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Penis and scrotum
Inflammatory lesions
Lichen sclerosus (Balanitis xerotica obliterans)
Reviewers: Antonio Cubilla, M.D. and Alcides Chaux, M.D. (see Author/Reviewers page)
Revised: 15 May 2010, last major update February 2010
Copyright: (c) 2002-2010, PathologyOutlines.com, Inc.
Definition
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● Male equivalent of lichen sclerosus et atrophicus of vulva, a chronic and atrophic mucocutaneous condition
Terminology
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● Also called lichen sclerosus et atrophicus
● Balanitis: inflammation of glans, from Greek (“acorn”)
● Xerotica: unable to determine origin of term, but used by Stuhmer in 1928 (see also Arch Dermat Syph 1941;44: 547)
Epidemiology
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● Affects middle-aged men
● Also occurs in young boys (Ann R Coll Surg Engl 2007;89:62, J R Soc Med 2003;96:449)
Sites
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● More frequent in inner foreskin, but coronal sulcus, glans and even urethra may be affected
Etiology
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● May have autoimmune etiology
● No strong association with HPV (Genitourin Med 1995;71:228)
Clinical features
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● Most common cause of pathological phimosis in boys
● May also cause narrowing of urethral meatus and paraphimosis
● Associated with low grade keratinizing squamous cell carcinoma (non HPV variants-squamous cell NOS, pseudohyperplastic, verrucous, papillary, Am J Surg Pathol 2003; 27:1448) in glans and foreskin
● Usually not associated with basaloid or warty carcinoma
● Atypical lichen sclerosus shows epithelial dysplastic changes (low grade or high grade)
Prognostic factors
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● Recommendations for followup to rule out carcinoma include (a) biopsy all cases of possible BXO (J Urol 2007;178:2268), or (b) biopsy if long standing BXO or BXO not resolved after circumcision (BJU Int 2006;98:74)
Case reports
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● 13 year old boy with BXO, phimosis and obstructive renal disease (Pediatr Surg Int 2008;24:961)
Treatment
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● Circumcision, but may recur at scar
Clinical images
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Source: Wilford Hall Medical University of Alabama AFIP 10-80: perimeatal glans is
Center Slide collection. pearly white (Atlas of genito-
urinary tract disorders 1988)
Gross description (Macroscopy)
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● Gray-white irregular geographic foci of atrophy in inner foreskin, glans or perimeatal area
● Erosion, ulceration and raised pearly white areas can also be seen
● In advanced cases, inner preputial folds may disappear due to replacement of elastic fibers by fibrous tissue
Micro description (Histopathology)
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● Thinning or thickening of epidermis with orthokeratotic (i.e. anuclear as in normal epidermis) hyperkeratosis, lamina propria thickening and loss of structures due to edema, sclerosis or hyalinization
● Vacuolar degeneration of basal layer, diffuse fibrosis, deep lymphocytic infiltrate
● Usually spares corpus spongiosum of glans and foreskin dartos
● Atypical cases have epithelial changes of penile intraepithelial neoplasia (PeIN), usually differentiated
Micro images
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Orthokeratotic hyperkeratosis Hyalinized lamina propria
and epidermal atrophy
AFIP 10-80B: bandlike subepithelial zone AFIP 10-80C: lamina propria is edematous
of dense fibrosis spares the corpus to focally hyalinized
spongiosum
Contributed by Dr. Alcides Chaux and Dr. Antonio Cubilla:
ATYPICAL LICHEN SCLEROSUS: differentiated penile intraepithelial neoplasia associated with underlying lichen sclerosus (left bottom field).
Other images: hyperkeratosis of prepuce #1; #2
Additional references
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End of Penis and scrotum > Inflammatory Lesions > Lichen sclerosus (Balanitis xerotica obliterans)
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