Could a careful clinical examination distinguish physiologic phimosis from balanitis xerotica obliterans in children?

Abstract

The diagnosis of balanitis xerotica obliterans (BXO) in children may be challenging, since clinical examination only could lead to an underestimation of its incidence. The aim of this retrospective and single-centre study is to assess the diagnostic performance of clinical examination, together with clinical history, in identifying BXO. Ninety-seven children underwent circumcision for phimosis from 2015 to 2019. Histology was routinely performed. Cohen’s kappa coefficient, sensitivity, specificity, predictive values, likelihood ratios and accuracy of macroscopic appearance of the foreskin, steroid administration and past medical history were estimated. Forty-eight patients (50%) were affected by BXO; 31 of them (69%) presented with suggestive clinical signs. A strictured or whitish urethral meatus was detected during surgery in nine cases (19%); this was associated to allergic or immune diseases (p = 0.046). Foreskin appearance alone mildly correlated with histology (k = 0.494; p < 0.001) and it showed a diagnostic accuracy of 75%. The specificity and positive predictive value of abnormal macroscopic findings at examination, together with a positive clinical history for other allergic or immune diseases, and/or for balanitis, were 100% and the positive likelihood ratio was greater than 10. Conversely, sensitivity decreased to 4.5% (95% CI 0–11%).Conclusion: Foreskin appearance together with clinical history could predict BXO with certainty. However, since the absence of a positive medical history could not exclude the diagnosis, foreskin histology is still highly recommended. What is Known:• Occurrence of balanitis xerotica obliterans may be underestimated in children and it could lead to long-term complications.• The diagnostic accuracy of clinical examination is controversial. What is New:• Clinical signs together with patients’ medical history present high specificity and positive predictive values but low sensitivity.• When suggestive clinical aspects are present, patient should be referred to surgery avoiding prolonged conservative treatment; and preputial histology is highly recommended.

Comparison of lichen sclerosus in boys and girls: A systematic literature review of epidemiology, symptoms, genetic background, risk factors, treatment, and prognosis

“…A positive clinical history included the presence of autoimmune or allergic disease, having experienced at least one episode of balanitis or a lower urinary tract infection and the lack of improvement after steroids. Clinical examination alone led to an underestimation of LS in boys 42 …”

“…Usually based on clinical features 39 Usually based on histopathology 33,[40][41][42] Genetic background Turner syndrome with LS (prevalence 17.3%) 50 HLA-DQ 7 in 50-66% 45,[47][48][49] Unknown Risk Factors Atopic constitution, vitiligo, thyroid disease, localized scleroderma, alopecia areata and rheumatic diseases 11,12,53,54 Celiac disease (case report) 55 History of urinary tract symptoms/urinary incontinence 21,27 Atopic constitution 57 Obesity 58…”

“…In girls, clinical findings are paramount, and biopsies are generally not necessary. 39 In boys, histology is more often performed, but the correlation between the clinical and histopathological diagnosis varies, ranging from 53 to 88%, 33,[40][41][42] often due to lack of recognition of LS in boys. Ghidini 42 found that an abnormal foreskin appearance together with a positive clinical history has a positive predictive value of 100% in boys with LS.…”

“…39 In boys, histology is more often performed, but the correlation between the clinical and histopathological diagnosis varies, ranging from 53 to 88%, 33,[40][41][42] often due to lack of recognition of LS in boys. Ghidini 42 found that an abnormal foreskin appearance together with a positive clinical history has a positive predictive value of 100% in boys with LS. A positive clinical history included the presence of autoimmune or allergic disease, having experienced at least one episode of balanitis or a lower urinary tract infection and the lack of improvement after steroids.…”

Design and development of a new type of phimosis dilatation retractor for children

“…Now treatments for intervening children’s phimosis are all twofold, and timely selection of the right therapy method can significantly improve the prognosis of children phimosis. Traditional circumcision, though the most widely used, has many disadvantages, including bleeding and infection of incisions after the operation, pain, obvious scar on surgical incisions, unsatisfactory outlook, and so on[ 2 , 3 ]. For infant and toddler phimosis, there is great controversy surrounding selection and timing of treatments at home and abroad[ 4 ].…”