Carbon dioxide laser treatment of balanitis xerotica obliterans

Balanitis xerotica obliterans (BXO) is a chronic and often painful condition of the glans penis. Its histology is similar to that of lichen sclerosus et atrophicus (LSA), and indeed, it probably does represent LSA of the glans. Many modalities have been used in the treatment of this condition but not always with success.

A patient came to our office with a histologic diagnosis of BXO that had been unresponsive to topical therapy. The involved area was treated with CO₂ laser vaporization and has remained free for 21 months after treatment.

CASE REPORT

A 39-year-old white man came to the surgical unit and laser treatment center of the Department of Dermatology of the University of Cincinnati Medical Center in September, 1981, with a biopsy-proved diagnosis of BXO of at least 2 years duration. The patient had experienced pain for some time before that and eventually had developed an inability to retract his foreskin, necessitating a circumcision that was performed in 199.

Following this procedure the patient was left with a raw, erosive, exquisitely painful glans penis. After 2 years of unsuccessful management, primarily with topical antibiotics and potent corticosteroids, he was referred for other treatment considerations.

Physical examination at the time of his initial visit revealed a superficial, hemorrhagic erosion of most of the surface of the glans penis (Fig. 1). The meatus and corona were free of involvement, and the remainder of the cutaneous examination was unremarkable.

The biopsy specimens were reviewed and coincided with the clinical diagnosis of BXO.

On September 30, 1981, with the patient under regional anesthesia, the involved area was vaporized through the handpiece of the articulating CO₂ laser, which was operating at 20 W of power output in the continous mode. The CO₂ laser spot size was 2 mm, and the power density delivered was approximately 600 W/cm2. This resulted in a dry, somewhat charred glans penis (Fig. 2) The entire affected area was vaporized to margins of apparently normal epithelialization. The wound was allowed to reepithelialize from these normal margins, with the thought that the resulting epithelium would remain uninvolved.

Once regional anesthesia was no longer effective, the patient experienced a syncopal episode and was hospitalized for observation. Application of topical lidocaine jelly relieved the symptoms, and the patient return to his home the next day. He was instructed to cleanse the area twice daily with hydrogen peroxide and to immediately apply an antibacterial ointment (Polysporin).

Occasional burning pain was still present to a minima degree until 3 weeks postoperatively. He has remained free of disease since that time, which is 21 months postoperatively (fig. 3).

DISCUSSION

Treatment of LSA may depend on its extent, location, symptoms, etc. Although not always successful, suggested modes of therapy have included topical or intralesional corticosteroids,¹ oral or topical estrogens,² topical antibiotics,² topical or intralesional androgens,³ cryosurgery,⁴ and, when the glans penis is involved, excision of the affected area.⁵ When more extensive involvement is present, meatotomy has been performed, but may believe that this procedure is rarely effective for any length of time.^6,7 Urethroplasty has been suggested as a possible treatment of choice,⁶ and a combination of circumcision, meatal dilatation, and meatoplasty has also been suggested.⁷

Most observers agree that the condition can be, and usually is, progressive and that symptoms can include difficulty with micturition, nonretractable foreskin, urinary retention, and pain and difficulty during intercourse.⁷ Our patient had not had intercourse since before his circumcision, 2 years before his initial visit to our unit.

Some reports indicate that development of leukoplakia can take place in LSA,⁴ and squamous cell carcinoma has been reported to occur in areas of involvement of BXO.^8,9 Radiation therapy might be a factor in the development of such tumors, however.^8,10

One report of CO₂ laser treatment is present in the urologic literature,¹¹ but the technique differed slightly from ours, and no mention was made of follow-up. The exact physics of CO₂ laser vaporization as employed here can be found in our earlier paper on treatment of port-wine stains.¹² Although the details of the treatment are the same, we are finding with time, that the power output for successful vaporization is probably much less than in much of our original work. Most CO₂ laser vaporization in our unit is now carried out at power outputs of between 5 and 10 W.

COMMENTS

It has been gratifying to us to be able to effect curative therapy for our patient after he had had several years of unsuccessful treatment. It is important to note that this patient never experienced any meatal edema or difficulty in micturition postoperatively. This can be attributed tto the mode of therapy and has been discussed in our earlier papers.^12-14 It is also important to note that he was restored to completely normal sexual function 3 months postoperatively, this after a hiatus of more than 2 years.

Although pain is generally not a factor following CO₂ laser surgery, it was quite prominent for a short time in this patient and must always be considered as a possible sequela.

We believe that CO₂ laser vaporization, as presented, represents an attractive alternative to conventional therapy for what is often a chronic, progressive, and difficult to treat entity. Its use may successfully obviate the need for more rigorous surgery at a later date and should be considered when other modes of therapy have failed.

From the Department of Dermatology,  University of Cincinnati Medical Center.

Reprint requests to: Dr. John Louis Ratz, Department of Dermatology,  Cleveland Clinic Foundation, 9500 Euclid Avenue., Cleveland, OH 44106.

The Circumcision Information and Resource Pages are a not-for-profit educational resource and library. IntactiWiki hosts this website but is not responsible for the content of this site. CIRP makes documents available without charge, for informational purposes only. The contents of this site are not intended to replace the professional medical or legal advice of a licensed practitioner.

  © CIRP.org 1996-2024 | Filetree | Please visit our sponsor and host:  IntactiWiki.