The treatment of balanitis xerotica obliterans (BXO) with testosterone propionate ointment

Stühmer¹⁵ introduced the term balanitis xerotica obliterans (BXO) to describe an atrophic and sclerotic condition of the glans penis leading to stenosis and occasionally obliteration of the external meatal orifice. He considered that the disease invariably resulted from circumcision or dorsal slit for phimosis but many cases have since been described unconnected with preputial surgery. They have usually had an insidious onset, associated with a long prepuce and constricted preputial openining⁶ BXO is a rare disease, occurring in men between 20 and 45 years of age. It affects the glans penis, external meatus, sulcus, and occasionally the penile shaft. Diagnostic difficulty arises when the eruption is of restricted distribution. There is a mottled or parchment-like appearance with white or ivory areas scattered throughout apparently normal tissue. There may be a stricture of the external meatus and sclerotic changes obliterating the frenum. Early lesions (especially with a long prepuce) consist of multiple moist red areas on the glans with possibly linear erosions on the mucosal surface of the prepuce. Serious or haemorrhagic bullae, which may rupture to form erosions may occur around the urinary meatus. Adhesions between the glans and prepuce may occur. Pigmentation and telangiectasia may develop, giving an appearance resembling radiodermatitis.

Lichen sclerosus et atrophicus (LSA)⁵ is clinically similar, but lesions occur on other areas such as the back, neck, shoulders, forearms, or axillae^7,9. Lesions of the vulva are often called kraurosis vulvae.

Histopathologically, LSA shows hyperkeratosis with keratotic plugging of follicles, atrophy of the stratum malpighii with hydropic degeneration of the basal cells, atrophy and homogenization of the upper dermal collagen and an infiltrate in he mid-dermis⁷. Apart from the natural absence of hair follicles on the penis, BXO shows a similar picture.

Stühmer¹⁵ reported malignant change in BXO, since confirmed several times. Many clinicians consider that malignant change is unlikely in LSA, but Fitzpatrick⁴ put the incidence at 3% and Newbold¹¹ at 15-50% in BXO/LSA. This high figure may be due to the inclusion of many mucosal cases in which malignant change is believed to be more likely.

Treatment recommended has included meatal dilatation^2,13, fluorinated corticosteroid ointments¹², male sex hormones topically or by injection¹, cold saline compress followed by topical corticosteroids⁴ and intralesional hydrocortisone acetate¹⁶. Powerful corticosteroids locally may cause atrophy and telangiectasia^2,10,14. Atrophy in LSA may lead to malignancy⁴ and this seems a good reason for an alternative to corticosteroids topically.

Initial experience in using testosterone propionate in the treatment of BXO was obtained in cooperation with the late T. E. Anderson and A. McPhater during the Second World War when about 15 cases were treated. The introduction of corti-costeroids temporarily superceded this treatment but the initial rapid improvement obtained tended to be followed by deterioration. More seriously in one case meatal obliteration and ulceration due to squamous carcinoma developed.

In the present series, 4 patients were treated with 2.5% testosterone propionate in a water-miscible base, (Neo-Hombreol-Organon)⁸. Biopsy was refused in each case. The diagnosis BXO is used whenever there is urethral involvement; otherwise, the term LSA is used.

CASE REPORTS

Case 1. A 19-year-old waiter reported in 1971 with increasingly severe attacks of urinary retention. There was typical BXO of the glans penis, sulcus and external meatus (Fig. 1) with mild urethritis. Dorsal slit had been performed at age 12 following circumcision for congenital phimosis. No response to previous local therapy. No response to previous local therapy.

Testosterone ointment was applied twice daily. The skin improved markedly within 3 months, the urethritis cleared and micturition became normal. Postal follow-up for 2 years indicated that he had remained symptom freem.

Case 2. A 64-year-old, married chartered accountant was referred in 1971 because of suspected penile cancer of 9 months duration. There were typical (but itching) atrophic, white telangiectatic patches of LSA on the glans and sulcus but no meatal involvement.

Testosterone propionate ointment was applied twice daily. For the first four weeks only, hydrocortisone was also used locally to alleviate the itch. There was noticeable improvement after 3 months and skin lesions had disappeared after 2 years.

Case 3. A 23-year-old student of architecture was seen in 1972 because of painful erections and a rash of about 5 months duration on the glans penis. He was uncircumcised. There was two atrophic, whitish telangiectatic patches of LSA on the glans penis only. After a short period on hydrocortisone ointment to relieve irritation, testosterone ointment therapy was started. He then developed a recurrent non-specific urethritis requiring repeated courses of oral tetracycline. The painful erections lessened but the skin lesions were unchanged. He later developed diabetes mellitus, which was controlled by diet and chlorpropamide (Diabenese; Pfizer). The LSA improved rapidly although assessment was difficult because of his obsession with his penile lesions. Direct correlation between the LSA and his diabetes was doubtful.

Case 4. A 31-year-old married waiter came to the clinic in 1972 with acute gonorrhoea. On examination he was found to be uncircumcised and to have sclerosing condition around the urethral meatus (Fig. 2) causing stenosis and which was diagnosed as BXO. The condition had been present for 5 or 6 years and required occasional catheterization. Treatment with testosterone ointment afforded considerable improvement within 4 months and after one year the meatus looked normal.

DISCUSSION

Since BXO (synonym, kraurosis penis) and LSA are believed to represent the same disease process, the question arises as to which diagnosis to use when the genitalia are involved. Most of patients seen have had widespread involvement of the glans penis, coronal sulcus and external urethral meatus (Fig. 1). These should be called balanitis xerotical obliterans. The term lichen sclerosus et atrophicus should be retained for cases of genital involvement without urethral involvement. For the opposite situation, where the urethra exclusively is involved, it would be logical to use the term obliterative urethritis (Fig.2). It seems justifiable for the venerologist to retain these diagnostic distinctions because of the higher risk of malignancy with the genital and especially urethral involvement, though this may seem academic to the dermatologist.

The absence of biopsies in this series, whilst regrettable, was not diagnostically crucial. Nevertheless if ulceration was present, biopsy would be imperative to exclude malignant change. The response of BXO/LSA to testosterone propionate has ranged from good, to complete resolution. These results are better than could have been expected with other treatments. The urethra was dilated when necessary and hydrocortisone ointment was used in the early stages for rapid relief of irritation.

Since malignancy may supervene in BXO in relation to the degree of atrophy present, there is a theoretical advantage in avoiding strong topical corticosteroids, as they tend to produce atrophy. The excellent response to testosterone propionate ointment suggests that its use may reduce the tendency for malignancy to develop. Testosterone propionate ointment appears to be the treatment of choice.

ACKNOWLEDGEMENTS

The author thanks those colleagues from the V.D. clinics in Glasgow and beyond, who referred patients to him.

Received May 31, 1976

T. A. H. Pasieczny, M.D.
Department of Dermatology
Royal Infirmary
Glasgow G4 0SF
Scotland

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