Cancer Association of South Africa (CANSA) Fact Sheet on Balanitis Xerotica Obliterans (BXO)
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1 Cancer Assciatin f Suth Africa (CANSA) Fact Sheet n Balanitis Xertica Obliterans (BXO) Intrductin Balanitis xertica bliterans (BXO), als knwn as lichen sclersus f the penis is a dermatlgical (skin) cnditin affecting the male genitalia. The cause f BXO is unclear. It was first described by Stuhmer in BXO cmmnly ccurs n the freskin and glans penis. Atrphic white patches appear n the affected area, and cmmnly, a whitish ring f indurated (hardened) tissue usually frms near the tip that may prevent retractin f the freskin. (Medscape; Wikipedia). [Picture Credit: Balanitis Xertica Obliterans] Yardley, et al (2007) believe that the prevalence f BXO is greater than previus series have shwn and that it may manifest in children at an earlier age than previus series have shwn. This belief is based n a study f 422 bys at a median age f 6 years 2 mnths (range, 3 m t 16 y), f whm 186 (44.1%) received treatment invlving surgery (148 circumcisin, 33 preputial adhesilysis, 5 frenulplasty). Of the 186 bys, 110 had histlgical tissue examinatin; 84.8% f skin samples were pathlgic. Specifically, tissue shwed chrnic inflammatin (n = 69; 46.6%), BXO (n = 51; 34.5%), and fibrsis (n = 4; 2.7%). Incidence f Balanitis Xertica Obliterans (BXO) in Suth Africa The Natinal Cancer Registry (2013) des nt prvide infrmatin regarding the incidence f Balanitis Xertica Obliterans (BXO) because it is nt a cancerus cnditin itself, hwever, if neglected it may develp int cancer f the penis. Accrding t the Natinal Cancer Registry (2013) the fllwing number f penile cancer cases was histlgically diagnsed in Suth Africa during 2013: Nvember 2017 Page 1
2 Grup 2013 Number f Cases Lifetime Risk Percentage f All Cancers All Males 168 1: ,46% Asian males 6 1:711 0,72% Black males 118 1: ,10% Clured males 8 1: ,19% White males 34 1:946 0,17% The frequency f histlgically diagnsed cases f penile cancer in Suth Africa fr 2013 was as fllws (Natinal Cancer Registry, 2013): Grup All males Asian males Black males Clured males White males Signs and Symptms f Balanitis Xertica Obliterans (BXO) Early in its curse, balanitis xertica bliterans [BXO] is relatively asymptmatic with nly mild visually bservable changes f the penis and glans. Physical changes ccur ver mnths r years and may include clur r textural changes. Early symptms are mre prevalent in uncircumcised patients. Symptms ccurring with time and prgressin f BXO are as fllws: Pruritus Burning Hypesthesia f the glans penis Dysuria Painful erectin with altered sexual functin Decrease in urinary frce r stream calibre Urethritis with r withut discharge Symptms ccurring in late BXO (in uncircumcised patients) are as fllws: Phimsis (inability t retract the freskin ver the glans) Paraphimsis (inability t return an already retracted freskin back ver the glans) The develpment f multifcal squamus cell carcinma (SCC) in persns with BXO f the penis and hepatitis C virus infectin has been reprted. SCC f the penis arising frm BXO alne has als been nted. (emedicine). Causes f Balanitis Xertica Obliterans (BXO) The cause f this cnditin is nt knwn but there is an assciatin with ther aut-immune cnditins such as vitilig and certain frms f thyrid disease. It is extremely imprtant t emphasise that the cnditin is nt transmissible thrugh sexual intercurse and is nt infectius neither can it be acquired thrugh sexual intercurse. Nvember 2017 Page 2
3 The cnditin is chrnic and prgressive and can lead t permanent changes in the glans penis and freskin which can give rise t stricture frmatin r narrwing f the urethra. These skin changes are characterised by the frmatin f a hard white lump arund the pening f the urethra. A reddened area then frms arund the lump and a chrnic prcess f inflammatin and scarring ensues which can smetimes lead t ulcer frmatin. The affected area can becme itchy and sre. (Irishhealth.cm). Cmplicatins f Balanitis Xertica Obliterans (BXO) Balanitis xertica bliterans (BXO) is described as an atrphic and sclertic cnditin f the glans penis, which can result in stensis and the bliteratin f the external meatal rifice. Studies have shwn that a significant number f patients with penile malignancy have a histlgic diagnsis f BXO. Males with BXO and thse in whm BXO persists despite circumcisin shuld underg bipsy and further evaluatin. (thebmj; Medscape) Medical Treatment f Balanitis Xertica Obliterans (BXO) N cnsistently effective treatment has been develped fr balanitis xertica bliterans [BXO], hwever, the fllwing therapies have varying degrees f reprted success. Tpical and intralesinal sterids: Tpical sterids can ffer a reliable ptin nly in the management f mild BXO limited t the prepuce in bys with minimal scar frmatin. Patients and their families must have realistic expectatins with regard t the success f such treatments. Sterid-based creams are ineffective in persns with established scarring. Studies have shwn that applying a ptent tpical sterid imprves BXO in the histlgically early and intermediate stages f disease and may inhibit further wrsening in the late stages. Kiss questined the utility f tpical sterid-based creams fr the treatment f clinical BXO. Differences in success rates may relate t an unwillingness t use superptent crticsterids. Tpical sterids and skin stretching: Ghysel et al reprted n successful therapy with tpical sterid applicatin and skin stretching n prepubertal bys with unretractable freskin and phimsis Tacrlimus: Successful treatment f BXO with tpical tacrlimus has been reprted Etretinate (n lnger available): Acitretin is the current equivalent Carbn dixide laser treatment An interesting new reprt ntes the successful use f intralesinal adalimumab, a medicatin fr psriasis amng ther things, fr BXO (Medscape). Surgical Treatment f Balanitis Xertica Obliterans (BXO) Balanitis Xertica Obliterans (BXO) is a chrnic, ften prgressive disease, which can lead t phimsis and urethral stensis, affecting bth urinary and sexual functin. Sterid creams are usually the first-line treatment but have a limited rle and surgical interventin is frequently necessary. Cnservative surgical prcedures (circumcisin) are ften preferred in Nvember 2017 Page 3
4 the first instance with the premise that recurrence f disease will require a mre definitive recnstructin. Surgical ptins are mre definitive, and includes circumcisin, dilating r surgically crrecting meatal stensis, and varius urethrplasty techniques. Carbn dixide laser has been used as an alternative t incisinal surgery t ablate BXO n the glans and fr the dilatatin f prximal stricture. (Hartley, et al., 2011; Depasquale, et al.). Medical Disclaimer This Fact Sheet is intended t prvide general infrmatin nly and, as such, shuld nt be cnsidered as a substitute fr advice, medically r therwise, cvering any specific situatin. Users shuld seek apprpriate advice befre taking r refraining frm taking any actin in reliance n any infrmatin cntained in this Fact Sheet. S far as permissible by law, the Cancer Assciatin f Suth Africa (CANSA) des nt accept any liability t any persn (r his/her dependants/estate/heirs) relating t the use f any infrmatin cntained in this Fact Sheet. Whilst CANSA has taken every precautin in cmpiling this Fact Sheet, neither it, nr any cntributr(s) t this Fact Sheet can be held respnsible fr any actin (r the lack theref) taken by any persn r rganisatin wherever they shall be based, as a result, direct r therwise, f infrmatin cntained in, r accessed thrugh, this Fact Sheet. Nvember 2017 Page 4
5 Surces and References Balanitis Xertica Obliterans Depasquale, I., Paark, A.J. & Bracka, A The treatment f balanitis xertica bliterans. BJU Internatinal, 86(4): emedicine Hartley, A., Ramanathan, C. & Siddiqui, H The surgical treatment f balanitis xertica bliterans. Indian J PlastSurg. Jan-Apr: 44(1): Di: / Irishhealth.cm Medscape Natinal Cancer Institute thebmj Wikipedia Yardley, I.E., Csgrve, C. & Lambert, A.W Paediatric preputial pathlgy: are we circumcising enugh?. Ann R Cll Surg Engl Jan. 89(1):62-5. Nvember 2017 Page 5
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