Balanitis xerotica obliterans (BXO) is a rare condition in which the foreskin becomes inflamed and hardened and covered with a dry whitish film. In adults the problem can result in progressive tightening of the foreskin, making retraction difficult and painful. The condition is poorly understood and the cause(s) unknown: it could be a viral, bacterial or fungal infection or (more probably) some sort of auto-immune response (where the body’s antibodies attacks its own tissue). The symptoms of BXO are similar to those of several other minor penis inflammations, so that its presence must be confirmed by appropriate specialist advice and finally established by laboratory analysis. Where BXO is confirmed, treatment options are limited: application of of steroid medications may help, but if they do not circumcision will be necessary. BXO is one of the very few conditions where therapeutic circumcision is warranted.

The most recent comprehensive survey of the medical literature reached the conclusion that, although rare, BXO may be increasing in frequency; that diagnosis is difficult and often mistaken; and that the principal treatment is circumcision, possibly assisted by appropriate anti-inflammatory medications. The abstract of the paper reads as follows:

OBJECTIVE Balanitis xerotica obliterans (BXO) is a chronic inflammatory disease that is considered as male genital variant lichen sclerosis. The incidence varies greatly in different series; diagnosis is mostly clinical but histopathological confirmation is mandatory. Various treatments are described, but there is no consensus that one is the best.

MATERIALS AND METHODS A literature review was made of BXO and lichen sclerosis in boys under 18 years of age, between 1995 and 2013, analyzing demographic dates, treatments and outcomes. In addition to that, we reviewed BXO cases treated in our centers in the last 10 years.

RESULTS After literature review, only 13 articles matched the inclusion criteria. Analyzing those selected, the global incidence of BXO is nearly 35% among circumcised children. Described symptoms are diverse and the low index of clinical suspicion is highlighted. The main treatment is circumcision, with use of topical and intralesional steroids and immunosuppressive agents.

CONCLUSION BXO is a condition more common than we believe and we must be vigilant to find greater number of diagnoses to avoid future complications. The main treatment for BXO is circumcision, but as topical or intralesional treatments are now available with potentially good outcomes, they may be considered as coadjuvants.

NOTE: The reference to 35% does not mean that 35% of children experience BXO, but that the condition was confirmed in 35% of the children referred with suspected BXO. The condition itself is quite rare.

Soledad Celis et al. Balanitis xerotica obliterans in children and adolescents: A literature review and clinical series. Journal of Pediatric Urology 10 (1) February 2014, 34-39. Full text available here.

Advice from paediatric surgeon

A paediatric surgeon has sent a letter to Circumcision Information Australia, explaining that while he is strongly opposed to routine, non-therapeutic circumcision of boys, BXO is one of the few pathological conditions where circumcision is usually necessary.

Throughout my training I have always been taught that BXO was the only absolute indication for circumcision. I am aware of some reports of steroid use and covered for a colleague in the UK once who used this as the first line of treatment. My experience was that this did not work, and that the disease usually progressed rapidly, making circumcision urgently necessary.

I did a quick Google search, and also a search of the Journal of Pediatric Urology, with BXO and steroid as the search strategy. The only article I found that helped much was a review of the literature and case series from UK (St George's, London) Ireland (Dublin) and Chile by Celis et al [referenced above]. The main findings were that the incidence of BXO is increasing. Also that circumcision is the main treatment, with steroids and other treatments having a supporting role.

Reading through the paper a couple of things caught my eye:

1. The correlation between clinical suspicion and histological diagnosis is not great — meaning that some clinically suspicious BXO turns out to be other scaring / inflammation.
2. Steroids, if they do work at all, only work with early inflammation affecting the prepuce and no scaring. I get the impression these patients had not had their diagnosis confirmed histologically
3. In a few patients who had trial of “tissue sparing surgery” (preputioplasty presumably) in a cohort from Chile there was a 100% relapse rate, needing to progress to circumcision.
4. Reinforcement of complications of inadequately treated BXO leading to progressive disease and significant morbidity needing complex surgical fixes as a result.

My summation is therefore that there may be cases of early clinically suspicious BXO which may respond to steroids, but that this probably is not BXO anyway. For those patients with established scaring the only treatment that is reliably effective is a circumcision and that failure to do this exposes the patient to considerable risk of really significant complications of progressive scaring. The role of steroids, therefore, is as a way of excluding non-BXO in patients with inflammation that has not developed established scaring, to temporise and limit disease progression until a definitive circumcision is carried out by an appropriately trained surgeon under a general anaesthetic with adequate analgesia / penile block etc. I would also use post-operative steroids to further reduce the risk of meatal scarring when the inflammation has already spread onto the glans (which I have also seen), despite adequate circumcision.

It would seem that whilst histologically it shares features of lichen sclerosis, the clinical behaviour of BXO is different to the disease seen in females. Sadly, at present, I do not think the strategy of primary treatment of established BXO with topical or intra-lesional drugs can be recommended. In the present state of medical knowledge the only sure cure for BXO is circumcision — though we may hope that medical treatments will eventually be developed.

The surgeon adds that he is concerned by the number of Queensland boys who have been subjected to unnecessary Plastibel circumcision in infancy.

I find it distressing how many boys are still subjected to the Plastibel circumcision. I see so many incidentally in my clinic (when looking at hernia, undescended testes etc) who have obviously had the Plastibel, with their shaft skin reaching only half way up the penis; and on occasions we get children referred with other complications — including buried penis, meatal stenosis and adherent preputial remnants.

In Scotland the National Health Service policy was to provide cultural circumcisions (almost entirely for the Muslim population), performed by paediatric surgeons in hospital under general anaesthetic, on the basis that the state had to respect religious/cultural beliefs and that we had a duty of care to minimise the trauma and suffering experienced by the children who were going to get the operation anyway. I do not agree however with “prophylactic” or essentially cosmetic circumcisions, and I am signed up to the international opinion of paediatric surgeons that there is no place for “routine” neonatal circumcisions in the developed world [Referenced in circinfo.org website]. On the few patients that do have persisting symptoms associated with phimosis I will discuss the alternative of a preputioplasty [a surgical operation on the foreskin that loosens it with minimal loss of tissue].