Balanitis Xerotica Obliterans - Causes, Signs, Diagnosis, and Treatment

What Is Balanitis Xerotica Obliterans?

The penis is a crucial organ of the male reproductive system. The penis is covered by a thin flap-like tissue known as the foreskin. When this foreskin is removed, it is known as a circumcised penis whereas, the other situation in which the foreskin is not removed is known as an uncircumcised penis. Normally, boys can pull back their foreskin to cover the tip of the penis by around ten years. However, the problem arises when the person cannot pull the foreskin back to its normal position. This situation gives rise to a condition known as balanitis xerotica obliterans. The foreskin and glans are the most commonly affected due to balanitis xerotica obliterans. Therefore, the condition must be treated at the earliest to avoid complications.

What Are the Causes of Balanitis Xerotica Obliterans?

Balanitis xerotica obliterans is also lichen sclerosus and is commonly seen in uncircumcised males. Insufficient information is available about the causes of the condition. However, the following factors increase the risk of balanitis xerotica obliterans:

1. Uncircumcised Penis: Circumcision is a procedure in which the foreskin is removed after birth. Some boys choose to remain uncircumcised due to social and ethical issues. The risk of lichen sclerosus or balanitis xerotica obliterans increases when the boys remain uncircumcised until they are 13. The foreskin provides a site for bacterial growth, which causes irritation and inflammation of the penis. When the person does not clean the penis after urinating, the urine accumulates, resulting in inflammation.

2. Micro Incontinence: Micro incontinence is a phenomenon in which urine leaks in small amounts after micturition. Studies have found that 91 % of men suffering from balanitis xerotica obliterans have reported micro incontinence.

3. Hormonal Problems: The male hormone deficiency, mainly testosterone, is responsible for this condition. Balanitis xerotica obliterans usually resolves when children hit puberty because of testosterone levels. However, adults have low testosterone levels and are more likely to develop this condition.

4. Autoimmune Diseases: Autoimmune diseases occur when antibodies destroy healthy body cells. Balanitis xerotica obliterans is commonly associated with autoimmune diseases.

5. Human Papillomavirus: Children suffering from balanitis xerotica obliterans are more likely to show the human papillomavirus. Studies have reported that 22 % of children suffer from lichen sclerosus and human papillomavirus disease.

What Are Some of the Major Signs and Symptoms of Balanitis Xerotica Obliterans?

The patient does not present with any symptoms in the initial stages, and only mild changes are noticed in the penis. However, as time passes, the following symptoms are usually noticed:

• Pruritus or itching.

• Burning sensation.

• Dysuria (painful urination).

• Decrease in the normal sensation of the penis.

• Painful erection.

• Difficulty in starting the urine stream.

• Urethritis (inflammation of the urethra).

• White and erythematous areas on the glans penis.

What Tests Are Done to Diagnose Balanitis Xerotica Obliterans?

Balanitis, or lichen sclerosus is mainly seen in people who did not undergo circumcision. No specific tests must be done because the condition becomes visible upon physical examination. The diagnostic methods are described below:

1. Medical History - The medical history should be taken to get knowledge about the patient’s condition. For example, patients suffering from autoimmune diseases or hormonal imbalances are more likely to develop balanitis xerotica obliterans.

2. Physical Examination - The doctor examines the penis to look for signs of inflammation. Initially, white or erythematous hypopigmented areas are visible on the glans penis. As the disease progresses, multiple papules (raised area of skin less than one centimeter) and macules (flat and discolored areas of the skin) are seen on the skin. These papules and macules accumulate and form white patches on the penis. If the doctor locates a white ring at the tip of the penis, it is confirmed that the patient is suffering from balanitis xerotica obliterans. When the condition becomes severe, the foreskin becomes attached to the glans, and the doctor might be unable to retract it.

3. Rapid Plasma Reagin Test - A rapid plasma reagin test is a blood test done to diagnose syphilis. As the patient experiences similar symptoms in syphilis and balanitis xerotica obliterans, this test helps to rule out syphilis and confirms the diagnosis. A needle is injected into the veins to take a blood sample in this test. The blood sample is evaluated for syphilis bacteria.

How to Manage Balanitis Xerotica Obliterans?

The treatment depends upon the severity of the condition. Mild cases can be treated by conservative methods, whereas severe cases require surgical intervention. The treatment options have been described below:

• Topical Steroids: Topical steroids effectively treat mild cases of balanitis xerotica obliterans. Scarring and phimosis are commonly seen if the disease progresses to a severe stage, and the steroids are ineffective. Betamethasone and Triamcinolone are the commonly used steroids to reduce itching and inflammation. The patient must apply them twice a day. The doctor might call the patient for follow-ups to check the condition. If there is an improvement, the frequency of application is reduced. Topical calcineurin inhibitors are also effective, but they are used as second-line therapy. Pimecrolimus and Tacrolimus are the commonly used topical calcineurin inhibitors.

• Surgery: Surgical treatment is only indicated for patients suffering from phimosis or conservative treatments that have failed to manage the condition. The foreskin is removed surgically because it provides an environment for bacterial growth. However, circumcision is only useful when the condition is restricted to the penis. If the infection has involved the urethra, urethral surgery must be done.

What Are the Complications of Balanitis Xerotica Obliterans?

Usually, the patient does not present with any complications as the infection subsides after applying topical steroids. However, the following complications occur if the condition is diagnosed late:

1. Painful Erection - The penis contains spongy tissues that receive blood and increase in size. When the person is doing his normal activities, the arteries that supply blood to the penis are partially open. However, when the person is sexually stimulated, the brain commands the arteries to open completely. As a result, the blood flows rapidly into the spongy tissues, and the penis gets enlarged. When this blood gets trapped in the penis, the condition is known as priapism or painful erection.

2. Urethral Stenosis - The urethra is a tube-like structure that drains urine outside the body. Urethral stenosis or narrowing of the urethra occurs due to the spread of infection. As a result, the person cannot urinate, resulting in severe urinary incontinence.

Conclusion:

Balanitis xerotica obliterans or lichen sclerosus is a condition in which erythematous white patches are seen on the penis and the surrounding areas. Uncircumcised boys are at a higher risk of suffering from this condition. This is because their foreskin provides a warm and moist environment for bacterial growth. This condition was previously considered rare but is now commonly seen in children and elderly males. The treatment depends upon how early the condition is diagnosed. Topical steroids are helpful in mild to moderate cases, whereas surgical intervention is required in severe cases. So, the patient must consult the doctor immediately to learn more about the condition and the treatment.