Testosterone combination for balanitis xerotica obliterans yields positive impact

Orlando, FL-Combining topical and systemic testosterone therapies following surgery for balanitis xerotica obliterans (BXO) can profoundly affect disease recovery, according to results of a study presented at the AUA annual meeting here.

"The improvements can be dramatic," said Charles L. Secrest, MD, of the Mississippi Urology Clinic in Jackson, who presented the findings. "Even the advanced cases have had near normalization of the glans, meatus, and prepuce with both topical and systemic replacement of testosterone."

The incidence of BXO is not well described, perhaps owing to its relative rarity. BXO strikes approximately five of 10,000 men, with complications that include meatal stenosis and urethral strictures, according to a 2003 study from the U.S. Army (South Med J 2003; 96:9-11). The incidence among African-Americans and Hispanics is twice that of Caucasians.

Dr. Secrest said that the overall presentation of men diagnosed with BXO led him to consider systemic testosterone.

"Many of these men were complaining of erectile dysfunction. They also had systemic complaints, such as fatigue and a lack of sex drive. These are symptoms of hypogonadism. We have always used testosterone topically, so my thought was, what if these men have problems not only with local levels of testosterone but also systemic levels?" he explained.

Dr. Secrest treated 59 patients for BXO between 1992 and 2007. The age range was 25 to 89 years. Of these, 41 had significant strictures (1 cm to 20 cm) with a mean length of 12.6 cm. Serum testosterone levels were available for 27 patients. The mean testosterone level was 274 ng/dL for this cohort, and 21 of the 27 (77.8%) were found to have testosterone levels of <350 ng/dL.

"Some of the patients with more advanced disease had extremely low testosterone levels-in the 100s," Dr. Secrest said.

The topical and systemic treatment was initiated in nine patients shortly following surgery. The systemic testosterone was administered via injection or with intramuscular pellets. Responses to the combined treatment began to appear within a few weeks of initiation, Dr. Secrest said. Eight patients had two-stage surgical treatment of BXO, and seven of the eight had successful outcomes during a median follow-up of 34 months. Surgical success was defined as the ability to pass a flexible cystoscope, absence of surgical revisions, and patient satisfaction with the outcome. Surgical results have improved dramatically since adding testosterone replacement to the protocol.

The findings of the study yield an improved treatment option as well as a window into the disease's etiology.

"It appears that this disease is directly under the influence of the hormonal status of the patient," said Dr. Secrest. "For whatever reason, their testosterone levels are low.

"Our early results have shown dramatic improvement. Two-stage urethral reconstruction is preferred and also allows direct application of testosterone cream to the diseased urethra."