balanitis xerotica obliterans ( bxo ) is a common penile disease , first described in 1928 by stuhmer .
it has been classified as a male variant of lichen sclerosis by the international society for the study of vulvovaginal disease and is a chronic inflammatory process . whilst the exact aetiology is still poorly understood
it is thought that it could be genetically determined and there is evidence to suggest a higher incidence of autoimmune diseases amongst patients with bxo .
the disease usually presents initially on the glans penis or prepuce , affecting the foreskin , meatus and distal urethra either individually or in combination .
left untreated it has been reported to affect the entire urethra , penile skin and scrotum .
bxo is most commonly found in patients aged 30 - 60 years but there have been increasing reports of the disease in the paediatric population and it is now known to be the most common cause of pathological phimosis in boys .
the clinical progression of bxo can vary ; it can present acutely with erythema and discharge leading to early blistering and fissuring or it can follow a more chronic course , presenting initially with grey - white skin discolouration leading to complications at a much later stage . in either case , patients can experience ulceration of the glans , fissuring , phimosis , meatal stenosis and urethral strictures in untreated disease leading to problems with urinary and sexual function . on many occasions ,
there have been cases reported of scrotal fistula formation , renal impairment and a documented association between chronic bxo and an increased risk of penile squamous cell carcinoma .
the differential diagnoses include lichen planus , scleroderma , leukoplakia , vitiligo and erythroplasia of queyrat .
the histological features are characteristic , showing hyperkeratosis with atrophic epidermis , thinned rete pegs , vacuolar degeneration of basal layer ,  washed out  appearance of the papillary and reticular dermis , amorphous band by dermal collagen at the dermal - epithelial junction and chronic inflammatory infiltrate deep to the band .
topical steroid creams are the mainstay of medical treatment used in early - stage disease but there is limited evidence to support their use in recurrent , severe or advanced disease .
but for patients with bxo involving the meatus or urethra the options include meatoplasty , urethrotomy , urethral dilatation or a more definitive procedure such as urethroplasty using buccal or bladder mucosal grafts and or excision of bxo with skin grafting if involving the glans , coronal sulcus and adjacent shaft of penis . in our unit the senior authors have an established hypospadias practice including adult salvage surgery and additionally offer male genital reconstruction for patients with advanced bxo .
all patients with bxo referred to the plastic surgery department at our unit ( tertiary referral centre ) between 2005 and 2009 were included in the study .
data was collected retrospectively using a data collection sheet to collate information from patient notes . referring specialty , the anatomical location of the bxo and duration of symptoms were noted .
previous management including surgical procedures was documented and any change in urinary or sexual function secondary to the disease process was recorded .
twenty - three patients aged between four and 78 ( mean age 38 ) [ figure 1 ] were referred from six different specialties .
forty - eight percent of referrals were from urology , 17% were from general practitioners ( gps ) and 13% were from dermatology .
the remaining patients were referred from the general surgery , genitourinary medicine and other plastic surgery units .
forty - seven percent of patients were seen at our unit within two years of being diagnosed with bxo but 21% of patients were not referred for over five years and two patients were suffering from bxo - related problems for over ten years . in the group of 23 there were seven patients who had bxo affecting between three and five areas of their genitalia , indicating severe progressive disease .
of the four that had had previous surgery prior to referral to our unit , all had either release of adhesions or urethral / meatal dilatation .
reconstructive surgery with excision of the affected area and skin grafting or urethroplasty was performed for these patients and they are still being followed in the clinic . to date
there is no recurrence of the disease and the patients have reported subjective improvement in their urinary and sexual function from before surgery .
a patient in our study who had bxo affecting his meatus and urethra had undergone two optical urethrotomies and four urethral dilatations over a period of 12 years [ figure 2 ] . due to the spread of the disease he needed to perform intermittent self - catheterisation twice a week to maintain a reasonable urinary flow for nearly ten years .
we performed distal urethrotomy of the dense stricture to allow urethroscopy which also showed skip lesions of bxo in the posterior urethra .
the patient underwent excision of the distal stricture and two - stage urethral reconstruction using a buccal mucosa graft [ figure 3 ] .
subsequently he was able to pass urine normally without the need for the self - catheterisation . at two years post procedure
chronic bxo urethral stricture pre - op ( a - d ) and cystourethrogram ( e ) post - op i stage -stricture excised ( a - d ) grafted using buccal mucosa & ii stage reconstruction ( a1-d4 ) in order to assess the progression of the disease , we recorded the anatomical location of the affected area
. patients were recorded as having bxo affecting the foreskin , glans , meatus , penile shaft , urethra and scrotum or any combination of these .
forty percent of patients had bxo confined to the foreskin and glans and a further 14% had disease affecting the foreskin only .
thirteen percent of patients had disease affecting three areas , a further 13% had disease affecting four areas and one patient had bxo involving the foreskin , glans , meatus , urethra and scrotum .
forty - three percent of patients had surgical intervention prior to referral and 60% of those had two or more procedures .
these included optical urethrotomy , circumcision , urethral dilatation , hypospadias repair , meatoplasty and debridement / release of penile skin [ figure 4 ] .
thirty percent had previous medical treatment in the form of steroid creams , anti - fungal cream , antibiotics or self - catheterisation .
sixty - one percent of patients had previously undergone circumcision ( a proportion of these were unrelated to the diagnosis of bxo ) .
previous surgical treatment forty - seven percent of patients had alteration of their urinary function due to the disease .
forty - eight percent had problems with sexual function and described fissuring , painful intercourse , bleeding , erectile dysfunction and discharge .
fifty - two percent of the procedures performed in our department were examination under anaesthesia ( eua ) and circumcision [ figure 5 ] .
this correlates with the proportion of patients diagnosed with bxo affecting only the glans or foreskin .
however , four patients underwent a two - stage urethroplasty with buccal mucosal reconstruction , two patients had urethral tubularisations and one had an optical urethrotomy .
the remainder had excision of the affected skin and grafting [ an example shown in figure 6 ] or meatal reconstruction .
early results showed that 100% of these patients had a subjective improvement in urinary or sexual function following plastic surgery input .
one hundred percent patients had no recurrence of the disease after treatment in our unit although 13% had bxo still visible but not advancing .
patients were followed up for an average of two years and five months prior to discharge .
bxo involving glans and corona ( a3-d3 ) excised and resurfaced with split skin graft ( a4-d4 )
when looking at the effectiveness of medical therapy for the treatment of bxo our results show limited success .
many cases eventually required surgical treatment . of the seven patients treated with steroid creams , anti - fungal or antibiotics three had disease confined to the foreskin and glans but with evidence of adhesions or scarring .
the remaining four patients had advanced disease that had spread to the penile shaft or scrotum .
a literature review conducted by pugliese et al . , in 2008 concluded that there was no guidance on the duration of treatment with a steroid cream or the type of steroid to use and it described limited long - term benefit and disease recurrence once treatment ceased .
this was supported by a study looking at a paediatric population using steroid cream which showed resolution in patients with clinically mild bxo that was limited to the prepuce but no reported benefit in those with more severe disease .
another paediatric study has shown a recurrence of symptoms following cessation of the steroid treatment despite initial disease regression .
for patients with disease confined to their glans or foreskin , circumcision offers cure by eliminating the moist urine - rich environment in which bxo can progress . in a case
series of 287 patients with bxo limited to the foreskin or glans treated by circumcision , 92% had cessation of symptoms and no further advancement of the disease following surgery .
our results support this finding and these patients , who had minimal urinary and sexual function symptoms prior to surgery , were discharged from clinic at an early stage . for patients with urethral or meatal involvement surgical intervention
is required . in the case of meatal stenosis or navicular fossa strictures , ventral meatotomy , dorsal meatoplasty or excisional meatoplasty
urethral strictures have a high associated morbidity , causing fibrosis of the corpora spongiosum and urinary outflow obstruction , which in turn can lead to high pressures in the upper urinary tract .
this method requires more specialised surgical training and a longer hospital stay than conventional methods such as urethral dilatation or urethrotomy . for these reasons ,
simple procedures are often chosen in preference to urethroplasty but they have limited success rates urethral dilatation has never been considered to be curative but is a simple procedure that can be offered under a local anaesthetic in a day case setting . in 1997 , steenkamp et al .
, performed a study directly comparing urethral dilatation to urethrotomy for the treatment of urethral strictures .
no statistical difference was found between these two procedures in terms of stricture recurrence rate but both procedures had poor outcomes if used for the treatment of strictures over 4 cm in length .
a recent cochrane review looked at the evidence comparing urethral dilatation , urethrotomy and urethroplasty for the treatment of urethral strictures .
whilst there was not enough current evidence to compare dilatation and urethrotomy to urethroplasty , there was no difference found between dilatation and urethrotomy in terms of cure rate .
a study directly comparing urethral dilation and urethrotomy found there was no long - term benefit in a second procedure ( either dilatation or urethrotomy ) for early stricture recurrence .
if urethroplasty is chosen as a treatment method , options for graft donor site include local genital skin or buccal or lingual mucosa .
trivedi et al . , had limited success with local grafts and favoured lingual over buccal mucosa due to easier graft harvesting and lower rates of donor site morbidity .
pugliese et al . , report high rates of disease recurrence in genital skin grafts and advocate the use of buccal grafts in either a one - stage or a two - stage reconstruction .
depasquale et al . , reported 90% stricture recurrence rate in a long - term follow - up of 42 cases of bxo urethral strictures excised and reconstructed using skin , many requiring reoperations using mucosa subsequently . there were no recurrences reported in their series of bxo urethral reconstructions carried out using buccal or bladder mucosa .
although our case series is small we think our results show the importance of early recognition of unresolved , progressive and recurrent bxo cases .
steroid creams have been shown to limit the progression of the disease but do not offer a cure in the majority of cases .
the progression of the bxo disease gets arrested following circumcision by removing the urine - rich environment and patients with meatal or urethral disease are most likely to require excision and/or reconstruction for a long - lasting cure .
suitable cases should be referred to specialised units for further assessment and surgical management by excision and/or reconstruction for a disease that is prevalent in the male population .
 background : balanitis xerotica obliterans ( bxo ) is a chronic , often progressive disease , which can lead to phimosis and urethral stenosis , affecting both urinary and sexual function . 
 steroid creams are usually the first - line treatment but have a limited role and surgical intervention is frequently necessary . 
 conservative surgical procedures ( circumcision ) are often preferred in the first instance with the premise that recurrence of disease will require a more definitive reconstruction . 
 this study looked at patients with pathologically proven bxo referred to the plastic surgery unit at james cook university hospital between 2005 and 2009 . 
 the aim was to look at their management in the past and subsequent management by us . 
 we also looked at whether early referral of progressive and recurrent bxo patients to reconstructive surgery could have prevented unnecessary delay in resolving symptoms at an earlier stage.materials and methods : data was collected retrospectively and information regarding the exact anatomical location affected , the extent of the disease , the referring specialty and any previous surgical interventions was obtained . 
 alterations in urinary and sexual function and relief of symptoms following reconstructive surgery were analysed.results:of the 23 patients in the study , 43% had previous surgery and 60% of those had undergone two or more procedures . 
 twenty - one percent of patients had a history of bxo for over five years . 
 forty - seven percent of patients had alteration in their urinary function and 48% alteration in their sexual function due to the disease , prior to referral . 
 early results showed remarkable improvement in urinary and sexual function following reconstructive surgery in this group.conclusions:steroid creams have been shown to limit the progression of the disease but do not offer a cure in the majority of cases . 
 circumcision can be a curative procedure in early disease . although there is conflicting evidence for treatment of recurring urethral strictures , repeated urethrotomy or urethral dilatation has poor long - term outcome . in patients with recurrent disease and associated complications 
 we propose early referral to a plastic surgeon with genitourinary interest or reconstructive urologist for definitive treatment . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS