PEDIATRIC UROLOGY

Balanitis xerotica obliterans in boys
Gargollo PC, Kozakewich HP, Bauer SB, Borer JG, Peters CA, Retik AB, Diamond DA
Department of Urology, Children’s Hospital Boston, Boston, Massachusetts, USA
J Urol. 2005; 174 (4 Pt 1): 1409-12

• Purpose: Balanitis xerotica obliterans (BXO) is a chronic dermatitis of unknown etiology most often involving the glans and prepuce but sometimes extending into the urethra. We report our 10-year experience with BXO in pediatric patients.
• Materials and Methods: Our pathology database was queried for all tissue diagnoses of BXO from 1992 to 2002. Available charts were reviewed and patient presentation, clinical and referral history, operative procedure(s) and postoperative course were recorded.
• Results: A total of 41 patients had a tissue confirmed diagnosis of BXO. Median patient age was 10.6 years. Of the patients 85% were 8 to 13 years old and all had referrals available for review. The most common referral diagnoses were phimosis (52%), balanitis (13%) and buried penis (10%). No patient had the diagnosis of BXO at referral. Of the patients 19 (46%) underwent curative circumcision or redo circumcision and had no recurrence at a mean followup of 12.5 months (range 1 to 57). A total of 11 patients (27%) had BXO involvement of the meatus and underwent circumcision combined with meatotomy or meatoplasty. Nine patients (22%) required extensive plastic operation(s) of the penis, including buccal mucosa grafts in 2.
• Conclusions: The incidence of BXO in pediatric patients may be higher than previously reported, with the diagnosis rarely made by pediatricians. Our study demonstrates that older patients, those with BXO involvement of the meatus and those with a history of surgery for BXO tend to have a more severe and morbid clinical course.
  
  
• Editorial Comment
  The authors describe a retrospective analysis of their institutional experience with this disease process over 10 years. 41 cases were found and analyzed. The majority was referred for foreskin problems; none were diagnosed with BXO at the time of referral. Of the 41 patients, 23 (56%) had glans involvement and 15 (37%) had meatal involvement. Circumcision was curative (at least in the short-term) for most of the minor cases. However, when BXO involved the meatus, the disease process was much more serious and required more extensive repair.
  BXO is largely underdiagnosed. The diagnosis can only be made histologically and many institutions do not require histological examine after routine circumcision. As such, many more cases may be occurring without being recognized. In our experience, BXO was found in many cases of meatal stenosis in patients with previous hypospadias surgery. Again, in most instances, the diagnosis was made only when biopsies of the area were sent for histological analysis. The etiology of the problem in these cases is unclear. Though most were operated on using older techniques, it is uncertain whether we will continue to see the problem in patients with current repairs who are followed for longer periods of time. In any event, when discovered, it appears that the entire involved area must be removed and the tissue replaced, either with uninvolved flaps or grafts. Indeed in the present series several patients required buccal mucosal grafts. Based on the seriousness of the problem and the effect of the diagnosis on prognosis, biopsy is recommended in all questionable cases.

Dr. Barry A. Kogan
Chief and Professor of Urology and Pediatrics
Albany Medical College
Albany, New York, USA