King Abdulaziz University 17 June 2009 On 7 th June Saturday ER doctor called Patient is having penile ulcer perineal mass History 65 years old male Not known medically From around ID: 1048430
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1. CASE PRESENTATIONOmar BahassanKing Abdulaziz University17 June 2009
2. On 7th June SaturdayER doctor calledPatient is having penile ulcer + perineal mass
3. History65 years old maleNot known medicallyFrom around TaboukI had difficulty in understanding the patient way of talking
4. HistoryHe was complaining of:Perineal mass for the last 2 weeksThe mass started gradually with increase in size and no improvement . Making only some discomfort with no pain.No discharge , no itching , no history of trumaNo weight loss , no history of fever
5. HistoryHe was having a penile lesion for the last 2 yearsThis lesion started 2 years ago. Slowly progression.Started with two small white spots around the meatus.Then involved the glansAssociated with weak stream and no other irritative or obstructive symptomsHe is using a urethral metalic dilator at home once per month
6. HistoryHis wife was deadHe has children
7. ExaminationVital signs :T 37 HR 80 BP 130 / 80Abdominal examination was unremarkableNormal skin no palpaple lymph nodes
8. ExaminationLocal examination:Penis :By inspectionWas edematusWith white patches on the hall glans and at the underlying skin of the shaftA lot of erosions and fissuresSever meatal stenosisPenis is deviated to the left and to the abdominal wall
9. ExaminationPenis :Palpation:Very hard glansThere was hard multiple plapues in palpation of the penis shaft ( tunica albuginea )Dorsally and vertally There was pus coming from the left side of the shaft of the penis
10. ExaminationScrotum :normal
11. ExaminationPerineal area :Round mass 7 x 5 cmNo sking color changes , no pus Hard in palpationNot tender
12. ExaminationDRE :Hemorroids in coming out the anusProstate was small, firm, non tender with no masses
13. InvestegationsPatient brought :Ultrasound filmsLeft kidney moderate hydronephrosisRight kidney was normal with minimal fullnessBiopsy report from the penis lesion : Balanitis Xerotica Obliterans
14. InvestegationsCBC :WBC 10 HB 13Creatinine 162
15. DiagnosisBalanitis Xerotica ObliteransPeyronie’s diseasePerineal abscessUrethral diverticulum? TBWe asked for ascending urethrogram
16. Day afterGeneral surgery team put a needle insidePus and bloodPatient refuse further management.
17. Balanitis Xerotica Obliterans
18. DefinitionIt is a genital variation of Lichen sclerosus et atrophicus.Presents as a whitish patch.
19. Description and AppearanceWhitish patch on :The prepuceGlansMeatusFossa navicularisSkin of the penile shaft
20. May be multiple.May assume mosaic appearance.
21. Meatus may appear :WhiteInduratedEdematous
22. Glanular erosionsFissuresMeatal stenosis
23. PresentationMost common in uncircumcised men.Most common in middle aged men.It does occur in boys.Most common cause of pathological phimosis in boys
24. EtiologyUnknownInfection ( Borrelia burgdorferi )Autoimmuneinflammation
25. SymptomsPainPainful erectionsLocal penile discomfortPruritusUrinary obstruction
26. InvestigationsAscending urethrogramBiopsyWhen in doubt, biopsy of penile lesions should be considered to establish a diagnosis.
27. HistologyAtrophic epidermisLoss of the rete pegsHomogenization of collagen on the upper third of dermisZone of lymphocytic and histocytic infiltration
28. TreatmentTo prevent disease progression
29. TreatmentTopical steroid creamInjectable steroidsSurgical excisionAntibiotics ( erythromycin )CIC
30. Meatal stenosis is a common problemRequiring repeated dilatationsSteroid injectionEven formal meatoplastyMay cause obstructive renal imperment
31. IMPORTANTIt is a premalignant cutaneous lesion.In Bouchot et al, 42 % of patients with squamous cell cancer had a history of preexisting penile lesions.
32. There are reports documenting:Association with squamous cell carcinomaDevelopment of carcinoma long after a lesion has been treated
33. Premalignant cutaneous lesionsCutaneous hornBalanitis xerotica obliteransPseudoepitheliomatous micaceousKeratotic balanitisLeukoplakiaAll require treatment or close follow up
34. Pubmed search
35. High incidence of balanitis xerotica obliterans in boys with phimosis: prospective 10-year study.Kiss A, Király L, Kutasy B, Merksz M.Department of Urology, Heim Pál Children's Hospital, Budapest, Hungary. kiss.horvath@alexero.huThis prospective study was designed to address the incidence and clinical and histologic characteristics of balanitis xerotica obliterans in a large random pediatric population with phimosis. We investigated 1178 boys who presented consecutively with phimosis between 1991 and 2001. All patients who underwent complete circumcision and surgical specimens were typed histologically as early, intermediate, or late forms of this disorder or as nonspecific chronic inflammation. Patients with balanitis xerotica obliterans were controlled at 1, 6, and 12 months postoperatively, then yearly. Balanitis xerotica obliterans was found in 471 of the 1178 patients (40%), with the highest incidence in boys aged 9 to 11 years (76%). Secondary phimosis occurred in 93% of boys with balanitis xerotica obliterans and in 32% of those without the disorder. In six instances of balanitis xerotica obliterans, meatotomy and in one meatoplasty was performed, as well as circumcision. On histologic evaluation, we found 19% had early, 60% intermediate, and 21% late form of balanitis xerotica obliterans. Glanular lesions disappeared completely within 6 months in 229 out of 231 patients. Our data strongly suggest that the true incidence of childhood balanitis xerotica obliterans is higher than previously assumed. Its incidence peaks in the 9 to 11 years age group, in whom secondary phimosis was almost exclusively caused by balanitis xerotica obliterans.
36. Carbon dioxide laser treatment of balanitis xerotica obliterans.Ratz JL.A case of balanitis xerotica obliterans unresponsive to topical therapy is presented. The condition was successfully corrected following epithelial vaporization with the carbon dioxide laser, the patient remaining free of recurrence for 21 months postoperatively.
37. 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 02115, USA.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.
38. Detection of human papillomavirus types in balanitis xerotica obliterans and other penile conditions.Lau PW, Cook N, Andrews H, Bracka A, Myint SH.Department of Microbiology & Immunology, University of Leicester, UK.OBJECTIVES--To determine the prevalence of human papillomavirus (HPV) types 6, 11, 16 and 18 in foreskin biopsies from patients with balanitis xerotica obliterans (BXO) and other penile conditions. MATERIALS AND METHODS--Foreskin biopsy specimens from 24 patients with penile lesions and 5 control patients were analysed by type-specific polymerase chain reaction (PCR). RESULTS--HPV6 or HPV16 were not detected in patients with BXO. HPV6 was detected in 2 controls. CONCLUSIONS--Genital papillomaviruses do not have a strong association with BXO.
39. Two cases reports in monozygot twinsNeed further data
40. Thank You