Penis: BALANITIS XEROTICA OBLITARANS(bxo)

BALANITIS XEROTICA OBLITARANS(bxo)

1. Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

1

2. Moderators:
Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr. A. Senthilvel, M.S., M.Ch.,

Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,
Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D. Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. INTRODUCTION
Chronic progressive sclerosing inflammatory
dermatosis of unknown origin that results in white
plaques with epidermal atrophy and
scarring……Lichen sclerosus

 Penile Lichen sclerosus (LS) is the preferred term for
Balanitis Xerotica Obliterans.
3 Dept of Urology, GRH and KMC, Chennai.

4. Lichen Sclerosus has Extragenital and Genital
manifestations like


a) Lichen Sclerosus et atrophicus (Dermatological Literature)

b) Balanitis Xerotica Obliterans (Glans penis presentation)

c) Kraurosis Vulvae (Vulvar presentation)
4 Dept of Urology, GRH and KMC, Chennai.

5. GENITAL LICHEN SCLEROSUS
BALANITIS XEROTICA
OBLITERANS
KRAUROSIS VULVAE
5 Dept of Urology, GRH and KMC, Chennai.

6. IMPORTANCE
Genital presentations of Lichen Sclerosus (both penile
and vulvar) outnumber the Extragenital presentations
by more than 5:1

83 % patients show genital involvement.

Increased risk of squamous cell carcinoma in Genital
disease has been noted although rare.
6 Dept of Urology, GRH and KMC, Chennai.

7. EPIDEMIOLOGY
 International incidence is 1 in 300-1000.

 In men, peak incidence is usually between 30-50
years. However any age group can be affected.

Commonly seen in uncircumcised and incompletely
circumcised men and boys. (98 %)
7 Dept of Urology, GRH and KMC, Chennai.

8. EPIDEMIOLOGY
AGE (In Years)
8 Dept of Urology, GRH and KMC, Chennai.

9. EPIDEMIOLOGY
In women Incidence is bimodal, with first peak before
puberty and another peak in postmenopausal age
group.

 No racial association has been noted yet, however
familial clustering has been apparent.

 Male to female ratio is 1:6, which reveals that the
females are more commonly affected.
9 Dept of Urology, GRH and KMC, Chennai.

10. PATHOPHYSIOLOGY
Inflamation and altered fibroblast function in
papillary dermis Fibrosis of the upper dermis.


 Increased GLUT-1 (Glucose transporter) and
decreased VEGF expression in affected skin supports
that hypoxia and ischemia has a role in initial cellular
and vascular damage.
10 Dept of Urology, GRH and KMC, Chennai.

11. ETIOLOGY
Multifactorial

 Uncircumcised state / Late Circumcision.
Foreskin Chronic irritation & serve to
maintain a friendly environment some infectious agent
Inflammation.

11 Dept of Urology, GRH and KMC, Chennai.

12. • Hormonal factors.

Testosterone Decreased serum levels
of free testosterone, androstenedione, and
dihydrotestosterone compared with control
subjects.


• Genetic factors.
12 Dept of Urology, GRH and KMC, Chennai.

13. • Autoimmune disease

Autoantibodies (including antinuclear, thyroid
antimicrosomal, antigastric parietal cell, anti-adrenal
cortex, antismooth muscle, and antimitochondrial
antibodies) have been detected in patients with lichen
sclerosus.



Vitiligo, thyroid disease, diabetes, and alopecia areata
have also been commonly reported in association with
lichen sclerosus.
13 Dept of Urology, GRH and KMC, Chennai.

14. Presence of Human Papillomaviruses


Patients with penile lichen sclerosus alone have
NOT been demonstrated to have a higher
incidence of HPV infection.
14 Dept of Urology, GRH and KMC, Chennai.

15. Lichen sclerosus is a complex immunological
disorder of the genitalia involving:
glans, meatus, coronal
sulcus and penile skin
navicularis, penile and bulbar
urethra
15 Dept of Urology, GRH and KMC, Chennai.

16. Lichen sclerosus is a chronic, evolving disease
2 yrs later
5 yrs later
16 Dept of Urology, GRH and KMC, Chennai.

17. Lichen sclerosus

Sexual activity
Urinary function
Aesthetic appearance of the genitalia
Poor quality of life
17 Dept of Urology, GRH and KMC, Chennai.

18. Lichen sclerosus: Association with SCC

The incidence of neoplastic changes in patientswith
lichen sclerosus ranges from 2.3% to 8.4%

Lichen sclerosus is a pre-cancerous condition for
atleast some types of penile cancers, especially
those not related to HPV
18 Dept of Urology, GRH and KMC, Chennai.

19. Lichen sclerosus and SCC
19 Dept of Urology, GRH and KMC, Chennai.

20. Lichen sclerosus and Verrucous Carcinoma
20 Dept of Urology, GRH and KMC, Chennai.

21. Lichen sclerosus & Queyrat’sErythoplasia
21 Dept of Urology, GRH and KMC, Chennai.

22. Lichen sclerosus and No Carcinoma
22 Dept of Urology, GRH and KMC, Chennai.

23. SIGNS &
SYMPTOMS
23 Dept of Urology, GRH and KMC, Chennai.

24. CLINICAL PRESENTATION
• Usually Asymptomatic
having mild observable
skin changes on Glans
and Penis.


• Itching (although not
usual)
24 Dept of Urology, GRH and KMC, Chennai.

25. • Symptoms occurring with time and
progression of penile lichen sclerosus are as
follows:

• Pruritus
•Burning
• Hypoesthesia of the glans penis
• Dysuria
• Painful erection with altered sexual function
• Decrease in urinary force or stream caliber
• Urethritis with or without discharge
25 Dept of Urology, GRH and KMC, Chennai.

26. On clinical Examination:

• Early penile lichen sclerosus 
mild, nonspecific erythema; mild
hypopigmentation.



• As the condition progresses, single
or multiple discrete erythematous
papules or macules progress and
coalesce into atrophic ivory, white,
or purple-white patches or plaques.
26 Dept of Urology, GRH and KMC, Chennai.

27. On clinical Examination:


• Lesions most commonly affect the
glans and prepuce. The frenulum,
urethral meatus, fossa navicularis,
penile shaft, and perianal areas may
become involved.



•A sclerotic white ring at the tip of
the prepuce is diagnostic at this
stage.
27 Dept of Urology, GRH and KMC, Chennai.

28. Uncircumcised patients can
present with:

Phimosis (inability to
retract the foreskin over
the glans)


Paraphimosis (inability
to return an already
retracted foreskin back
over the glans)
28 Dept of Urology, GRH and KMC, Chennai.

29. With further disease progression,
the glans may become adherent to
the prepuce.

• The coronal sulcus and frenulum
may be sclerotically destroyed.

• The urethral meatus may narrow
to the point of urinary retention.

• Renal Insufficiency.
29 Dept of Urology, GRH and KMC, Chennai.

30. •Squamous Cell Carcinoma of the penis arising
from BXO alone has also been noted.


• Urethral stone manifesting as a stop valve has
been reported.


•Older patients should be examined to see if they
have BXO if they have symptoms of difficulty
with urination.
30 Dept of Urology, GRH and KMC, Chennai.

31. Vulvar lichen Sclerosus usually presents with
progressive pruritus, dyspareunia, dysuria or genital bleeding.
31 Dept of Urology, GRH and KMC, Chennai.

32. INVESTIGATIONS
• Rapid protein reagin test
helps exclude syphilis.


• Biopsy & histopathology
32 Dept of Urology, GRH and KMC, Chennai.

33. HISTOPATHOLOGICAL FINDINGS
Histopathologic changes of genital lichen sclerosus are
similar to those of non-genital lichen sclerosus.
 Epidermal findings include
 Orthokeratosis
 Hyperkeratosis with follicular plugging
 Hyperkeratosis without follicular plugging
 Stratum malpighii atrophy
 Basal layer hydropic degeneration
 Dermoepidermal clefting
33 Dept of Urology, GRH and KMC, Chennai.

34. • Significant dermal edema and homogenization of the
collagen in the upper dermis occurs, with dilatation of
blood and lymph vessels and a loss of elastic fibers.



• The immune cells moving into areas of BXO include
lymphocytes, plasma cells, and histiocytes in the mid
dermis. The inflammatory infiltrate is less pronounced
in long-standing lesions.
34 Dept of Urology, GRH and KMC, Chennai.

35. 35 Dept of Urology, GRH and KMC, Chennai.

36. Lichen sclerosus: Histology
36 Dept of Urology, GRH and KMC, Chennai.

37. The 5 histopathological features for diagnosis of
lichen sclerosus


 Hyperkeratosis of the epithelium
• Hydropic degeneration of the basal cells
• Sclerosus of the subepithelial collagen
• Dermal lymphocytic infliltration
• Atrophic epidermis with loss of rete pegs and
homogenization of the collagen in the upper third
of the dermis
37 Dept of Urology, GRH and KMC, Chennai.

38. Lichen sclerosus: Histology
SLIGHT

MODERATE

SEVERE
38 Dept of Urology, GRH and KMC, Chennai.

39. Lichen sclerosus
and
Urethral stricture




Epidemiology
39 Dept of Urology, GRH and KMC, Chennai.

40. Lichen sclerosus is increasing in all Centres
specialized in treatment of urethral and genitalia
diseases
Involvement of the urethra in genital lichen
sclerosus appears to be much more common than
previously reported
 Prior to diagnosis, many patients had symptoms
for years, thus encouraging the disease’s
progression over time
Lichen sclerosus and Urethral stricture,In our
experience, when the urethra is involved in the
disease,41% of patients showed panurethral
stricture

40 Dept of Urology, GRH and KMC, Chennai.

41. Pathogenesis
The embriology of the glans may explain the
involvement of the external urinary meatus
and navicularis tract in lichen sclerosus
The developing glanural urethra involves the preputial folds that
fuse to genital folds
41 Dept of Urology, GRH and KMC, Chennai.

42. 1 foreskin
2 glans
3 meatus
4 Penile urethra
42 Dept of Urology, GRH and KMC, Chennai.

43. Lichen sclerosus and Urethral stricture
99 patients (mean age 46 years)
274 biopsies for LS
43 Dept of Urology, GRH and KMC, Chennai.

44. Lichen sclerosus and Urethral stricture
Navicularis urethral
mucosa
Epidermized navicularis urethral mucosa.
LS similar to cutaneous counterpart
44 Dept of Urology, GRH and KMC, Chennai.

45. Lichen sclerosus and Urethral stricture
Penile urethral
mucosa
Epidermized penile urethral mucosa.
LS similar to cutaneous counterpart
45 Dept of Urology, GRH and KMC, Chennai.

46. Lichen sclerosus and Urethral stricture
Bulbar urethral
mucosa
Transition from normal startified cylindrical epithelium
(left) through squamous nonkeratinizating metaplastic
epitelium to keratinizing squamous metaplastic
hyperplasia (right)
46 Dept of Urology, GRH and KMC, Chennai.

47. Lichen sclerosus and Urethral stricture
Squamous metaplasia involves the ductus of the periurethral glands,
which becomes rigid and wide open. Thus the retrograde
urethrography is able to depict the periurethral glands
47 Dept of Urology, GRH and KMC, Chennai.

48. Lichen sclerosus and Urethral stricture
Involvement of external urinary meatus is a
prognostic factor for spread Lichen sclerosus
through the navicularis and penile tracts.
More than 10 years are required to Lichen
sclerosus progress.
It is possible to document Lichen sclerosus in
navicularis and penile urethral mucosa by
histology.
It is not possible do document Lichen sclerosus in
bulbar urethral mucosa.

48 Dept of Urology, GRH and KMC, Chennai.

49. THANK YOU
49 Dept of Urology, GRH and KMC, Chennai.