Balanitis xerotica obliterans is a sclerotic-fibrous and atrophic process with a weakly pronounced inflammatory component affecting the glans penis. It is characterized by the appearance of whitish spots and hyperkeratotic foci in the area of the head and inner leaf of the foreskin, wrinkling of the skin, as a result of which the development of foreskin stenosis, phimosis, narrowing of the urethra mouth is possible. Recognition is performed on the basis of examination, biopsy and establishment of histological diagnosis. Circumcision is performed, meatotomy, if necessary, urethral plastic surgery, local therapy with glucocorticoids is prescribed.
Balanitis xerotica obliterans (sclerosing lichen) it can develop at any age: in children, middle-aged and elderly men, but it is more common in patients older than 50 years. Experts regard balanitis xerotica obliterans as a condition predisposing to the development of penile cancer.
According to histological signs, balanitis xerotica obliterans is similar to scleroatrophic lichen and some local forms of scleroderma. In gynecology, limited scleroderma can be detected in the area of the external genitals in women in the absence of data for vulvar kraurosis. These observations make it possible to combine cutaneous and urogenital sclerosing processes into one group having a dystrophic nature.
The etiology of sclerosing lichen is unclear. It is believed that a wide range of factors can lead to the development of the disease – genetic, autoimmune, infectious, mechanical, hormonal. In modern andrology, dermatology and gynecology, there are observations of familial cases of sclerotic lichen and sclerosing lichen of the genitals. The studies conducted in this direction have revealed a number of genes responsible for the development of inherited balanitis xerotica obliterans and the degree of its severity.
Data from some scientific studies indicate a link between this form of balanitis and autoimmune lesions – vitiligo, psoriasis, rheumatic polymyalgia, systemic lupus erythematosus, diabetes mellitus, myxedema, primary biliary cirrhosis of the liver, alopecia, etc. In addition, local manifestations of pathology are similar to characteristic tissue changes in autoimmune diseases. The role of viral agents is not excluded, in particular, in the tissues of the foreskin after performing circumcision, pathogens of genital herpes and papillomavirus infection are often detected.
In some cases, the dependence of the occurrence of the disease on local skin damage – mechanical, chemical or thermal trauma, scuffs, chronic irritation with urine, radiation exposure during radiation therapy is traced. A number of researchers have noted the connection of sclerotic-fibrous changes in the glans penis area with previous surgical circumcision of the foreskin for phimosis. It is assumed that the development of pathology may be associated with an age-related drop in testosterone levels or a violation of tissue sensitivity to male sex hormones.
The head of the penis and the inner skin of the foreskin are affected – initially whitish spots, blisters with hemorrhagic contents and atrophic areas appear, which then transform into sclerotic plaques. In the future, a circular sclerotic ring is formed, as the head is compacted, the removal of the head becomes more difficult. Against this background, additional infection can lead to bacterial inflammation of the glans penis – balanitis. In the final stage of balanitis with the development of cicatricial phimosis, the head completely stops opening.
In men who have previously undergone circumcision, balanitis xerotica obliterans usually begins in the area of a postoperative skin scar. A decrease in the elasticity of the skin of the foreskin may be accompanied by its tears, especially during sexual intercourse. With scarring of the external opening of the urethra and part of the urethra in the area of the navicular fossa, difficult urination develops, requiring straining; the urine stream becomes thin and intermittent. The course of pathology is recurrent, prolonged.
Sclerotrophic and hyperkeratotic processes in balanitis xerotica obliterans not only worsen the quality of life, but can also cause recurrent urinary tract infections (urethritis, cystitis, pyelonephritis), urolithiasis, hydronephrosis and even kidney failure.
During the diagnosis, it is necessary to exclude other diseases with similar symptoms – bacterial and fungal balanoposthitis, herpetic, chlamydial infection, acquired phimosis, kraurosis and leukoplakia of the penis. In the diagnostic complex, bacteriological and PCR examination of smears is performed. The final confirmation is obtained by biopsy of the altered foci of the skin of the penis and urethra and their morphological study.
Histological examination reveals areas of follicular hyperkeratosis, thinning of the layer of the germinal epidermis, homogeneous collagen sclerosis, reduction or atrophy of elastic fibers, dense lymphoplasmocytic infiltration. In addition to verifying this type of balanitis, a biopsy allows you to exclude cancer of the penis and urethra. In order to identify urethral strictures, urethrography and urethroscopy are indicated.
Treatment tactics are determined by the prevalence of sclerosing changes. In the initial I stage of sclerosing lichen, when only the foreskin is involved in pathological changes, the operation of circumcision of the foreskin (circumcision) is performed with subsequent observation.
In stage II, characterized by narrowing of the opening of the urethra, meatotomy is required – surgical dissection of the meatus. In the future, long-term courses of local therapy with glucocorticoid creams are prescribed. In the III and IV stages, proceeding with total involvement of the foreskin, penis head, urethra, extensive excision of scar tissue is necessary, reconstructive plastic surgery of the urethra during, then – local glucocorticoid therapy.
Prognosis and prevention
With timely treatment, the prognosis is favorable, urination disorders are observed in the later stages, and the likelihood of developing penile cancer increases. Special prevention has not been developed. It is recommended to avoid traumatization of the genitals and STDs, regularly perform hygienic procedures, and promptly contact specialists about extragenital pathology. If any changes are detected in the area of the glans penis, a consultation with an andrologist is necessary. Early excision of the affected tissues, conservative therapy and observation help to avoid serious complications.