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Long standing balanitis xerotica obliterans resulting in renal impairment in a child
Abstract
Balanitis xerotica obliterans (BXO) is the most common cause of pathological phimosis in boys. Presented here is the case of a previously well 13-year-old boy who developed obstructive renal impairment (serum creatinine = 190 micromol/l) at least in part from phimosis due to BXO. A circumcision and, 2.5 months later, meatal dilatation were done. Nine months after his initial presentation, his serum creatinine returned to a permanently elevated nadir of 119 mumol/l. Presentation with the complications of phimosis can be delayed in teenage boys because they may feel embarrassed to come forward. Circumcision remains the definitive treatment of BXO induced phimosis though if the penile meatus is involved, more complex surgery is sometimes required. Topical steroids are useful for residual disease. Follow-up is very important due to the frequent involvement of the skin of the glans. In the very long term there is an increased chance of penile malignancy, which can occur even after circumcision.
... Ці зміни можуть призвести до обструкції вихідного відділу сечового міхура, що проявляється нетриманням сечі, яке вперше виникло, інфекцій сечовивідних шляхів і гострої затримки сечі, ниркової недостатності [8,9]. У 2-12,5% випадків патологічний процес може набути злоякісного перебігу. ...
The objective: to evaluate the clinical effectiveness of treatment of patients with scleroatrophic lichen of the penis using intrafocal injection of a suspension which contains 0.4% triamcinolone acetonide. Materials and methods. 25 patients with scleroatrophic lichen of the penis participated in the study. The average age of men was 34.1±5.7 years, the duration of the disease was 1.1±0.3 years. Patients were divided into two groups: 11 patients of the I group were prescribed external ointment with 0.05% clobetasol propionate twice a day for 3 months; 14 patients of the II group received an ointment containing 0.05% clobetasol propionate twice a day for 3 months, and a suspension with 0.4% triamcinolone acetonide was administered intradermally in lesions once every 3 weeks for 3 months. For clinical diagnosis verification, an incisional biopsy of the skin from the lesion was performed in 6 patients, followed by a histological examination. The clinical effectiveness of therapy was assessed after 1, 2 and 3 months according to the following criteria: size, color and number of lesions. The time of complete clinical remission onset was also evaluated. Results. After 3 months of intralesional administration of a suspension containing 0.4% triamcinolone acetonide in patients with lichen sclerosus together with the external use of an ointment containing 0.05% clobetasol propionate, better treatment results were found in patients of the II group (p=0.046). Clinical remission was registered in 50.0% and 9.1% of patients in the II and I groups, respectively; significant improvement – in 35.7% and 27.2%; improvement – in 14.3% and 45.5%; no changes – 0% and 18.2% of patients in the II and I groups, respectively. Conclusions. Treatment of patients with scleroatrophic lichen of the penis with the use of intrafocal injection of a suspension containing 0.4% triamcinolone acetonide together with the external use of an ointment containing 0.05% clobetasol propionate ensures the achievement of clinical remission in 50.0% of patients after 3 months and a significant improvement in the condition of the skin in the lesions – in 35.7%. Interdisciplinary management of patients with scleroatrophic lichen by dermatovenerologists and urologists is important for long-term control of the disease.
... [1,5] BXO is most commonly found in patients aged 30-60 years [4] but there have been increasing reports of the disease in the paediatric population and it is now known to be the most common cause of pathological phimosis in boys. [6] The clinical progression of BXO can vary; it can present acutely with erythema and discharge leading to early blistering and fissuring or it can follow a more chronic course, presenting initially with grey-white skin discolouration leading to complications at a much later stage. [1] In either case, patients can experience ulceration of the glans, fissuring, phimosis, meatal stenosis and urethral strictures in untreated disease leading to problems with urinary and sexual function. ...
Background: Balanitis Xerotica Obliterans (BXO) is a chronic, often progressive disease, which can lead to phimosis and urethral stenosis, affecting both urinary and sexual function. Steroid creams are usually the first-line treatment but have a limited role and surgical intervention is frequently necessary. Conservative surgical procedures (circumcision) are often preferred in the first instance with the premise that recurrence of disease will require a more definitive reconstruction. This study looked at patients with pathologically proven BXO referred to the Plastic Surgery Unit at James Cook University Hospital between 2005 and 2009. The aim was to look at their management in the past and subsequent management by us. We also looked at whether early referral of progressive and recurrent BXO patients to reconstructive surgery could have prevented unnecessary delay in resolving symptoms at an earlier stage. Materials and Methods: Data was collected retrospectively and information regarding the exact anatomical location affected, the extent of the disease, the referring specialty and any previous surgical interventions was obtained. Alterations in urinary and sexual function and relief of symptoms following reconstructive surgery were analysed. Results: Of the 23 patients in the study, 43% had previous surgery and 60% of those had undergone two or more procedures. Twenty-one percent of patients had a history of BXO for over five years. Forty-seven percent of patients had alteration in their urinary function and 48% alteration in their sexual function due to the disease, prior to referral. Early results showed remarkable improvement in urinary and sexual function following reconstructive surgery in this group. Conclusions: Steroid creams have been shown to limit the progression of the disease but do not offer a cure in the majority of cases. Circumcision can be a curative procedure in early disease. Although there is conflicting evidence for treatment of recurring urethral strictures, repeated urethrotomy or urethral dilatation has poor long-term outcome. In patients with recurrent disease and associated complications we propose early referral to a plastic surgeon with genitourinary interest or reconstructive urologist for definitive treatment.
... Between 20 and 47% of patients receiving circumcision for BXO require a subsequent operation for meatal pathology [27,28]. A case study Sandler et al. described a 1-month course of twice daily hydrocortisone cream as effective in treating meatal stenosis following circumcision for BXO prior to meatal dilatation under anaesthesia [47]. Bochove-Overgaauw et al. also describe using post-operative topical corticosteroids [7]. ...
Lichen sclerosus (LS) is a severe, chronic, dermatosis characterised by inflammatory, sclerotic, pruritic lesions that causes significant morbidity in patients of all genders and ages. In boys, the lesions typically affect the foreskin and glans (termed balanitis xerotica obliterans (BXO)), leading to phimosis and potentially meatal stenosis. The incidence of the disease is not well reported but the average age of affected boys is 8 years (range 1–16). Diagnosis can often be made clinically, although histological study remains important to rule out important differential diagnoses. Complications include genital scarring, urinary and sexual dysfunction as well as the development of carcinomas in adult life. Circumcision has been regarded as definitive management of BXO in boys, but this may be supplemented with medical therapies such as topical steroids, immune modulators, intralesional triamcinolone and ozonated olive oil. Supportive measures including emollients, avoidance of irritants, surveillance of complications and recurrence as well as education and counselling remain important.
Conclusion: BXO remains an important cause of phimosis in boys. The frequency of this condition appears unclear but seems likely to be less than 1% of males. Treatment generally involves circumcision, with some evidence that topical steroids or immunomodulators may decrease the incidence of recurrent meatal stenosis.What is Known:
• Surgical circumcision is considered the definitive management of BXO
• Many aspects of BXO are still in contention or require further study including the epidemiology and aetiology.
What is New:
• There is increasing awareness of non-surgical modalities that may be used in adjunct to surgery including topical corticosteroids, immune modulators, intralesional triamcinolone and ozonated olive oil
• Awareness of meatal stenosis-related BXO has led to the development of surgical techniques such as preputioplasty as well as buccal mucosal inlay grafts
... Retrograde dam- age to the bladder and kidney has also been documented. 27,40 BXO is considered a premalignant disease. Based on a num- ber of studies, malignant transformation is estimated at between 4 and 8%, similar to vulvar lichen sclerosis at 5%. 28 Circumcision is indicated in the instance of phimosis and paraphimosis. ...
Balanitis xerotica obliterans (BXO), or penile lichen sclerosus, is a progressive sclerosing inflammatory dermatosis of the glans penis and foreskin. It is associated with significant morbidity and may result in impaired urinary and sexual function. It was initially described by Stuhmer in 1928, named after its pathological features, and is considered the male equivalent of vulvar lichen sclerosis (LS). The etiology of BXO is uncertain; however, autoimmune disease, local trauma, and genetic and infective causes have been proposed. BXO occurs most commonly on the prepuce and glans penis. It is considered to have premalignant potential to transform into squamous neoplasia. This postulation rests on retrospective studies and parallels drawn with vulvar LS and squamous cell carcinoma (SCC) development. Histologically, BXO and vulvar LS are considered the same disease. There is a paucity of evidence‐based guidelines to assist with appropriate follow‐up for patients with BXO.
... In our experience, 8 patients underwent a successful meatoplasty (in 3 after failed cycles of progressive urethral dilatation), one patient healed after progressive urethral dilatation and another required a two stage urethral reconstruction for severe urethral stricture. While rare, the morbidity that can result from progression of this disease can be significant, leading to obstructive disease with impaired bladder and renal function (7,30). The diagnosis of BXO can be straightforward with earlier diagnosis and we consider as mandatory the surveillance of patients with BXO following circumcision and to perform UF during follow-up for monitoring changes in urinary flow, evaluating response to topical therapy and deciding whether to switch to second-level exams and/or therapeutic management. ...
Introduction:
To evaluate the outcome of circumcised patients with balanitis xerotica obliterans (BXO) using uroflowmetry (UF).
Methods:
Between 2011 and 2013, 180 children underwent a circumcision for phimosis. The foreskin was examined on microscopy. Patients with an histological diagnosis of BXO were included in the study. Patients with BXO underwent UF two weeks after surgery and treatment with clobetasol propionate ointment. Patients were re-evaluated at 6, 12, 18 and 24 months postoperatively clinically and using UF.
Results:
75 of 180 circumcised patients (41.6%) were included. At two weeks, Thirtytwo of 75 patients (42.7%) displayed a pathological UF. At six months, 15 patients (20%) had pathological UF and a new cycle of clobetasol was prescribed. At one year, 10 patients (13.3%) displayed patholgocial UF and underwent progressive urethral dilatation or meatoplasty. At 18 months, 71 patients (94.7%) displayed regular UF, 3 underwent a meatoplasty and one a staged urethroplasty for a severe urethral stenosis. At two years, UF was normal in 74 out of 75 (98.7%).
Conclusions:
We recommend to send for hystological examination all foreskins excised after circumcision. We believe that a clinical and uroflowmetric follow-up of pediatric patients with BXO is mandatory for a prompt identification of post-voiding dysfunction.
... Although meatal stenosis related to lichen sclerosus is a less severe condition than this same pathology affecting the urethra, it does not mean it represents an inferiorly dangerous entity, as it can give rise to serious complications such as urinary infections or chronic urine retention rarely associated to renal insufficency, which is why meatal stenosis should not be considered as a trivial pathology [8] . ...
... These days, with the increasingly high proportion of the secondary kidney disease, over 50% cases with CKD are due to diabetes and hypertension in developed countries (Reutens et al., 2011;, except for a lot of cases of CKD which are caused by recurrent urinary tract infection (UTI). Phimosis, with high incidence in young male patients, without proper treatment, may lead to recurrent UTI, adherent foreskin, and even urethral stricture (Sandler et al., 2008). Therefore, it can be inferred that through inducing chronic UTI phimosis disease may indirectly cause chronic renal failure. ...
Chronic urinary tract infection is a familiar cause of chronic kidney disease. Phimosis, with high incidence in boys may cause recurrent urinary tract infection, which will do harm to the kidney. We presented a case of a patient with phimosis-associated chronic pyelonephritis, who finally developed end stage renal disease followed by a review of literature. It was concluded that phimosis might be a cause of chronic kidney disease, proper treatment on which may be necessary to reduce the damage to kidney.
... [1,5] BXO is most commonly found in patients aged 30-60 years [4] but there have been increasing reports of the disease in the paediatric population and it is now known to be the most common cause of pathological phimosis in boys. [6] The clinical progression of BXO can vary; it can present acutely with erythema and discharge leading to early blistering and fissuring or it can follow a more chronic course, presenting initially with grey-white skin discolouration leading to complications at a much later stage. [1] In either case, patients can experience ulceration of the glans, fissuring, phimosis, meatal stenosis and urethral strictures in untreated disease leading to problems with urinary and sexual function. ...
Balanitis Xerotica Obliterans (BXO) is a chronic, often progressive disease, which can lead to phimosis and urethral stenosis, affecting both urinary and sexual function. Steroid creams are usually the first-line treatment but have a limited role and surgical intervention is frequently necessary. Conservative surgical procedures (circumcision) are often preferred in the first instance with the premise that recurrence of disease will require a more definitive reconstruction. This study looked at patients with pathologically proven BXO referred to the Plastic Surgery Unit at James Cook University Hospital between 2005 and 2009. The aim was to look at their management in the past and subsequent management by us. We also looked at whether early referral of progressive and recurrent BXO patients to reconstructive surgery could have prevented unnecessary delay in resolving symptoms at an earlier stage.
Data was collected retrospectively and information regarding the exact anatomical location affected, the extent of the disease, the referring specialty and any previous surgical interventions was obtained. Alterations in urinary and sexual function and relief of symptoms following reconstructive surgery were analysed.
Of the 23 patients in the study, 43% had previous surgery and 60% of those had undergone two or more procedures. Twenty-one percent of patients had a history of BXO for over five years. Forty-seven percent of patients had alteration in their urinary function and 48% alteration in their sexual function due to the disease, prior to referral. Early results showed remarkable improvement in urinary and sexual function following reconstructive surgery in this group.
Steroid creams have been shown to limit the progression of the disease but do not offer a cure in the majority of cases. Circumcision can be a curative procedure in early disease. Although there is conflicting evidence for treatment of recurring urethral strictures, repeated urethrotomy or urethral dilatation has poor long-term outcome. In patients with recurrent disease and associated complications we propose early referral to a plastic surgeon with genitourinary interest or reconstructive urologist for definitive treatment.
Lichen sclerosus (LS) or balanitis xerotica obliterans (BXO) is a chronic atrophic dermatitis involving the anogenital area affecting females more than males. The etiology is unknown, but it is thought to be due to abnormal immune response to a causative factor, leading to inflammation and subsequent sclerosis. The microscopic picture is characterized by epithelial hyperkeratosis, hydropic degeneration of basal cells, hyalinization of elastic fibers, subepithelial fibrosis, and dermal lymphocytic infiltration deep to the hyalinized band in the upper dermis. Medical treatment may work in early diagnosis and includes corticosteroids and immunosuppressive and antibiotic agents. Surgical treatment is needed in advanced cases and includes radical excision of the affected epithelium and buccal mucosal grafting.KeywordsHypospadiasBXOBuccal mucosa graftLSMeatal stenosisUrethral stricture
Background:
Lichen sclerosus (LS), (balanitis xerotica obliterans), causes pathological phimosis. Many boys present with obstructive symptoms, the cause is usually obvious on examination so ultrasound scans (USS) of the urinary tract are not routinely indicated. We review a series of abnormal USS in boys with LS.
Methods:
Retrospective note review for boys undergoing surgical treatment for LS between 2000 and 2017. Seventy-eight boys had a USS prior to surgery, those with abnormal USS form the study population. Boys with neuropathic bladder or congenital urinary tract abnormalities were excluded.
Results:
Nineteen of 78 boys (24%), mean age 9 years, were included. Seventeen had obstructive symptoms, 13 had culture proven UTIs, 12 had new onset incontinence. On USS 3 (17%) had acute retention, 8 (78%) had an isolated post-void residual volume (PVR) >10% of estimated bladder capacity (EBC); 3 had bladder wall thickening +/- PVR >10%, 5 had upper tract changes. Symptoms resolved with successful treatment of LS. Six boys had post treatment USS, abnormalities resolved in 5.
Conclusions:
Clinicians should consider LS in boys presenting with UTIs, new onset incontinence and obstructive urinary tract symptoms. Routine USS are not indicated though should be considered in those with an atypical history or examination.
Type of study:
Case Series.
Level of evidence:
Level 4.
Background. Balanitis xerotica obliterans (BXO) is a rarely diagnosed disease of unestablished, etiology. The illness is classified as a form of lichen sclerosus et atrophicus. BXO typically occurs in men between the 3th and 5th decade of life, but it may also affect young boys. Case report. The authors report the case of a 17-year-old patient with acute urinary retention due to BXO. Conclusions. Because of the risk of severe urodynamic complications due to urethral stenosis and carcinogenesis later in life, patients with BXO need a quick evaluation and a proper treatment.
Young males with lichen sclerosus (LS) commonly present with phimosis; complete urinary obstruction has also been described in this population, but is much rarer. We present the case report of a boy with acute renal failure secondary to urethral obstruction caused by LS, with a review of the literature regarding the occurrence of complete urinary obstruction and renal failure associated with this disease process.
A comprehensive review of the literature was conducted using MEDLINE and EMBASE to characterize the association of lichen sclerosus with significant obstructive complications of the urinary tract.
The true incidence of LS is unknown. Reported rates have ranged from 10% to 95% of boys presenting with phimosis. Our review identified 14 cases of complicated urinary obstruction (seven in children) and two cases of renal failure secondary to lichen sclerosus (both in boys).
Distinctive features make this inflammatory process identifiable to the astute physician, such that new onset of phimosis in a school-age boy should raise clinical suspicion of the diagnosis. Successful outcomes, with medical and/or surgical therapy, are commonplace in this cohort. If undiagnosed, however, progression of LS can lead to significant morbidity in the form of renal failure.
Balanitis xerotica obliterans was studied in 48 fully developed and 6 early cases in children aged 2-15 years. It occurred in 9% of 100 consecutive circumcisions for all, including religious, reasons and in 19% of 232 other circumcisions for disease of the prepuce and penis. Seven cases developed after surgery for hypospadias. The boys nearly always presented with inability to retract the prepuce; half also had discomfort after micturition, and a quarter had obstructive signs, usually minor. At surgery, half had involvement of glans or meatus, previously considered rare in childhood, 3 requiring meatotomy. The condition, once seen, was easily recognized clinically as well as microscopically. The early cases, characterized by focal narrow hyaline edematous zones in severe diffuse chronic balanitis, suggest that the condition may be an inflammation in which the usual increased permeability of small vessels in inflammatory reaction is accentuated in a loose vascular region.
This report is based on 7 children with balanitis xerotica obliterans. Of these patients 5 had stenosis of the urethral meatus that required meatotomy and the postoperative results were good. The frequency of balanitis xerotica obliterans in children at our center, as well as the findings of other authors, suggests that possibly more cases would be diagnosed during infancy if all dried foreskin were examined systematically.
We prospectively investigated 100 pediatric patients suffering from phimosis and found a 10% incidence of lichen sclerosus et atrophicus. This condition usually can be diagnosed preoperatively because of its classic manifestation of severe phimosis due to a sclerotic, whitish ring at the tip of the prepuce, which in our cases was accompanied by sclerogenous glanular lesions. To our knowledge our study represents the first evidence that the development of secondary phimosis with no apparent reason in school-age boys is highly suggestive for lichen sclerosus et atrophicus. Complete circumcision is the therapy of choice because it completely removes all affected tissue and it allows spontaneous regression or resolution of glanular lesions. There has been no recurrence after 5 years of followup.
We evaluate whether steroid application alone or retraction and hygiene are responsible for successful results in boys treated with topical steroids for phimosis.
A prospective study was performed, which included a control group of 42 patients with phimosis seen at our outpatient department from January to June 1997. During that time we trained the parent to retract and clean the foreskin only. From July 1997 to June 1998 topical steroid cream was prescribed in addition to retraction and hygiene in 276 boys with phimosis. All cases were divided into 3 subgroups of asymptomatic, symptomatic and buried penis.
The response rate was greater than 95% in patients who received topical steroid treatment in addition to improved hygiene. Only 13 boys (less than 5%) had no response to steroid treatment. Of the control patients 23 (55%) had no response to gentle retraction and personal hygiene. There was a significant difference (p<0.001) in response rate between the study and control groups. However, the subgroup with a buried penis responded poorly to steroid, retraction and hygiene treatment. There was significant difference (p<0.001) in response rate between the buried penis and other steroid groups but no significant difference (p>0.05) in the control group.
Phimosis is a physiological condition in neonates due to natural adhesion between the foreskin and the glans. Chronic infection due to poor hygiene is responsible for most cases of childhood phimosis. Circumcision is the traditional treatment of choice for phimosis or unretractable foreskin, although it is not always desired by parents or surgeons. Topical steroid cream is an easy, safe and nonsurgical alternative for phimosis. However, boys with a buried penis are not good candidates for steroid treatment.
Genital lichen sclerosus (LS) has sporadically been reported to be associated with penile squamous cell carcinoma (SCC).
The purpose of this study was to assess the risk of malignant degeneration in a series of male patients affected by genital LS.
All cases of histologically proven epithelial malignancy associated with penile LS recorded in our pathology files over a 10-year period (1987-1997) were reviewed. Assessment for presence of human papillomavirus (HPV) was performed from paraffin-embedded tissues using polymerase chain reaction (PCR).
Five of 86 white and uncircumcised men with genital LS (mean age at diagnosis, 53 years; range, 22-83 years) showed malignant or premalignant histopathologic features: 3 had SCC, one had erythroplasia of Queyrat (unifocal SCC in situ), and one verrucous carcinoma. The average lag time from onset of LS was 17 years (range, 10-23 years). Histologically, transition from LS to frank neoplastic foci was evident in all cases of SCC. In these SCC cases, areas of epithelial dysplasia were well evident at the tumor periphery. In the remaining cases, the histologic findings were consistent with erythroplasia of Queyrat and verrucous carcinoma. PCR detected HPV 16 infection in 4 of the 5 cases; one SCC patient was negative for HPV.
Malignant changes were associated with 5.8% of the cases of penile LS in our series. Therefore patients with genital LS are at considerable risk of the development of penile SCC, as well as other epithelial and in situ carcinomas, namely verrucous carcinoma and erythroplasia of Queyrat. HPV infection probably plays a major role because 4 of 5 patients were positive for HPV. Histologically, epithelial dysplasia may represent a precancerous stage before the development of neoplasia in atrophic nonproliferative LS lesions, as its presence at the tumor periphery in our SCC biopsy samples seemed to suggest.
Three cases of urethral stricture due to balanitis xerotica obliterans (BXO) after hypospadias repair are reported. The first patient showed white, dense scarring on the prepuce before the hypospadias repair and developed a stricture of the urethra after the operation. The second and the third were uneventful for 6 and 2 years, respectively, after the hypospadias repair, and then developed urethral strictures. Pathologic diagnosis of the stenotic lesion is essential. Complete excision of the affected urethra with topical steroid ointment or sublesional triamcinolone injection is recommended for this condition. Although the complication of BXO after hypospadias repair is rare (3 out of 796 cases with hypospadias in our series), surgeons need to be aware of this condition as a cause for late onset of urethral problems.
Balanitis xerotica obliterans (BXO) is a scarcely known disease, wrongly considered rare. With a high degree of suspicion and histologic examination, the condition will prove to be much more frequent than one generally believes. The etiology of the condition is unknown at present. Many cases of BXO occurring after circumcision may be cases of secondary phimosis due to BXO not being recognized at the time of surgery. Most of the cases of BXO are seen in the third to fifth decades of life, even though they may occur at the extremes of age. Biopsy of the lesions is not essential in all cases and is indicated to differentiate from penile cancer and in atypical cases. Early diagnosis and treatment of BXO are very important in preventing the urological complications of the diseases such as urethral stricture. Treatment of BXO depends on the anatomic location of the lesions and their extent and severity, together with the rapidity of progression of the disease process. The treatment may vary from topical corticosteroids, laser vaporization in early cases to meatoplasty and urethroplasty in extensive cases. Topical pharmacotherapy is useful in the early stages to reduce the initial symptoms and slow down the progression, but is not effective in all cases and is not the curative treatment of disease. Meatal stenosis, phimosis, scar adhesions, fissures, erosions of glans and prepuce and involvement of the urethra are indications for surgical treatment. Surgery seems to be the only treatment that can relieve the symptoms of advanced disease. Modified circumcision, with total removal of inner preputial layer, definitively relieves phimosis without any recurrence. Meatotomy will not prevent the recurrence of meatal stenosis. Excision of the scleroatrophic tract and grafting of the glans base, coronal sulcus, and the end of the shaft give a complete relief of pain during erection and intercourse in circumcised patients with balanopreputial adhesions and restore the elasticity of the skin of penile shaft. These procedures have been shown to yield excellent functional results during a follow-up period of up to 4 years. BXO involving anterior urethra can be treated by 2-stage urethroplasty or substitution urethroplasty. The complete excision of the stricture and flap urethroplasty seems to be better than a 2-stage procedure. However, at the present time, it is not possible to say that surgery can completely resolve this chronic and progressive disease. Despite many reports in the literature of cases of BXO associated with squamous cell carcinoma, the etiologic relationship between the two conditions is uncertain.
Circumcision has been the traditional treatment for phimosis. Recent reports of medical management of phimosis with topical steroids quote success rates of 67%-95%. We present our results with topical steroid therapy for treatment of phimosis.
Retrospective review of 69 boys between the age of 3 and 13 years (average 7.4) who were referred to Urology clinic over a one year period (August 1999-2000) with phimosis. Boys without a distal preputial ring were excluded. A course of triamcinolone cream was prescribed and parents/patients were instructed to apply it to the preputial outlet twice daily for one month. Six weeks after treatment initiation patients were reassessed. Results were classified as follows: Full retraction (FR)-entire glans and coronal margin seen, Moderate retraction (MR)-proximal glans seen, residual preputial adhesions, Partial retraction (PR)-distal glans and meatus seen, and Failure (F)-no change. FR, MR, and PR were considered successful outcomes. Statistical analysis was performed with Splus software using the prop.test and ordinal logistic regression procedures.
Follow-up ranged from 1-12 months, and 8 patients were lost to follow-up. Of the remaining 61 boys, 82% (12 FR, 26 MR, 12 PR) were successfully managed with topical steroid (95% confidence interval: 69%-90%). Scarring on examination was observed to negatively impact outcome (92% versus 67%) and was statistically significant using ordinal logistic regression (Chi square test=4.48, p-value=0.034). Two boys with severe balanitis xerotica obliterans (BXO) and two boys with buried penis and penoscrotal webbing failed treatment and required surgery. There was an association noted between older age and poorer outcome but this was not statistically significant. There were no local or systemic side effects noted.
Local application of steroid cream to the phimotic foreskin may allow some degree of retraction and avert the need for circumcision. Although the length of follow-up is insufficient to decree ultimate success, topical steroid appears to be a safe and effective treatment for boys over three years of age with evidence of a tight preputial ring. Boys with severe BXO or buried penis and penoscrotal webbing should be considered primarily for surgery.
This prospective study was designed to address the incidence and clinical and histologic characteristics of balanitis xerotica obliterans in a large random pediatric population with phimosis. We investigated 1178 boys who presented consecutively with phimosis between 1991 and 2001. All patients who underwent complete circumcision and surgical specimens were typed histologically as early, intermediate, or late forms of this disorder or as nonspecific chronic inflammation. Patients with balanitis xerotica obliterans were controlled at 1, 6, and 12 months postoperatively, then yearly. Balanitis xerotica obliterans was found in 471 of the 1178 patients (40%), with the highest incidence in boys aged 9 to 11 years (76%). Secondary phimosis occurred in 93% of boys with balanitis xerotica obliterans and in 32% of those without the disorder. In six instances of balanitis xerotica obliterans, meatotomy and in one meatoplasty was performed, as well as circumcision. On histologic evaluation, we found 19% had early, 60% intermediate, and 21% late form of balanitis xerotica obliterans. Glanular lesions disappeared completely within 6 months in 229 out of 231 patients. Our data strongly suggest that the true incidence of childhood balanitis xerotica obliterans is higher than previously assumed. Its incidence peaks in the 9 to 11 years age group, in whom secondary phimosis was almost exclusively caused by balanitis xerotica obliterans.
Balanitis xerotica obliterans (BXO) is a chronic dermatitis of unknown etiology most often involving the glans and prepuce but sometimes extending into the urethra. We report our 10-year experience with BXO in pediatric patients.
Our pathology database was queried for all tissue diagnoses of BXO from 1992 to 2002. Available charts were reviewed and patient presentation, clinical and referral history, operative procedure(s) and postoperative course were recorded.
A total of 41 patients had a tissue confirmed diagnosis of BXO. Median patient age was 10.6 years. Of the patients 85% were 8 to 13 years old and all had referrals available for review. The most common referral diagnoses were phimosis (52%), balanitis (13%) and buried penis (10%). No patient had the diagnosis of BXO at referral. Of the patients 19 (46%) underwent curative circumcision or redo circumcision and had no recurrence at a mean followup of 12.5 months (range 1 to 57). A total of 11 patients (27%) had BXO involvement of the meatus and underwent circumcision combined with meatotomy or meatoplasty. Nine patients (22%) required extensive plastic operation(s) of the penis, including buccal mucosa grafts in 2.
The incidence of BXO in pediatric patients may be higher than previously reported, with the diagnosis rarely made by pediatricians. Our study demonstrates that older patients, those with BXO involvement of the meatus and those with a history of surgery for BXO tend to have a more severe and morbid clinical course.
Balanitis xerotica obliterans in boys doi:10.1097/01.ju.0000173126
- Pc Gargollo
- Hp Kozakewich
- Bauer