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Omar Bahassan King Abdulaziz University 17 June 2009.

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Presentation on theme: "Omar Bahassan King Abdulaziz University 17 June 2009."— Presentation transcript:

1 Omar Bahassan King Abdulaziz University 17 June 2009

2 On 7 th June Saturday ER doctor called Patient is having penile ulcer + perineal mass

3 History 65 years old male Not known medically From around Tabouk I had difficulty in understanding the patient way of talking

4 History He was complaining of: 1. Perineal mass for the last 2 weeks The mass started gradually with increase in size and no improvement. Making only some discomfort with no pain. No discharge, no itching, no history of truma No weight loss, no history of fever

5 History He was having a penile lesion for the last 2 years This lesion started 2 years ago. Slowly progression. Started with two small white spots around the meatus. Then involved the glans Associated with weak stream and no other irritative or obstructive symptoms He is using a urethral metalic dilator at home once per month

6 History His wife was dead He has children

7 Examination Vital signs : T 37 HR 80 BP 130 / 80 Abdominal examination was unremarkable Normal skin no palpaple lymph nodes

8 Examination Local examination: 1. Penis : By inspection Was edematus With white patches on the hall glans and at the underlying skin of the shaft A lot of erosions and fissures Sever meatal stenosis Penis is deviated to the left and to the abdominal wall

9 Examination Penis : Palpation: Very hard glans There 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 Examination Scrotum : normal

11 Examination Perineal area : Round mass 7 x 5 cm No sking color changes, no pus Hard in palpation Not tender

12 Examination DRE : Hemorroids in coming out the anus Prostate was small, firm, non tender with no masses

13 Investegations Patient brought : Ultrasound films Left kidney moderate hydronephrosis Right kidney was normal with minimal fullness Biopsy report from the penis lesion : Balanitis Xerotica Obliterans

14 Investegations CBC : WBC 10 HB 13 Creatinine 162

15 Diagnosis 1. Balanitis Xerotica Obliterans 2. Peyronie’s disease 3. Perineal abscess 4. Urethral diverticulum 5. ? TB We asked for ascending urethrogram

16 Day after General surgery team put a needle inside Pus and blood Patient refuse further management.

17

18 Definition It is a genital variation of Lichen sclerosus et atrophicus. Presents as a whitish patch.

19 Description and Appearance Whitish patch on : 1. The prepuce 2. Glans 3. Meatus 4. Fossa navicularis 5. Skin of the penile shaft

20 May be multiple. May assume mosaic appearance.

21 Meatus may appear : 1. White 2. Indurated 3. Edematous

22 Glanular erosions Fissures Meatal stenosis

23 Presentation Most common in uncircumcised men. Most common in middle aged men. It does occur in boys. Most common cause of pathological phimosis in boys

24 Etiology Unknown Infection ( Borrelia burgdorferi ) Autoimmune inflammation

25 Symptoms Pain Painful erections Local penile discomfort Pruritus Urinary obstruction

26 Investigations Ascending urethrogram Biopsy When in doubt, biopsy of penile lesions should be considered to establish a diagnosis.

27 Histology Atrophic epidermis Loss of the rete pegs Homogenization of collagen on the upper third of dermis Zone of lymphocytic and histocytic infiltration

28 Treatment To prevent disease progression

29 Treatment Topical steroid cream Injectable steroids Surgical excision Antibiotics ( erythromycin ) CIC

30 Meatal stenosis is a common problem 1. Requiring repeated dilatations 2. Steroid injection 3. Even formal meatoplasty May cause obstructive renal imperment

31 IMPORTANT It 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: 1. Association with squamous cell carcinoma 2. Development of carcinoma long after a lesion has been treated

33 Premalignant cutaneous lesions 1. Cutaneous horn 2. Balanitis xerotica obliterans 3. Pseudoepitheliomatous micaceous 4. Keratotic balanitis 5. Leukoplakia All 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. Kiss AKirály LKutasy BMerksz M Department of Urology, Heim Pál Children's Hospital, Budapest, Hungary. This 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 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. 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. Gargollo PCKozakewich HPBauer SBBorer JGPeters CARetik ABDiamond 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 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. Lau PWCook NAndrews HBracka AMyint 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 twins Need further data

40 Thank You


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