Balanitis xerotica obliterans

Dr Keith Hopcroft continues his series of fascinating but often unrecognised conditions

The case

‘This thrush just won't go,' says a middle aged male patient as he plonks himself disconsolately in my consulting room chair. A glance at his notes reveal that this is the third time in the last six months or so that he's attended about itching and soreness of his penis, associated with white marks on the glans.

Standard antifungal creams have had no effect and the symptoms are deteriorating – the discomfort is worse when he has an erection, which, in turn, is starting to interfere with his sex life.

He is uncircumcised, has no skin trouble elsewhere and, apart from mild asthma – for which he takes occasional salbutamol – he is fit and well.

The diagnosis

This is not thrush, though it's understandable why the diagnosis was made in the first place – given the combination of itching and white plaques in the genital area. The temptation then, in the light of persisting symptoms, is to simply try an alternative anti-fungal cream, perhaps with a urinalysis to exclude underlying diabetes. But, in fact, the diagnosis is balanitis xerotica obliterans (BXO), sometimes also known as lichen sclerosus. The cause and prevalence figures are unknown, though it's generally agreed that the disease is probably under-reported.

Typical features

BXO may be asymptomatic. In its early stages it can cause irritation and soreness, typically in the uncircumcised middle-aged male. As the disease progresses, the foreskin becomes depigmented, thickened and adherent to the underlying penis, until erections may be very painful and a phimosis can develop. The underlying glans may be affected, too, with – in rare and severe cases – urethral stenosis.

Treatment

BXO may respond to potent topical steroids. Failing that, circumcision may be necessary.

Issues for the GP

Initial presentation may be indistinguishable from thrush. But the persistence and deterioration of the problem should alert the GP to some other problem. Awareness of the diagnosis and its typical features will enable the patient to receive the correct treatment and prevent further distressing management cul-de-sacs – such as referral to rule out sexually transmitted infection.

Dr Keith Hopcroft is a GP in Laindon, Essex

Be prepared to revise your – or someone else's – original diagnosis if the symptoms aren't responding, even in the context of an apparently minor problem.