Post-operative steroids in boys with histologically proven balanitis xerotica obliterans reduce the need for subsequent meatal dilatation.

AIM: Post-circumcision topical steroids may reduce the number of patients with balanitis xerotica obliterans (BXO) who require subsequent meatal dilatation. However, their use has only been investigated in the presence of an abnormal urethral meatus. The aim of this study is to determine if post-operative topical steroids reduce the need for subsequent meatal dilatation in patients with histologically proven BXO independent of the appearance of the urethral meatus. To determine if post-operative topical steroids reduce the need for subsequent meatal procedures in patients with histologically proven BXO. To determine if the appearance of the meatus at circumcision affects the need for subsequent meatal procedure. METHODS: We performed a retrospective review of all paediatric patients with histologically confirmed BXO post circumcision. We excluded all those with 'chronic inflammation' or 'early BXO'. Patients were divided into groups based on whether post-operative topical steroids were prescribed. The appearance of the urethral meatus at circumcision was recorded. Primary outcome was progression to subsequent meatal dilatation. Statistical significance was calculated using Fisher's exact test. A P value < 0.05 was considered significant. RESULTS: One hundred and seventeen patients with histologically confirmed BXO were identified between October 2012 and December 2017. Fifty-nine patients were prescribed post-operative topical steroids (50%). Nine patients required subsequent meatal dilatation procedure (8%) and only one of these had been prescribed post-operative topical steroids (P = 0.0165). Abnormal meatus was noted in 24 (21%) patients. Three patients in this group required subsequent meatal dilatation compared with 6 in the group with a normal meatal appearance (P = 0.385). CONCLUSIONS: Post-operative topical steroids can reduce the need for subsequent meatal dilatation in boys with BXO. The appearance of the urethral meatus at circumcision does not predict the need for subsequent meatal dilatation.

Lichen Sclerosus and Phimosis - Discrepancies Between Clinical and Pathological Diagnosis and Its Consequences.

OBJECTIVE: To assess the accuracy of clinical diagnoses and the true incidence of lichen sclerosus (LS) in patients with phimosis. MATERIALS AND METHODS: The 92 adult male patients who were qualified for circumcision due to phimosis, were included in the study. The patients were diagnosed clinically by a urologist and dermatologist before the surgical procedure. After the circumcision, the resected foreskins were examined by 2 independent uropathologists. RESULTS: Preoperative clinical diagnosis of LS was established in 54 patients (58.7%); healthy-looking skin in 26 (28.3%) and other penile diseases in 12 (13.1%) patients. After histopathological examination, the diagnosis of LS was established in 62 patients (67.4%), but only in 44 patients with previous LS clinical diagnosis. LS was histopathologically confirmed in 18 other patients with clinically diagnosed healthy skin (n = 17) or lichen planus (n = 1). Healthy skin was histopathologically confirmed in 10 cases in patients diagnosed clinically before as LS. Other 15 histopathological diagnoses were Zoon balanitis (n = 3), nonspecific balanitis (n = 5), lichen planus (n = 1), psoriasis (n = 1), invasive penile cancer (n = 3), Bowen's disease (n = 1), penile intraepithelial neoplasia 2 usual type (n = 1). CONCLUSION: LS has been revealed as the most common histopathological diagnosis in patients undergoing circumcision in our study. Histopathological examination seems to be necessary to exclude this disease.

Balanitis Xerotica Obliterans Associated With Differentiated Penile Intraepithelial Neoplasia and "Bramble-Bush" Elastic Fibers Accumulation: A Finding Not Specific for Penicillamine Intake.

We describe the association of balanitis xerotica obliterans and differentiated penile intraepithelial neoplasia (PeIN) with dermal elastosis and "bramble-bush" elastic fibers in a diabetic patient with no history of penicillamine intake. An 84-year-old man presented with urethral obstruction syndrome that required postectomy, meatotomy, and foreskin excision. Histopathological examination revealed changes of lichen sclerosus and differentiated PeIN. Orcein staining showed striking dermal elastosis and transepidermal elimination of elastic fibers. At higher magnification, multiple serrations and buds arising from the borders of the elastic fibers were observed giving the so-called bramble-bush appearance. Balanitis xerotica obliterans is considered a premalignant disease, and 14% of patients have evidence of PeIN. The differentiated subtype can be difficult to diagnose because of the minimal basal cell atypia, so a striking dermal elastosis, which may even occur before the neoplasm becomes invasive, may facilitate its diagnosis. The term "acquired perforating dermatosis" seems appropriate to describe those cases of perforating elastosis that occurs in adults with systemic diseases. The bramble-bush appearance of elastic fibers is not specific for penicillamine-induced elastopathy, and it may occur in other diseases, such as diabetes mellitus. This peculiar morphology of elastic fibers may be related to the enzymatic imbalance between matrix metalloproteinases and lysyl oxidase, an enzyme required for the cross-linking of elastic fibers.

Treatment of balanitis xerotica obliterans in pediatric patients. / Tratamiento de la balanitis xerótica obliterante en pacientes pediátricos.

OBJECTIVES: Balanitis xerotica obliterans (BXO) is a chronic inflammatory disease with a little known incidence in pediatric population. The objective of this work was to describe our experience in the treatment of BXO. MATERIALS AND METHODS: Retrospective study carried out in 419 patients undergoing circumcision surgery between January 2014 and January 2017. Demographic, clinical, therapeutic, and anatomical and pathological variables, as well as complications during follow-up, were analyzed. RESULTS: Of the 419 patients, 41 (9.78%) were diagnosed with BXO. 6 patients were excluded owing to lack of follow-up, so 35 patients were analyzed. Mean age at diagnosis was 8.6 years. Suspicion diagnosis was clinical at physical exploration in 17 patients (48.6%), and at surgery in 18 patients (51.4%). Anatomical and pathological confirmation was performed in a total 35 patients (100%). During follow-up, 6 patients (17.14%) had lesions in the glans, 3 (8.57%) in the urethra, and 9 (25.71%) in both. 6 meatotomies (17.14%) and 5 new circumcisions (14.28%) had to be carried out. Mean recurrence time was 32.43 months. In 19 patients (54.28%), topical corticoids - ointment - were applied, and 1 patient (2.85%) received topical immunosuppressants. CONCLUSIONS: A close follow-up of patients with clinical or anatomical and pathological diagnosis of BXO is required given its high morbidity. The complications described in pediatric population include meatal and urethral stenosis, as well as recurrent phimosis, unless a sufficient amount of foreskin is resected.

OBJETIVOS: La balanitis xerótica obliterante (BXO) es una enfermedad crónica inflamatoria de incidencia poco conocida en la población pediátrica. El objetivo de este trabajo es describir nuestra experiencia en el tratamiento de las BXO. MATERIAL Y METODOS: Estudio retrospectivo de 419 pacientes intervenidos de circuncisión en el periodo comprendido entre enero de 2014 y enero de 2017. Analizamos variables demográficas, clínicas, anatomopatológicas, terapéuticas y complicaciones durante el seguimiento. RESULTADOS: De los 419 pacientes, 41 fueron diagnosticados de BXO (9,78%). Seis pacientes fueron excluidos por falta de seguimiento, por lo que se analizaron 35 pacientes. La media de edad al diagnóstico fue de 8,6 años. El diagnóstico de sospecha fue clínico durante la exploración física en 17 pacientes (48,6%) y durante la intervención en 18 (51,4%), realizando la confirmación anatomopatológica en un total de 35 pacientes (100%). Durante el seguimiento 6 pacientes (17,14%) presentaron lesiones en glande, 3 (8,57%) en uretra y 9 (25,71%) en ambas localizaciones, siendo necesaria la realización de 6 meatotomías (17,14%) y de nueva circuncisión en 5 (14,28%). El tiempo medio de recidiva fue de 32,43 meses. En 19 pacientes (54,28%) se aplicaron corticoides tópicos en pomada y en 1 paciente inmunosupresores tópicos (2,85%). CONCLUSIONES: Es necesario un seguimiento estrecho de los pacientes con diagnóstico clínico o anatomopatológico de BXO dada su elevada morbilidad. Las principales complicaciones descritas en la población pediátrica son la estenosis meatal y uretral, así como la recidiva de la fimosis si no se reseca el prepucio suficientemente.

Topographical Evaluation of Penile Lichen Sclerosus Reveals a Lymphocytic Depleted Variant, Preferentially Associated With Neoplasia: A Report of 200 Cases.

Since the seminal study of Hart and Helwig in 1975, there are few detailed pathological studies of lichen sclerosus (LS). The aims of this study were to provide a detailed histopathological description of penile LS, as well as to explore its relationship with penile intraepithelial neoplasia (PeIN) or invasive carcinoma. We evaluated 200 patients and designed a topographical approach for the histological evaluation focusing in alterations of the following anatomical layers: squamous epithelium, lamina propria, dartos, and corpus spongiosum. We documented the quantity and topographical location of stromal lymphocytes. The prevalent lesions found were epithelial hyperplasia, atrophy, PeIN, basal cell vacuolization, lamina propria sclerosis, and variable patterns of lymphocytic infiltration. Various unique patterns of stromal sclerosis were described: perivascular, globular, linear, and solid fibrosis/hyalinization; any of them were found to be diagnostic for LS. The variation in the topography and density of lymphocytes was determinant for the identification of LS morphological variants: lichenoid, band-like, lymphocytic depleted, and mixed. A major finding was the identification of the variant designated as lymphocytic depleted LS, which we considered as the morphological prototype of LS associated with penile neoplasia. The detailed description of this complex lesion presented in this study may help pathologists in practice to identify and better define LS. The identification of the special variants suggests a role of the stromal lymphocytes in the process of carcinogenesis. Confirmation of the observations with more studies is necessary to determine the significance of these findings.

10 Years' Experience in Balanitis Xerotica Obliterans: A Single-Institution Study.

INTRODUCTION: Balanitis xerotica obliterans (BXO) is uncommon in children. Diagnosis of the condition is almost always clinical and supported by histology. Our aim was to evaluate the outcomes of children undergoing circumcision for BXO and explore the correlation between surgical and histological findings. MATERIALS AND METHODS: A 10-year retrospective review (2007-2017) of all children, aged 16 and less, undergoing circumcision at a tertiary teaching hospital was conducted. Statistical analysis was performed using Fisher's exact test. RESULTS: BXO occurred in 91/1025 (8.9%) children. The highest incidence of BXO was in the 5 to 10 age group (13.3%; p < 0.0001). The commonest symptom was foreskin scarring (62.6%). Intraoperatively, involvement of foreskin alone was seen in 26.4%, foreskin and meatus in 47.2%, and foreskin, meatus, and glans in 26.4%. Preoperatively, 24.2% of patients were prescribed steroid cream. Histologically, all patients showed microscopic changes confirming BXO. A total of 87.9% of patients only had a circumcision, and 11% required a meatal procedure along with the circumcision. Postoperatively, 19.8% of patients required a further procedure after an average duration of 5.8 months (range: 2-12 months); the majority of whom (83.3%) were prescribed postoperative steroid cream. CONCLUSION: Clinical correlation by surgeons has a high degree of accuracy (>90%). Meatal involvement is more common than previously reported. The use of pre- or postoperative steroids does not obviate the need for further surgical procedures. Patients can have recurrent symptoms 1 year following surgery, and prolonged follow-up is necessary.

The diagnosis and management of male genital lichen sclerosus: a retrospective review of 301 patients.

INTRODUCTION: Male genital lichen sclerosus (MGLSc) is an acquired, chronic, inflammatory skin disease that is associated with significant morbidity and squamous cell carcinoma of the penis (PSCC). However, some clinical, diagnostic and management controversies endure, including the relationship with penile intraepithelial neoplasia (PeIN). OBJECTIVES: To clarify clinical presentations, diagnostic approaches, histological findings, response to treatment and the relationship with PeIN. METHODS: Retrospective review of patients with a diagnosis of MGLSc who attended a specialist male genital dermatoses clinic. RESULTS: 301 patients were identified: 260 had isolated MGLSc and 41 both MGLSc and PeIN. Referrals were made from the local Urology and Andrology departments (128), primary care (89), GUM (54), other dermatology departments (28) and other specialties (2). In isolated MGLSc, 94.6% were diagnosed clinically with 93.5% accuracy (based on data from subsequent circumcisions). In combined MGLSc/PeIN, 85.4% were diagnosed following diagnostic biopsy and 14.6% retrospectively after circumcision. In isolated MGLSc, 50% were treated topically, and 50% required surgery. In MGLSc/PeIN, 78% required surgical interventions. In isolated MGLSc, 92.2% achieved resolution of symptoms, 3.5% were awaiting procedures, and 4.8% were receiving ongoing topical therapy. In MGLSc/PeIN, 90.2% achieved clearance, 2.4% were waiting surgery, and 7.3% were treated topically. Only 2.7% reported ongoing symptoms, all in patients treated surgically. None progressed to PSCC. DISCUSSION: MGLSc is generally a disease of the uncircumcised; the majority of cases of MGLSc are accurately diagnosed clinically; suspected PeIN or PSCC requires histological confirmation; circumcision histology can be non-specific; most men are either cured by topical treatment with ultrapotent corticosteroid (53.1%) or by circumcision (46.9%); surgical intervention is required in most cases of concomitant MGLSc and PeIN; the majority of patients with MGLSc alone or with MGLSc and PeIN remit with this approach; effective management appears to negate the risk of malignant transformation to PSCC.

Correlación clínica e inmunohistoquímica de la balanitis xerotica obliterans / Clinical and immunohistochemical correlation of balanitis xerotica obliterans

Objetivo. La balanitis xerotica obliterans (BXO) es una enfermedad de etiología incierta, que afecta a piel y mucosa de genitales masculinos de cualquier edad. La incidencia en niños es baja (9-19%) y en adultos se considera una lesión premaligna. El objetivo de este estudio es establecer la incidencia de BXO en nuestro centro y determinar la correlación entre las características clínicas y los hallazgos inmunohistoquímicos (IHQ). Métodos. Cohorte prospectiva de niños ≤14 años con fimosis circuncidados entre 2014-2016. Análisis estadístico de las características clínicas e histológicas e IHQ para valorar la respuesta inflamatoria, presencia de lesiones premalignas y asociaciones microbiológicas. Resultados. Se incluyeron 176 pacientes circuncidados con una edad media de 7 ± 3 años (rango 2-14 años). La sospecha clínica de BXO, 28,4% (n= 50), se confirmó mediante anatomía patológica en 29,5% (n= 52) con muy buena fuerza de concordancia interobservador (κ= 0,81: p<0,01). El 63,5% (n= 33/52) recibieron corticoterapia como tratamiento inicial. El 7,69% (4/52) presentaron estenosis meatal requiriendo dilataciones meatales/uretrales. Los casos de BXO presentaron una respuesta mediada por linfocitos-T: CD3+ (p< 0,01). Conclusiones. BXO es una enfermedad inflamatoria crónica mediada por linfocitos-T con una incidencia mayor a la reportada. La concordancia interobservador entre la sospecha de BXO y la confirmación histológica es muy buena. La elevación de p53 en los pacientes con BXO indica un posible potencial maligno que requiere tratamiento quirúrgico (circuncisión) y un seguimiento adecuado (AU)

Aim. Balanitis xerotica obliterans (BXO) is a disease of the skin and mucosa of male genitals of unknown etiology that may affect children of any age. It has a low incidence (9-19%) and in adults is considered a potential premalignant lesion. The aim of our study is to establish the incidence of BXO in our center and to determine its correlation between the clinical and immunohistochemical (IHC) findings. Methods. Prospective cohort including all children < 14 years with foreskin pathology that required a circumcision between 2014-2016. Statistical analysis of the clinical characteristics, histological and IHC findings searching for inflammatory response, premalignant lesions and microbiological findings. Results. A total of 176 boys with phimosis had circumcision with a mean age of 7 ± 3 years (Range 2-14). Presurgical diagnosis of BXO was suspected in 28.4% (n= 50) whereas the AP confirmed a total of 29.5% (n= 53) with a very good interobserver concordance (κ= 0.81: p < 0.01). Previous treatment with corticoids in BXO was found in 63.5% (n= 33/52). Meatal stenosis was found in 7.69% (n= 4/52) requiring meatal/urethral dilations. Patients with BXO had a T-Lymphocytes CD3+ mediated inflammatory response with a positive correlation between tumor suppressing protein (p53) expression and chronic inflammation. Conclusions. BXO is a chronic inflammatory disease mediated by T-lymphocytes with an incidence greater than previously reported. Surgeons' criterion has a very good concordance with the AP findings. The elevation of p53 in children with BXO may indicate a plausible malignant potential that may require a surgical treatment (circumcision) and an adequate follow-up (AU)

Lichen sclerosis: clinicopathological study of 60 cases from Lebanon.

BACKGROUND: Lichen sclerosus (LS) is an uncommon idiopathic chronic inflammatory debilitating disease with predilection for the genital region. Our recent encounter with an LS case exhibiting perineural inflammation microscopically prompted us to assess the features of all patients diagnosed with LS at our institution. MATERIALS AND METHODS: All cases of LS diagnosed between 1990 and 2014 were retrospectively reviewed. Diagnosis was confirmed with demonstration of microscopic features typical of LS. RESULTS: Sixty patients (42 women and 18 men) with 65 biopsy specimens of LS were identified, of which 41 were extragenital, 16 genital, and three had both. Histopathologically, significantly higher proportions of follicular plugging, atrophy, and vacuolar interface changes were observed in extragenital LS cases, while angiokeratoma-like, mycosis fungoides-like, and pseudoepitheliomatous changes were only seen in genital LS. Perineural inflammation was observed as a novel finding in 22 cases (33.8%) of LS. CONCLUSION: Features of patients with LS in this study are generally comparable to those published in the literature, with some differences. In contrast to the literature, extragenital LS was more frequently encountered. Histopathologically, perineural inflammation was not an uncommon feature of LS and thus may serve as a clue in the differentiation of LS from its mimickers.

Balanitis xerotica obliterans in children and adolescents: a literature review and clinical series.

OBJECTIVE: Balanitis xerotica obliterans (BXO) is a chronic inflammatory disease that is considered as male genital variant lichen sclerosis. The incidence varies greatly in different series; diagnosis is mostly clinical but histopathological confirmation is mandatory. Various treatments are described, but there is no consensus that one is the best. MATERIALS AND METHODS: A literature review was made of BXO and lichen sclerosis in boys under 18 years of age, between 1995 and 2013, analyzing demographic dates, treatments and outcomes. In addition to that, we reviewed BXO cases treated in our centers in the last 10 years. RESULTS: After literature review, only 13 articles matched the inclusion criteria. Analyzing those selected, the global incidence of BXO is nearly 35% among circumcised children. Described symptoms are diverse and the low index of clinical suspicion is highlighted. The main treatment is circumcision, with use of topical and intralesional steroids and immunosuppressive agents. CONCLUSION: BXO is a condition more common than we believe and we must be vigilant to find greater number of diagnoses to avoid future complications. The main treatment for BXO is circumcision, but as topical or intralesional treatments are now available with potentially good outcomes, they may be considered as coadjuvants.

Histopathological examination of the prepuce after circumcision: Is it a waste of resources?

BACKGROUND: The aim of this article is to evaluate the histopathological findings of foreskin after circumcision for medical indications and to find out if analyzing the biopsy is a waste of resources. MATERIAL AND METHODS: This retrospective analysis was carried out of the medical records and histopathological findings of 112 boys who underwent circumcision from June 2002 to June 2005. The study group consisted of 52 boys that were circumcised for medical indications, while the control group consisted of 60 boys who underwent circumcision for religious belief. RESULTS: The mean (range) age of children in the study group was six (2-12) years. 36 boys had phimosis, 15 had recurrent balanoposthitis and one had paraphimosis as an indication for circumcision. Balanitis xerotica obliterans (BXO) was diagnosed in eight out of 52 biopsies (15%). In five of the eight BXO, the histopathological examination revealed focal lichenoid infiltrate which was considered as early form of BXO. There was no suspicion of BXO in the physical examination of those five patients. Chronic inflammation was reported in seven patients, while minor changes in the form of minimal inflammation and oedema were found in another 15 patients. The rest of the biopsies (22 patients) showed normal preputial pathology. The histopathological examinations of the control group revealed chronic inflammation in three patients and acute inflammation with cellular oedema in another three patients. CONCLUSIONS: There is a place for routine biopsy after circumcision for medical indications. The clinical examination failed to suspect 5 of the 8 cases of BXO that were diagnosed by histopathology.

Genital lichen sclerosus/balanitis xerotica obliterans in men with penile carcinoma: a critical analysis.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The European Association of Urology guidelines identify lichen sclerosus (LS) as a strong risk factor for penile squamous cell carcinoma (pSCC). However, this statement is based on the findings of case-control studies (Level of Evidence 2a) and a direct causal relationship between LS/balanitis xerotica obliterans (BXO) and pSCC remains to be established. Firm guidelines with respect to the appropriate follow-up policy for LS/BXO are lacking, whereas the impact of synchronous LS/BXO on the prognosis of pSCC remains to be determined. The presence of histologically-confirmed synchronous LS/BXO in patients diagnosed with pSCC is relatively high, although it is not associated with an increased risk of adverse histopathological features. LS/BXO can develop in extragenital skin grafts used for reconstruction after organ-sparing surgery for pSCC. OBJECTIVES: To determine the rate of lichen sclerosus/balanitis xerotica obliterans (LS/BXO) in patients with penile squamous cell carcinoma (pSCC) and establish whether the presence of LS/BXO is associated with adverse histopathological features of pSCC. To report the phenomenon of LS involving non-genital skin grafts in patients who underwent organ-sparing surgery and split-skin graft (SSG) reconstruction PATIENTS AND METHODS: Between January 2002 and January 2010, 223 men underwent surgical treatment for pSCC. A group of 52 patients with histologically-confirmed synchronous LS was identified (group A; overall rate of LS/BXO = 23.3%) and compared with a group of patients without synchronous LS (group B; n = 171; 76.7%). A subgroup of patients who underwent surgical excision and SSG reconstruction was also identified The histology reports of graft biopsies obtained during follow-up were reviewed and the rate of LS involving the graft was also recorded. RESULTS: Mean (range) age at diagnosis was 60.9 (34-81) years and 60.7 (28-89) years for groups A and B, respectively (P = 0.958). The mean (range) duration of follow-up was 38.3 (4-92) months for group A and 45.5 (4-107) months for group B (P = 0.162) No statistically significant differences were noted between groups A and B in terms of tumour grade (P = 0.091), stage (P = 0.697), presence of lymphovascular invasion (P = 0.333), histological subtype (P = 0.107), associated carcinoma in situ (P = 0.246) or nodal status at initial diagnosis (P = 0.555). In the subgroup of 188 patients who underwent SSG reconstruction, 41 (21.8%) patients had histologically-confirmed synchronous LS; in this subgroup, 26 (13.8%) patients underwent graft biopsy during follow-up. Genital LS involving the graft was identified in seven specimens, although none of these seven cases had associated recurrent pSCC. CONCLUSIONS: The presence of histologically-confirmed synchronous LS in patients with pSCC is relatively high but is not associated with increased rates of adverse histopathological features, including carcinoma in situ. LS can develop in extragenital skin grafts, although its association with the long-term risk for recurrent pSCC is not apparent in the present study.

Diagnosis and treatment of lichen sclerosus: an update.

Lichen sclerosus (LS) is a chronic, inflammatory, mucocutaneous disorder of genital and extragenital skin. LS is a debilitating disease, causing itch, pain, dysuria and restriction of micturition, dyspareunia, and significant sexual dysfunction in women and men. Many findings obtained in recent years point more and more towards an autoimmune-induced disease in genetically predisposed patients and further away from an important impact of hormonal factors. Preceding infections may play a provocative part. The role for Borrelia is still controversial. Trauma and an occlusive moist environment may act as precipitating factors. Potent and ultrapotent topical corticosteroids still head the therapeutic armamentarium. Topical calcineurin inhibitors are discussed as alternatives in the treatment of LS in patients who have failed therapy with ultrapotent corticosteroids, or who have a contraindication for the use of corticosteroids. Topical and systemic retinoids may be useful in selected cases. Phototherapy for extragenital LS and photodynamic therapy for genital LS may be therapeutic options in rare cases refractory to the already mentioned treatment. Surgery is restricted to scarring processes leading to functional impairment. In men, circumcision is effective in the majority of cases, but recurrences are well described. Anogenital LS is associated with an increased risk for squamous cell carcinoma of the vulva or penis. This review updates the epidemiology, clinical presentation, histopathology, pathogenesis, and management of LS of the female and male genitals and extragenital LS in adults and children.

Paediatric balanitis xerotica obliterans: an 8-year experience.

OBJECTIVE: Balanitis Xerotica Obliterans (BXO) is rarely described in the paediatric population. We report our 8-year experience, at Harold Wood Hospital, with BXO in circumcised boys. MATERIALS AND METHODS: Pathological tissue diagnoses of BXO from 1997 to 2005 were extracted from our histopathology database. Patient records were reviewed and demographic features, clinical presentation, referral history, operative procedure(s) and postoperative course were recorded. RESULTS: A total of 40 patients had a confirmed tissue diagnosis of BXO. Mean patient age was 9.6 years. The most common referral diagnoses were phimosis (70%), balanitis (25%) and only 2 patients (5%) had a referral diagnosis of BXO. 35 (87%) underwent curative circumcision and had no recurrence at a median follow-up of 13.5 months. A total of 5 patients (15%) had BXO involvement of the meatus and underwent circumcision combined with meatotomy or meatoplasty. No patients required extensive plastic operations of the penis. CONCLUSIONS: The incidence of BXO in paediatric age group may be higher than previously reported. Early recognition of this condition is important because of the associated urethral stricture formation. Hence, we recommend that all circumcision specimens are sent for histopathological analysis (especially in areas where circumcision is widely practiced for ritual and religious reason) and patients should be followed up appropriately.

Management of boys with abnormal appearance of meatus at circumcision for balanitis xerotica obliterans.

INTRODUCTION: The aim of this study was to develop a standardised management plan for boys with abnormal appearance of meatus at circumcision for balanitis xerotica obliterans (BXO). METHODS: Between 1995 and 2008, 107 boys underwent circumcision for BXO (confirmed on histology). Of these, 23 had abnormal appearance of the meatus at operation; their case notes were reviewed for age, presenting symptoms, management, outcome and follow up. RESULTS: The age range at operation was 3-15 years (mean: 9 years). Patients commonly presented with phimosis and balanitis. Seven patients had an additional procedure at circumcision: six had meatotomy, one had meatal dilatation. Thirteen were treated with topical steroid cream post-operatively. Eight of these (62%) subsequently required meatotomy. Three patients were observed and did not require further intervention. Meatotomy was required in 9 patients, 6-29 months after circumcision (mean: 11 months). Two patients required dilatation, including one with a previous intraoperative meatotomy, who required multiple dilatations. CONCLUSIONS: We propose the following standardised management plan: 1. With clinical evidence of BXO at circumcision, prepuce should be sent for histology. 2. If BXO is confirmed but the meatus appears normal, patients should be seen once post-operatively to give information about meatal stenosis. 3. When the meatus appears scarred with a narrowed lumen at operation, a meatotomy should be performed, with follow up for at least two years. 4. If the lumen is scarred but adequate, patients should be followed up in clinic for the same period for possible development of stenosis. 5. Topical steroid cream can be considered for voiding discomfort without decreased urine stream.

The surgical management of lichen sclerosus of the glans penis: our experience and review of the literature.

INTRODUCTION: Lichen sclerosus (LS) of the glans penis is a chronic, progressive, scleroatrophic inflammatory process of unknown etiology affecting the glans penis, prepuce, and urethra and may lead to severe impairment of sexual and urinary function. AIMS: To report our experience of surgical management of LS of the glans penis. MAIN OUTCOME MEASURES: Complications, patients' satisfaction, cosmesis, resolution of pain and puritus, and postoperative sexual function and were recorded retrospectively. METHODS: The surgical outcome of the 31 patients who have undergone resurfacing of the glans penis with the use of skin grafting for the management of genital LS in our institute is reported. RESULTS: After a median follow-up of 12.8 months, 26 patients (84%) were fully satisfied with cosmetic and functional results, and 71% of them have resumed sexual activity. CONCLUSIONS: Resurfacing of the glans penis represents a simple and reproducible technique for the management of LS and yields excellent functional and cosmetic results.

Routine biopsies in pediatric circumcision: (non) sense?

OBJECTIVE: At our institute we usually send the foreskin after circumcision for pathological examination. Does this make sense or is it merely medical overconsumption? MATERIAL AND METHODS: A retrospective analysis was carried out of all pediatric patients who underwent a circumcision, from August 2005 to January 2008, for persisting pathological phimosis after treatment with topical steroids. Religious circumcisions were excluded. RESULTS: Balanitis xerotica obliterans (BXO) was diagnosed in 37 out of 135 biopsies (27%). In 19 of the 37 boys with pathological evidence of BXO (51%), the physical examination matched the pathology. Meatal stenosis was found in six cases; four were also diagnosed with BXO. CONCLUSIONS: In this study, 27% of all biopsies were positive for BXO. The results show that the diagnosis BXO must be based on biopsy, because clinical findings underestimated the incidence of BXO by almost 50%. BXO implies a higher incidence of meatal stenosis, urethral pathology and has a known association with penile carcinoma. We conclude that there is a place for routine biopsy of the foreskin after circumcision for pathological phimosis, taking into account the potential clinical consequences when BXO is diagnosed.