Balanitis xerotica obliterans: has its diagnostic accuracy improved with time?

Abstract

Objectives: We observed whether general practitioners are referring more appropriately for balanitis xerotica obliterans in regards to circumcision, especially at a time of clinical concern, and whether their discriminative abilities were affected by age. We also aimed to explore if balanitis xerotica obliterans was over-diagnosed by surgeons potentially leading to unnecessary circumcisions of healthy foreskins.

Design: Cross-sectional descriptive study.

Setting: Leicester Royal Infirmary.

Participants: All children less than 16 years of age were included and were subsequently split into two categories: those less than or equal to five years and those above five years. Circumcision was justified if surgeon found pathology under foreskin commissioning guidelines set by the Royal College of Surgeons of England. After clinical diagnosis of balanitis xerotica obliterans, the pathological database was searched for histological confirmation.

Main outcome measures: Has diagnostic accuracy improved amongst general practitioners for balanitis xerotica obliterans and is there a high clinical to histological confirmation.

Results: Of the total patients, 14.5% were diagnosed clinically with balanitis xerotica obliterans. Only 66.7% of cases were histologically confirmed with chronic inflammation found in the rest; 5.5% of all boys referred had balanitis xerotica obliterans on histology; and 8.2% of children <5 had clinical balanitis xerotica obliterans with 1.7% confirmed histologically. This was in contrast with 18.1% and 9.2% found in the older cohort.

Conclusion: There remains a high diagnostic inaccuracy amongst general practitioners when referring for balanitis xerotica obliterans. This is greatest in those under five years. Although balanitis xerotica obliterans was over-diagnosed, no healthy foreskin underwent unnecessary circumcision.

Keywords: general practice; medical education; paediatrics; surgery.

Figure 1.

Age distribution of those with balanitis xerotica obliterans, chronic inflammation, other forms of pathological phimosis and pain on arousal.

Figure 2.

Incidence of preputial pathology in those referred for pathological phimosis. Distributed by age. *Seven patients referred appropriately but for specialist diagnosis not matching initial referral reason: 3 – preputial adhesions, 3 – pain on arousal and 1 – tight phimotic band.