What is Balanitis Xerotica Obliterans?
Balanitis xerotica obliterans, also known as lichen sclerosus, is a condition that creates white inflammation patches on the skin. It can occur in both men and women. For men, these patches often appear on the foreskin and the tip of the penis, in a subtype of the condition specifically called balanitis xerotica obliterans. This condition often leads to two common issues: urethral stricture disease, which is a narrowing of the tube that carries urine from the bladder, and meatal stenosis, a narrowing of the opening at the end of the penis.
What Causes Balanitis Xerotica Obliterans?
The exact cause of balanitis xerotica obliterans is not known. However, it is suggested that several factors might cause it, such as different types of infections, injuries to the penis, or chronic (long-term) inflammation.
Risk Factors and Frequency for Balanitis Xerotica Obliterans
Determining the prevalence of a condition like lichen sclerosus can be tricky, mainly because the initial symptoms can be observed by doctors from various fields. Nevertheless, research estimates that approximately 0.1 to 0.3 percent of people suffer from this condition.
- Boys between the ages of 6.8 and 9 are most commonly affected, with the average age of diagnosis being 7.
- Not being circumcised is a potential risk factor for developing a related condition called balanitis xerotica obliterans.
- While there doesn’t seem to be a preference for this condition among different races, it is reported to be higher in African American and Hispanic populations. This may be due to lower rates of circumcision in these communities.
Signs and Symptoms of Balanitis Xerotica Obliterans
Balanitis is often found in uncircumcised men or men who have had late-life circumcisions. The exact cause is unknown, but it’s often linked to chronic irritation and inflammation. In the initial stages, balanitis usually doesn’t have any symptoms. However, red changes or white spots on the penis head or foreskin may later become visible.
This all-over inflammation can cause a condition known as phimosis, which makes it hard to pull back the foreskin. This can lead to issues with urination and sexual function.
If not properly addressed, other symptoms may develop:
- Pain during urination
- Retention of urine
- Kidney failure
Moreover, the red changes can turn into more visible sores around the ridge of the penis and the foreskin. This could even spread to the opening of the urethra and further, and cause the urethra to narrow, known as stricture disease.
Testing for Balanitis Xerotica Obliterans
Balanitis often occurs in males who aren’t circumcised. You might see white or red areas on the tip of the penis or the foreskin. As this condition worsens, the foreskin can become too tight to be pulled back over the head of the penis. A study by Mattioli and colleagues showed that 15% of the foreskins examined had a condition called hypospadias. Other conditions that could be confused with balanitis include psoriasis, cancer, contact dermatitis, Zoon balanitis, leukoplakia, and a specific type of allergic reaction to a drug.
There’s a small chance that the condition could turn into squamous cell carcinoma (a type of skin cancer) – this happens in 3% to 6% of women and 2% to 8% of men.
Psoriasis is a long-term skin condition that gives you red, itchy patches that can appear anywhere on your body. It’s not contagious, and it’s linked to your immune system causing skin cells to multiply too fast. Sometimes, these patches can pop up on the penis.
Contact dermatitis can show up anywhere on your body and is caused by contact with a particular substance. It makes your skin red, itchy and may look like a rash with cracked skin.
Zoon balanitis – also known as plasma cell balanitis – is a harmless condition that usually affects older men. People with this condition often have a flat red patch that sometimes also has smaller red spots on it. A biopsy (a test where a small piece of tissue is taken for examination) is needed to diagnose this condition.
Leukoplakia symptoms are very similar to those of lichen sclerosis – there is a white, flat patch on the skin. This condition can turn malignant or cancerous. It is usually caused by long-term irritation between the tip of the penis and the foreskin.
To diagnose lichen sclerosus, a doctor will look for clinical signs. A biopsy can be done to rule out other possible causes of symptoms. For patients who have lesions in the urethral (the tube that allows urine to pass outside the body), a cystoscopy (a procedure that allows a doctor to view the inside of the urinary tract) may be needed to see how far the disease has spread.
Treatment Options for Balanitis Xerotica Obliterans
Lichen sclerosus of the penis can be managed using both medical and surgical methods. When the disease doesn’t cause any symptoms, treatment might not be necessary. However, if there are symptoms, the main treatment option is lotions that contain steroids, such as betamethasone or triamcinolone. These should be applied twice daily, and the response is monitored. If the treatment works well over two months, the frequency of application can be reduced.
It should be noted that these creams do not work as effectively if the patient does not use them consistently. Apart from steroids, other creams including pimecrolimus and tacrolimus, also known as topical calcineurin inhibitors, can be used, but they are usually considered a second-choice option for treatment. Oral steroids generally do not show any benefits in the treatment of this condition.
Surgery becomes necessary when the disease causes extreme tightening of the foreskin, medically known as symptomatic phimosis. Circumcision, which is the removal of the foreskin, is the usual treatment. Applying steroid creams first might help reduce the inflammation before surgery.
If the disease affects the urinary tract, a procedure called cystourethroscopy can be performed to identify the extent of the disease. This allows doctors to see the severity of any narrowing due to lichen sclerosus and rule out other potential causes of symptoms. Treatments for this narrowing may include dilation and direct visual internal urethrotomy, or in more advanced cases or in cases where previous treatments have not worked, urethroplasty may be necessary.
Patients should have check-ups at least annually to monitor if the disease comes back or if there’s any development of squamous cell carcinoma, a type of skin cancer.
What else can Balanitis Xerotica Obliterans be?
- Cancer that is only in the surface layer of skin
- Psoriasis (a skin condition that causes red, flaky, crusty patches of skin)
- A type of skin cancer called squamous cell carcinoma
- A skin infection called cellulitis
- Contact dermatitis (skin inflammation caused by contact with certain substances)
- Zoon balanitis (a skin condition that mainly affects the head of the penis)
- Leukoplakia (white patches in the mouth or on the tongue)
- Scleroderma (a rare skin condition causing hard, thickened areas of skin)
- Fixed drug reaction (a skin reaction caused by certain medications)
What to expect with Balanitis Xerotica Obliterans
Long-term monitoring is important because the condition could develop into more serious health problems, such as narrowing of the body passage (stricture disease) or cancer. A ten-year study published by Pradhan et al, focused on patients with a condition called balanitis xerotica obliterans. They found that around 62.6% of participants had foreskin scarring and 47.2% had both foreskin and meatus (opening at the end of the penis) affected. A further 26.4% had the foreskin, glans (tip of the penis), and meatus affected.
Within this group of patients, most needed a circumcision before they were 16, and an extra 19.8% required an additional procedure after their circumcision and/or a process to widen the meatus. An early diagnosis and treatment can help delay or prevent the disease from getting worse.
Possible Complications When Diagnosed with Balanitis Xerotica Obliterans
Complications from delayed diagnosis of lichen sclerosus can often include conditions like phimosis, which is a tightening of the foreskin, and urinary retention, which means having difficulty completely emptying the bladder. It’s proposed that the constant inflammation from this condition can potentially lead to a type of skin cancer known as squamous cell carcinoma.
A study from Italy by a group known as Nasca and colleagues, found that 9.3% of participants developed cancer in the penis. This and other studies indicate that we might be underestimating the link between a condition called balanitis xerotica obliterans and penis cancer.
Thus, we can conclude:
- Delayed diagnosis can lead to complications, such as phimosis and urinary retention.
- Constant inflammation from lichen sclerosus can result in squamous cell carcinoma.
- A significant percentage (9.3%) of patients can develop penile cancer.
- The association between balanitis xerotica obliterans and penile cancer might be underestimated.
Preventing Balanitis Xerotica Obliterans
Patients should have a check-up with their primary care doctor every year. If there’s any worry about conditions related to the genital or anal region, they should be referred to a specialist, known as a urologist. It’s also important that patients learn how to correctly check their own genitals for any changes or abnormalities.
For patients being treated with creams for a skin condition called lichen sclerosus, sticking to the prescribed usage schedule is crucial. There will be some patients who require more complex treatments if these creams or an earlier surgical procedure, called circumcision, don’t relieve the symptoms.
