans and foreskin can be permanently changed or scarred.

Treatments of BXO

At this moment in time we recommend circumcision to be performed. There is some debate that foreskins can be left intact with injection of steroids or the use of topical steroids. This has currently not been proven and due to the ongoing risks associated with this condition, we would recommend a formal circumcision to ensure this is BXO through histology and guarantee the situation has treated properly. Since BXO is a progressive and painful condition, it is usually best to tackle it swiftly with surgery rather than to wait to see if other, less reliable treatments might help.

Circumcision is the main component of balanitis xerotica obliterans treatment, but it is also vital to follow the post-surgical treatment plan to reduce the risk of further problems. Medication can prevent the urethra from becoming narrower after the operation. In some cases, further surgery may be required to ensure that the urethra is able to function properly.

BXO Post-Surgery

We prescribe a small amount chloramphenicol cream to be used for a number of days to allow the tissues to settle down. At around 5 days after surgery, a course of hydrocortisone cream is used twice a day for 6 weeks to stop the meatus from narrowing. It is our experience that this may help make a significant difference to the insistence of meatal stenosis in this population. Your child will then attend a follow-up review to ensure that their opening is nice and wide and they are voiding without any difficulties.

BXO if left for the long term can be extremely severe and cause a huge amount of pain. Prolonged BXO can also allow the opening of the penis to narrow and this can require the need for further surgery and dilatation. There is also an association with penile cancer in later life if undiagnosed.

Balanitis xerotica obliterans surgery is usually very effective, especially when circumcision is combined with post-operative medication. However, there is a small chance that the remaining skin will still be affected by lichen sclerosis.