Balanitis Xerotica Obliterans

Tight Foreskin (phimosis) due to lichen sclerosus

What is Balanitis xerotica obliterans (BXO) Foreskin?

BXO consists of thin, white, wrinkled patches that appear over the foreskin. If left untreated, it can be troublesome and cause a tight foreskin (a condition known as phimosis) in both children and adults. It is also referred to as lichen sclerosus, Csillag’s, or white spot disease.

Who gets the BXO

BXO is a condition that can impact uncircumcised males, from young boys to older adults. Fortunately, it is rare in children under the age of five. This condition, often referred to as BXO phimosis, is characterised by the tightening of the foreskin due to repeated splitting, cracking and healing by scarring. It's important to note that individuals with diabetes may experience a higher incidence of BXO. 

What causes the BXO?

The exact cause of BXO is unknown. Sometimes, it is associated with diseases in which the body’s immune system attacks normal tissues (autoimmune diseases). Despite its tendency to affect the genital skin, BXO is not infectious, so sexual partners cannot pick it up. Rarely, BXO can occur in relatives. Urinary dribbling is a possible causative factor in the production of BXO. In one study, the association of human papillomavirus with BXO has been reported.

What are the symptoms of BXO?

Many patients have itching and burning sensations at the foreskin, and cracked foreskin are the most common symptoms of BXO. The patches on the foreskin can also hurt if the skin breaks down during sexual activities. The scar can tighten the foreskin, interfering with sexual intercourse in affected men. BXO can make the foreskin tight and difficult to retract and even partly block urine flow.

What does BXO look like?

On the parts of the foreskin, the spots of BXO look like small ivory-coloured, slightly raised areas, which can form white patches. Some have tiny yellowish horny plugs within the pale areas. After a while, the surface of the spots can look like wrinkled tissue paper. The white, thin, fragile regions, sometimes surrounding the foreskin in figure-of-eight patterns, have a wavy surface; their fragility may lead to easy bruising and erosions. Later, the foreskin opening can shrink, leading to painful intercourse. Less often, BXO can develop in children. It can make the retraction of the foreskin difficult and interfere with passing water. BXO can be confused with a thrush infection.

How will BXO be diagnosed?

The diagnosis of BXO can usually be made based on the condition's typical appearance. This will be confirmed after examining the foreskin skin (a biopsy) £150 under the microscope.

Can the BXO be cured?

No treatment is likely to reverse the changes of BXO completely, but the symptoms and signs of the disease can usually be well controlled with a steroid application and circumcision.

How can BXO be treated?

A variety of treatments are available for BXO. In early cases, steroid creams or ointments can relieve symptoms. Light moisturisers help soften and protect the skin. In adults, tightening of the foreskin will often respond to steroid ointments in the early stages; if not, a circumcision may be worth considering in adults. In children, circumcision is usually required.

The fragile skin of BXO may be more susceptible than normal skin to infection with Candida yeasts (thrush) or bacteria and may split or even bleed. We will treat them with antifungal or antibiotics if they arise. 

Can It be serious?

Cancer of the penis’ skin is rarely associated with BXO, which has been present for many years than in normal skin. If you have any lumps or non-healing ulcers, you should ask your doctor to look at them. It is essential to follow up with your GP or Urologist if BXO persists even after circumcision and treatment.

The price for adult circumcision with frenuloplasty is £760, with Glue and biopsy £150 to confirm the diagnosis. Follow-up usually after four weeks fee of £150

Tight Foreskin - Phimosis in adults and children. Is this associated with Balanitis Xerotica Obliterans (BXO), and what is the best evidence-based management? (Reported by MEDSCAPE in 2019)

“No consistently effective treatment has been developed for penile lichen sclerosus (balanitis xerotica obliterans [BXO]); however, the therapies described below have been reported to have varying degrees of success.

1.      Topical and intralesional steroids have been used. Topical steroids can offer a reliable option in managing mild or early BXO limited to the prepuce in boys with minimal scar formation. Patients and their families must have realistic expectations about the success of such treatments.

2.      Circumcision with frenuloplasty in adults and children with BXO

3.      Further treatment, or treatment of circumcised patients, is more challenging. Intraurethral steroids provide efficacious therapy for stricture disease in patients with biopsy ­proven BXO before invasive surgery.

4. Various surgical techniques can be used to treat more severe penile BXO. Uncircumcised patients usually benefit from therapeutic circumcision. Provide regular follow-up care to observe any changes in problematic areas suggestive of malignancy. Foreskin preputioplasty combined with intralesional triamcinolone might be a tenable alternative against circumcision to treat BXO.

5.      Consider surgical intervention for symptoms or signs of meatal urethral stenosis.

6.      Buccal mucosal graft for BXO ­induced urethral stricture can work.

7.      Consider consultation with our Urologists for the following reasons:

• Therapeutic circumcision

• Circumcision for symptomatic phimosis or paraphimosis

• Significant narrowing or obstruction of the urethral meatus or changes in urinary flow

• In some cases of male genital lichen sclerosus (BXO), painful erections may limit sexual function

• A careful clinical examination, history of skin disease, and recent tight Foreskin (phimosis) give a diagnosis of balanitis xerotica obliterans with certainty

Source: http://emedicine.medscape.com/article/1074054 (Accessed  on 19 June 2017)

London circumcision Centre, South Woodford and Leyton Healthcare, Leyton, East London, are the best circumcision clinics for managing tight Foreskin with penile BXO. 

PATHWAY FOR PATIENTS WITH PHIMOSIS DUE TO BXO IN OUR CLINIC  

1. Assessment and advice for the option of treatment like steroid cream, circumcision or further operations   

2. Consultation before the circumcision  

3. Circumcision with Glue because glue circumcision is better than stitches

4. Aftercare advice following the circumcision  

5. To send the biopsy to confirm the diagnosis and exclude any malignancy 

6. Further treatment after six weeks of circumcision  

7. Please make a follow-up £150 appointment at our clinic with a urologist or see your GP after 4-6 weeks of operation.   

8. Long-term follow-up is required if biopsy-proven BXO is found after the circumcision  

Please get in touch with us for specialist and professional opinions.

PS: This information is only for guidance. This is not a replacement for professional medical advice. Please get advice from the specialist by calling the telephone number +447527314081