Balanitis xerotica obliterans
Synonyms and keywords:BXO, Penile lichen sclerosus

# Overview
Balanitis xerotica obliterans (BXO) is a dermatological (skin) condition affecting the male genitalia. It was first described by Stuhmer in year 1928. The exact pathophysiology of balanitis xerotica obliterans is unknown. Balanitis xerotica obliterans (BXO) commonly occurs on foreskin and glans penis. Patients with BXO usually present with atrophic white patches with indurated (hardened) whitish ring near the tip of penis. Definitive diagnosis is provided by cutaneous biopsy. Prognosis is usually good with treatment. Treatment options for balanitis xerotica obliterans (BXO) include both medical and surgical modalities.

# Historical Perspective
In 1928, Stuhmer for the first time in medical literature has described  lichen sclerosus on penis as balanitits xerotica obliterans.

# Classification
There is no established classification system for balanitits xerotica obliterans.

# Pathophysiology
The exact pathophysiology of balanitits xerotica obliterans is unknown. Studies have shown that multiple factors were associated with development of BXO. These include:

## Histopathology
Histopatholgy findings in BXO include the following:

### Early stage of BXO
- Moderately heavy lymphocytic infiltrate found in basal epidermis and superficial dermis in early stages of the lesion.

### Late stages of BXO
- Epidermis becomes atrophic with surface hyperkeratosis and thickened basement membrane
- Broad zone of subepidermal oedema with homogenization of collagen, which becomes sclerotic over time
- In few cases, epidermis is detached from dermis resulting in formation of haemorrhagic bullae

# Epidemiology and Demographics

### Incidence
There are no comprehensive studies studying the incidence and prevalence in general population. A recent study conducted in an unselected cohort of 153,432 patients presenting to an outpatient clinic in Brookes Army Medical Center in the United States reported the incidence of BXO at 0.07%.

### Age
BXO commonly affects middle age group, with men in their twenties were found to be at twice the risk on comparison with other age groups.

### Race
On comparison with white men, BXO is more prevalent in black and hispanic men.

# Screening
There are no established screening guidelines for BXO.

# Natural History, Complications, and Prognosis

## Natural history
If left untreated, BXO may involve the penile skin, scrotum, and entire urethra leading to the complications such as phimosis and urinary retention.

## Complications
Complication of BXO include:
- Phimosis
- Painful erection
- Reduced urinary flow
- Urinary retention
- Risk of malignant transformation into squamous cell carcinoma (long-term prospective studies are needed to determine the real risk of malignant transformation)

## Prognosis
Prognosis is usually good with treatment.

# Diagnosis

## History and symptoms
Patients with BXO could be asymptomatic or symptomatic presenting with:

### More common symptoms
- Whitening or reddening of penile region
- Difficulty in retracting foreskin
- Painful erection
- Reduced urinary flow
- Urinary retention

### Less common symptoms
- Burning sensation (paraesthesia)
- Purple rash in the genitial region(purpura)
- Small red or purple clusters, often spidery in appearance, on penis(telangiectases)
- Itching(pruritus) of the genitalia
- Discomfort in urination(dysuria)

## Physical examination
Physical examination findings include:
- Whitening or reddening of glans penis, foreskin(prepuce) and coronal sulcus
- Induration of glans and foreskin
- Phimosis
- Purpura
- Telangiectases

## Laboratory findings
Cutaneous biopsy will provide a definitive diagnosis of BXO.

# Treatment
Treatment of BXO include both surgical and medical modalities, these include:

## Prevention
There are no established preventive measures for preventing BXO. Studies have shown that circumcision in males can help in reducing the risk of having BXO.