Increased incidence of balanitis xerotica obliterans in the obese pediatric male
Molly E. Fuchs, MD, Daryl J. McLeod, MD, Daniel G. Dajusta, MD.
Nationwide Children's Hospital, Columbus, OH, USA.
Balanitis xerotica obliterans (BXO) is a condition of hyperkeratosis and hyperplasia of the squamous mucosa and homogenous collagen deposition in the dermis that affects penile skin. While the exact etiology is unclear, BXO is more common in some conditions such as hypospadias and secondary phimosis. The reported rates of BXO in children ranges from 9 - 40%. In the adult literature, increased BMI has been associated with increased risk of BXO, however little is known about this potential relationship in children. The purpose of this study was to determine if boys with BXO at the time of circumcision have a higher rate of obesity than an age-matched group of boys undergoing circumcision with normal pathology.
Materials & Methods
We reviewed all foreskin pathology specimen reports at Nationwide Children’s Hospital between 2008 and 2015 for the diagnosis of BXO. Boys, 18 years of age and younger who underwent circumcision were included. Subjects were excluded if they had a concomitant procedure other than circumcision. An age-matched group of boys who also underwent circumcision during the same time period who did not have the pathologic diagnosis of BXO were also selected. To improve the power of our sample we included a 5:1 ratio of normal to affected subjects. The medical record from all subjects was reviewed and height, weight and BMI from the day of surgery were recorded. We used the Center for Disease Control and Prevention BMI-for-age growth chart to adjust for age. Any child with age-adjusted BMI ≥95 percentile was classified as obese and BMI 85 - 94 percentile as overweight. Odds ratios and 95% confidence intervals were then calculated.
A total of 50 boys with BXO were confirmed by surgical pathology (mean age 10.17 yrs [5.76 - 17.03]) and 250 age-matched boys without BXO on circumcision pathology were identified as controls (mean age 10.06 yrs [5.11 - 17.96]). Twenty-one boys (42%) with BXO were obese compared to 31 (12.4%) in the control group (OR 5.12, 95% CI 2.6 to 10.06) while 26 (52%) boys with BXO were either obese or overweight compared to 58 (23%) in the control group (OR 3.6, 95% CI 1.91 to 6.72).
This data suggests that there is a similar association between obesity and BXO in children as seen in adults. Given the long-term health consequences associated with BXO including urethral stricture and malignancy, a higher level of suspicion may be warranted when examining and counseling obese boys with foreskin abnormalities
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