Balanitis Xerotica Obliterans: Epidemiologic Distribution in an Equal Access Health Care System

Key Points

• Black and Hispanic patients have twice the risk of white patients for acquiring balanitis xerotica obliterans.
• All age groups were susceptible to developing balanitis xerotica obliterans, with the diagnosis at approximately 2 years and continuing well into the 90s.
• The incidence of balanitis xerotica obliterans was higher among men in their third decade of life.

Balanitis xerotica obliterans (BXO) was first described in the urologic literature in 1928 by Stühmer,¹ who reported it as a postcircumcision phenomenon. White, scaly papules generally involve the glans, prepuce, and urethral meatus, and may distort the penile architecture. Upon closer examination, white or brown horny, follicular plugs may be seen on the surface of these lesions, a feature referred to as delling.² Typically, patients present with painful erections, itching, difficulty in retracting the foreskin, and loss of glanular sensation.³ Voiding complaints may accompany meatal involvement.^3-6

This disease must be differentiated by skin biopsy from lichen planus, erythroplasia of Queyrat and leukoplakia, as all are grossly similar. Histologically, BXO is remarkable for hyperkeratosis, a thinned epithelium, and loss of the rete pegs. (In contrast, the other conditions will show hypertrophied rete pegs.) The most dramatic characteristic of BXO is a pale-staining subepidermal layer composed of homogenized collagen and edema (Fig. 1). In later stages the papillary dermis is infiltrated with lymphocytes and plasma cells. Balanitis xerotica obliterans is now commonly regarded as synonymous histologically and clinically with male genital lichen sclerosus et atrophicus.⁷

As rare as BXO is thought to be, it remains the most common cause of acquired urethral meatal stenosis in children and adults.^4,8 The epidemiologic breakdown, however, has yet to be reported. In our retrospective epidemiologic study of 108 patients with BXO, some interesting findings are worthy of note.

Methods

We performed a retrospective computer search of the militarys Standard Ambulatory Data Records for Brooke Army Medical Center at Fort Sam Houston, TX. The data were searched for patients first date seen on an outpatient basis for treatment of BXO during the fiscal years 1997 to 1999. Records with insufficient or questionable data on BXO were reviewed individually for clarification. Patients were classified by age and ethnicity (white, black, Hispanic, and other/ unknown), and the incidences were documented. A 95% largesample confidence interval was used for analysis of all data.

Results

Of a total eligible population of 153,432 male patients, 108 had BXO diagnosed for the first time at Brooke Army Medical Center from 1997 to 1999 (an incidence of 0.070% [7.04 ± 1.33/10,000 eligible patients]). The distribution by age and ethnic background is shown in Tables 1 and 2, respectively. Results showed a relatively even distribution of BXO throughout all age groups, with one exception: the age group 21 to 30 years showed a nearly double incidence of BXO. A comparison of BXO by ethnic background reflected virtually identical incidences between black and Hispanic patients (10.59 and 10.67/10,000), but these were double the incidence in white patients (5.07/10,000 eligible patients).

Table 1

Incidence of balanitis xerotica obliterans by age group

                  No. of  Eligible
Decade of life  patients  patients        Incidence (a)

 0-10                 12    19,154       6.27 ± 3.54
11-20                  8    24,767       3.23 ± 2.24
21-30                 18    13,127      13.71 ± 6.33
31-40                 11    16,318       6.74 ± 3.98
41-50                 14    22,757       6.15 ± 3.22
51-60                 13    20,195       6.44 ± 3.50
61-70                 19    20,811       9.13 ± 4.10
71-80                 11    12,679       8.68 ± 5.12
81-90                  2     3,624       5.52 ± 7.65

(a) Per 10,000 eligible patients.

Table 2

Ethnic distribution of patients with balanitis xerotica obliterans

                 No. of   Eligible
Race/ethnicity  patients  patients     Incidence (a)

White              55      108,472       5.07 ± 1.34
Black              22       20,765      10.59 ± 4.42
Hispanic           24       22,503      10.67 ± 4.26
Other/unknown       7        1,692      41.37 ± 30.58

(a) Per 10,000 eligible patients

Discussion

Our findings do not support those of previous studies, which have suggested that BXO is predominantly a disease of middle-aged white men. In fact, in both black and Hispanic patients we noted an incidence twice that in whites. In addition, we found the highest incidence in young adults (in the third decade [13.71 cases/10,000]), with a relatively even distribution among all other age groups (Table 1).

To suggest an explanation for these findings, it is necessary to review the etiology of BXO. Although one single cause has not been definitively named, the many suspected causes carry the common denominator of chronic inflammation. Autoimmune phenomena have long been implicated in the progression to BXO, and a strong association with class II antigens has strengthened this argument significantly. In a study of 84 white female patients, Marren et al⁹ showed a 78% concurrence with class II DQ human lymphocyte antigens in patients with lichen sclerosus et atrophicus. A history of trauma with resultant scarring and eventual progression to histologic BXO (ie, Köbners phenomenon) has been noted in other studies.^10,11 After hypospadias repair, BXO with urethral stricture has been reported in 0.4% (3 of 796 cases).¹² Various infectious agents, including human papilloma virus (serotype 16 in particular), spirochetes and atypical mycobacteria, have been implicated in the progression to BXO, though this remains unsubstantiated.

The epidemiology of BXO is likewise uncertain. Most studies concur that the common distribution lies between the third and sixth decades.^13,14 Others address a correlation between BXO and late circumcision for phimosis and hypospadias repair.^12,15-17 These reports conclude that although BXO is regarded as a disease of the middle-aged, its prevalence in young boys is both underestimated and understudied. Approximately 35% of our patients treated for BXO had a history of late circumcision, genital trauma, or surgery for urethral stricture. The higher incidence among those aged 21 to 30 may be related to the high numbers of patients in that age group in the military receiving regular physical screenings, in comparison with veterans and dependent children. Our findings suggest that all other age groups are equally susceptible, except the very young (0-2 yr).

In addition, most previous studies have focused on the white population, only three reports discussing lichen sclerosus in patients of other ethnic backgrounds.^18-20 We found no published analysis of the demographics of BXO by ethnicity with which to compare our findings. One possible explanation for the ethnic differences in our study may be the better access to medical care for minorities through the military health care system. A second explanation might be cultural: at-birth circumcision was introduced into the United States by the white population, in whom the practice maintains greater popularity than in other ethnic groups.²¹ Therefore, a higher percentage of phimosis and late circumcision among black and Hispanic men might not be surprising. A final explanation may be that BXO is more prevalent in regions with more temperate climates, as is penile cancer. Although BXO has not been putatively linked to squamous cell carcinoma, we believe that trends noted in our study could show BXO to be more prominent in tropical or subtropical regions. Further investigation of the comparative incidence in different regions and climates is warranted.

Conclusion

Our contemporary epidemiologic assessment of balanitis xerotica obliterans suggests that black and Hispanic patients have twice the risk of white patients of acquiring the disease. Second, BXO is a chronic inflammatory disease to which all age groups are equally susceptible, although it appears more frequently during the third decade. The range for diagnosis begins at approximately 2 years and continues well into the 80s and 90s. Finally, we recommend further research comparing the incidence of BXO in temperate and colder climates to assist in further identifying its cause.

From the Department of Urology,  Brooke Army Medical Center, Fort Sam Houston, TX.

Reprint requests to Allen F. Morey, MD, Urology Service, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234-6200. Email: allen.morey@cen.amedd.army.mi

Accepted May 24, 2002.

The views expressed in this article are those of the authors and do not reflect the official policy or position of the U.S. Army, the U.S. Department of Defense, or the U.S. Government.

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