Balanitis xerotica obliterans

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Balanitis xerotica obliterans
Lichen sclerosus - high mag.jpg
Micrograph showing the characteristic subepithelial fibrosis and loss of the rete pegs seen in balanitis xerotica obliterans; these changes are identical to those of lichen sclerosus, which is seen in women. H&E stain.
Classification and external resources
Specialty urology
ICD-10 N48.0 Leukoplakia of penis
DiseasesDB 31995
eMedicine derm/46

Balanitis xerotica obliterans (BXO), also known as lichen sclerosus of penis is a dermatological (skin) condition affecting the male genitalia. It was first described by Stuhmer in 1928, though earlier reports describe what may have been the same condition.[1] BXO commonly occurs on the foreskin and glans penis.[2] Atrophic white patches appear on the affected area,[3] and commonly, a whitish ring of indurated (hardened) tissue usually forms near the tip that may prevent retraction.[2]

It has been regarded as identical to lichen sclerosus of penis, though this may be incorrect. It has also been named leukoplakia of penis and kraurosis of penis.


The true prevalence of Balanitis xerotica obliterans is controversial and unclear. One study calculated a rate of 0.6% of boys are affected by their 15th birthdays.[4] Another reported a rate of 0.07%.[5] However, a review noted that "with a high degree of suspicion and histologic examination, the condition will prove to be much more frequent than one generally believes."[6] Another suggested that "more cases would be diagnosed during infancy if all dried foreskin were examined systematically."[7] Another remarked that the condition "may be misdiagnosed or ignored in the young boy."[8] Yet another commented that "its true incidence is not appreciated because most cases are cured by circumcision, and unfortunately many surgeons still fail to send their circumcision specimens for histology."[9] Another remarked that the "extent of asymptomatic disease in this series would suggest the true prevalence of LS in men might be much higher than published work suggests."[10]

According to some authors, the disease most frequently affects middle-aged men.[2] However, a large study reported that the age distribution was similar from 2 to 90 years of age, except for men in their twenties, who were at twice the risk.[5] The same study found that black and Hispanic men had approximately twice the risk of white men. The authors suggested possible reasons for this, including access to health care, differences in neonatal circumcision rates, and climate differences.

Mallon et al. found that Balanitis xerotica obliterans was related to circumcision status. Adjusting for age, lack of circumcision was associated with an odds ratio of 53.55. The finding was statistically significant.[11] However, Balanitis xerotica obliterans has also been noted to occur after late circumcision, especially when performed for phimosis.[1][5][11]


What causes Balanitis xerotica obliterans is uncertain. However, some possibilities have been suggested.

Some studies have shown that patients with the condition also show signs of suffering from autoimmune disorders.[12][13][14] However, this finding is not repeated in every study.[13]

Infection from "human papilloma virus (serotype 16 in particular), spirochetes and atypical mycobacteria" has also been suggested as a cause.[5] Additional suggestions include "pemphigus vulgaris and chronic nonspecific bacterial balanitis".[15]

Relationship to phimosis[edit]

Balanitis xerotica obliterans is a common cause of pathological phimosis.[2][3]

Kiss et al. report that 40% of boys with phimosis suffered from Balanitis xerotica obliterans.[16] Shankar and Rickwood reported Balanitis xerotica obliterans in 84% of phimosis patients.[4] Evans reported Balanitis xerotica obliterans in 10.5% of phimosis patients.[17] Clemmensen et al. reported Balanitis xerotica obliterans in 14.2% of phimosis patients.[18] Bale reported that Balanitis xerotica obliterans was found in 19% of circumcisions performed for diseases of the prepuce and penis.[19] Mattioli observed Balanitis xerotica obliterans in 60% of patients with acquired phimosis and 30% of patients with congenital phimosis.[20] Rickwood reported Balanitis xerotica obliterans in 20 of 21 patients circumcised for pathological phimosis.[21]

Relationship to lichen sclerosus[edit]

Many researchers regard Balanitis xerotica obliterans as lichen sclerosus et atrophicus (LSA) of the penis, LSA is also known as lichen sclerosus (LS). Lately Balanitis xerotica obliterans was coded as part of LSA by Medical literature search tool Medline.[22][23][24] However, Mallon et al. suggest that Balanitis xerotica obliterans "may be a consequence of other fibrosing dermatoses, such as lichen planus and cicatricial pemphigoid."[11] When occurring on the male genitals, the term 'Balanitis xerotica obliterans' is traditionally used.[2]


There is no known means of preventing BXO. However, one study reports that the data "suggest that circumcision prevents or protects against common infective penile dermatoses."[11]


BXO is chronic and often progressive.[2] Please see the following section on treatment.

The condition may cause pain, irritation, and disturbance of sexual function.[15]

In later stages, a meatal stricture may occur, causing urinary retention.[1][2] This may result in bladder or kidney damage.[2]

The coronal sulcus and frenulum may be destroyed.[2]

Phimosis or paraphimosis may occur.[2]

Several studies indicate that BXO may play a pre-cancerous role,[25][26][27][28][29] resulting in squamous cell carcinoma of the penis, a form of penile cancer.


Neuhaus and Skidmore report that "Tzanck smear and cutaneous biopsy, along with a rapid protein reagin test, will provide a definitive diagnosis."[30]

Depasquale et al. note that many surgeons do not send circumcision specimens for histology. They caution that this practice "is becoming medicolegally indefensible in a litigation-conscious society, where the clinical sequelae of BXO are often misinterpreted by the patient as surgical errors."[9]


In a study involving applying a cream and stretching the foreskin twice daily, the treatment appeared effective for 9 out of the 12 individuals with penile lichen sclerosus,[31] which is believed to be equivalent or very related to BXO.

Preputioplasty can cure BXO more effectively than circumcision, according to a study in which the specific technique involved triradiate preputial incisions and injection of triamcinolone intralesionally.[32]

Therapy focuses on prevention of disease progression.[30]

Shelley reported some success with long-term antibiotic therapy. However, relapses were seen upon stopping treatment.[33]

Some success has been reported with topical steroids,[34] when scarring is minimal,[35] though some have found this ineffectual.[36]

Moderate therapeutic results have been reported using etretinate.[37]

Some success has been reported in the use of carbon dioxide laser therapy.[38][39][40]

Many authors report that circumcision is the treatment of choice,[2][9][41] with modifications if necessary.[42] Pasieczny suggests testosterone ointment, however.[43]

Glansectomy may be required.[9]

See also[edit]


  1. ^ a b c Freeman C, Laymon CW (1941). "Balanitis xerotica obliterans" (Reprint:The CIRP Circumcision Reference Library). Arch Dermat Syph 44 (4): 547–59. doi:10.1001/archderm.1941.01500040002001. Archived from the original on 25 September 2006. Retrieved 2006-10-01. 
  2. ^ a b c d e f g h i j k Keogh GC. "Balanitis xerotica obliterans". Archived from the original on 2 August 2005. Retrieved 2005-08-15. 
  3. ^ a b Buechner S (September 2002). "Common skin disorders of the penis". BJU Int 90 (5): 498–506. doi:10.1046/j.1464-410X.2002.02962.x. PMID 12175386. 
  4. ^ a b Shankar K, Rickwood A (July 1999). "The incidence of phimosis in boys". BJU Int 84 (1): 101–2. doi:10.1046/j.1464-410x.1999.00147.x. PMID 10444134. 
  5. ^ a b c d Kizer W, Prarie T, Morey A (January 2003). "Balanitis xerotica obliterans: epidemiologic distribution in an equal access health care system". South Med J 96 (1): 9–11. doi:10.1097/00007611-200301000-00004. PMID 12602705. 
  6. ^ Das S, Tunuguntla H (December 2000). "Balanitis xerotica obliterans--a review". World J Urol 18 (6): 382–7. doi:10.1007/PL00007083. PMID 11204255. 
  7. ^ Garat J, Chéchile G, Algaba F, Santaularia J (August 1986). "Balanitis xerotica obliterans in children". J Urol 136 (2): 436–7. PMID 3735511. 
  8. ^ McKay D, Fuqua F, Weinberg A (November 1975). "Balanitis xerotica obliterans in children". J Urol 114 (5): 773–5. PMID 1237636. 
  9. ^ a b c d Depasquale I, Park AJ, Bracka A. (2000). "The treatment of balanitis xerotica obliterans" (Reprint:The CIRP Circumcision Reference Library). BJU Int 86 (4): 459–65. doi:10.1046/j.1464-410X.2000.00772.x. PMID 10971272. Retrieved 2006-10-01. 
  10. ^ Riddell I, Edwards A, Sherrard J. (August 2000). "Clinical features of lichen sclerosus in men attending a department of genitourinary medicine". Sex Trans Infect 76 (4): 311–3. doi:10.1136/sti.76.4.311. PMC 1744198. PMID 11026891. 
  11. ^ a b c d Mallon E, Hawkins D, Dinneen M, Francics N, Fearfield L, Newson R, Bunker C (March 2000). "Circumcision and genital dermatoses". Arch Dermatol 136 (3): 350–4. doi:10.1001/archderm.136.3.350. PMID 10724196. 
  12. ^ Azurdia R, Luzzi G, Byren I, Welsh K, Wojnarowska F, Marren P, Edwards A (January 1999). "Lichen sclerosus in adult men: a study of HLA associations and susceptibility to autoimmune disease". British Journal of Dermatology 140 (1): 79–83. doi:10.1046/j.1365-2133.1999.02611.x. PMID 10215772. 
  13. ^ a b Meyrick Thomas R, Ridley C, Black M (December 1983). "The association of lichen sclerosus et atrophicus and autoimmune-related disease in males". Br J Dermatol 109 (6): 661–4. doi:10.1111/j.1365-2133.1983.tb00546.x. PMID 6652042. 
  14. ^ Harrington C, Dunsmore I (May 1981). "An investigation into the incidence of auto-immune disorders in patients with lichen sclerosus and atrophicus". Br J Dermatol 104 (5): 563–6. doi:10.1111/j.1365-2133.1981.tb08172.x. PMID 7236515. 
  15. ^ a b Edwards S. (1996). "Balanitis and balanoposthitis: a review" (Reprint:The CIRP Circumcision Reference Library). Genitourin Med 72 (3): 155–9. doi:10.1136/sti.72.3.155. PMC 1195642. PMID 8707315. 
  16. ^ Kiss A, Király L, Kutasy B, Merksz M (Jul–Aug 2005). "High incidence of balanitis xerotica obliterans in boys with phimosis: prospective 10-year study". Pediatr Dermatol 22 (4): 305–8. doi:10.1111/j.1525-1470.2005.22404.x. PMID 16060864. 
  17. ^ Evans D (2000). "Retrospective study of male lichen sclerosus and outcome in Leicester: 1995-9 inclusive: experience of a genitourinary medicine clinic". Sex Transm Infect 76 (6): 495. doi:10.1136/sti.76.6.495. PMC 1744250. PMID 11221136. 
  18. ^ Clemmensen O, Krogh J, Petri M (April 1988). "The histologic spectrum of prepuces from patients with phimosis". Am J Dermatopathol 10 (2): 104–8. doi:10.1097/00000372-198804000-00002. PMID 3239715. 
  19. ^ Bale P, Lochhead A, Martin H, Gollow I (1987). "Balanitis xerotica obliterans in children". Pediatr Pathol 7 (5-6): 617–27. doi:10.3109/15513818709161425. PMID 3449818. 
  20. ^ Mattioli G, Repetto P, Carlini C, Granata C, Gambini C, Jasonni V (May 2002). "Lichen sclerosus et atrophicus in children with phimosis and hypospadias". Pediatr Surg Int 18 (4): 273–5. doi:10.1007/s003830100699. PMID 12021978. 
  21. ^ Rickwood AMK, Hemalatha V, Batcup G, Spitz L. (1980). "Phimosis in boys" (Reprint:The CIRP Circumcision Reference Library). Brit J Urol 52 (2): 147–50. doi:10.1111/j.1464-410X.1980.tb02945.x. PMID 7191744. 
  22. ^ Finkbeiner A (January 2003). "Balanitis xerotica obliterans: a form of lichen sclerosus". South Med J 96 (1): 7–8. doi:10.1097/01.SMJ.0000047973.46602.E8. PMID 12602704. 
  23. ^ Laymon CW, Freeman C. (1944). xerotica obliterans/laymon1/ "Relationship of balanitis xerotica obliterans to lichen sclerosus et atrophicus" Check |url= value (help) (Reprint:The CIRP Circumcision Reference Library). Arch Dermat Syph 49: 57–9. doi:10.1001/archderm.1944.01510070060010. 
  24. ^ Neill S, Tatnall F, Cox N (October 2002). "Guidelines for the management of lichen sclerosus". Br J Dermatol 147 (4): 640–9. doi:10.1046/j.1365-2133.2002.05012.x. PMID 12366407. 
  25. ^ Velazquez E, Cubilla A (November 2003). "Lichen sclerosus in 68 patients with squamous cell carcinoma of the penis: frequent atypias and correlation with special carcinoma variants suggests a precancerous role". Am J Surg Pathol 27 (11): 1448–53. doi:10.1097/00000478-200307000-00015. PMID 14576478. 
  26. ^ Cubilla A, Velazquez E, Young R (July 2004). "Pseudohyperplastic squamous cell carcinoma of the penis associated with lichen sclerosus. An extremely well-differentiated, nonverruciform neoplasm that preferentially affects the foreskin and is frequently misdiagnosed: a report of 10 cases of a distinctive clinicopathologic entity". Am J Surg Pathol 28 (7): 895–900. doi:10.1097/00000478-200407000-00008. PMID 15223959. 
  27. ^ Perceau G, Derancourt C, Clavel C, Durlach A, Pluot M, Lardennois B, Bernard P (May 2003). "Lichen sclerosus is frequently present in penile squamous cell carcinomas but is not always associated with oncogenic human papillomavirus". Br J Dermatol 148 (5): 934–8. doi:10.1046/j.1365-2133.2003.05326.x. PMID 12786823. 
  28. ^ Powell J, Robson A, Cranston D, Wojnarowska F, Turner R (July 2001). "High incidence of lichen sclerosus in patients with squamous cell carcinoma of the penis". Br J Dermatol 145 (1): 85–9. doi:10.1046/j.1365-2133.2001.04287.x. PMID 11453912. 
  29. ^ Micali G, Nasca M, Innocenzi D (June 2001). "Lichen sclerosus of the glans is significantly associated with penile carcinoma". Sex Transm Infect 77 (3): 226. doi:10.1136/sti.77.3.226. PMC 1744293. PMID 11402247. 
  30. ^ a b Neuhaus I, Skidmore R (Nov–Dec 1999). "Balanitis xerotica obliterans and its differential diagnosis". J Am Board Fam Pract 12 (6): 473–6. doi:10.3122/jabfm.12.6.473. PMID 10612365. 
  31. ^ Ghysel, Christophe; Vander Eeckt, Kathy; Bogaert, Guy A (2009). "-term efficiency of skin stretching and a topical corticoid cream application for unretractable foreskin and phimosis in prepubertal boys.". Urol. Int. 82 (1): 81–88. doi:10.1159/000176031. PMID 19172103. 
  32. ^ Wilkinson DJ1, Lansdale N, Everitt LH, Marven SS, Walker J, Shawis RN, Roberts JP, Mackinnon AE, Godbole PP. (April 2012). "Foreskin preputioplasty and intralesional triamcinolone: a valid alternative to circumcision for balanitis xerotica obliterans.". J Pediatr Surg 47 (4): 756–759. doi:10.1016/j.jpedsurg.2011.10.059. PMID 22498393. 
  33. ^ Shelley W, Shelley E, Grunenwald M, Anders T, Ramnath A (January 1999). "Long-term antibiotic therapy for balanitis xerotica obliterans". J Am Acad Dermatol 40 (1): 69–72. doi:10.1016/S0190-9622(99)70529-3. PMID 9922014. 
  34. ^ Kiss A, Csontai A, Pirót L, Nyirády P, Merksz M, Király L (January 2001). "The response of balanitis xerotica obliterans to local steroid application compared with placebo in children". J Urol 165 (1): 219–20. doi:10.1097/00005392-200101000-00062. PMID 11125410. 
  35. ^ Vincent M, Mackinnon E (April 2005). "The response of clinical balanitis xerotica obliterans to the application of topical steroid-based creams". J Pediatr Surg 40 (4): 709–12. doi:10.1016/j.jpedsurg.2004.12.001. PMID 15852285. 
  36. ^ Wright J (May 1994). "The treatment of childhood phimosis with topical steroid". Aust N Z J Surg 64 (5): 327–8. doi:10.1111/j.1445-2197.1994.tb02220.x. PMID 8179528. 
  37. ^ Neuhofer J, Fritsch P (1984). "Treatment of localized scleroderma and lichen sclerosus with etretinate". Acta Derm Venereol 64 (2): 171–4. PMID 6203311. 
  38. ^ Kartamaa M, Reitamo S (March 1997). "Treatment of lichen sclerosus with carbon dioxide laser vaporization". Br J Dermatol 136 (3): 356–9. doi:10.1111/j.1365-2133.1997.tb14943.x. PMID 9115915. 
  39. ^ Peterson C, Lane J, Ratz J (August 2004). "Successful carbon dioxide laser therapy for refractory anogenital lichen sclerosus". Dermatol Surg 30 (8): 1148–51. doi:10.1111/j.1524-4725.2004.30343.x. PMID 15274708. 
  40. ^ Windahl T, Hellsten S (September 1993). "Carbon dioxide laser treatment of lichen sclerosus et atrophicus.". J Urol 50 (3): 868–70. PMID 8345602. 
  41. ^ Meuli M, Briner J, Hanimann B, Sacher P (September 1994). "Lichen sclerosus et atrophicus causing phimosis in boys: a prospective study with 5-year followup after complete circumcision". J Urol 152 (3): 987–9. PMID 8051779. 
  42. ^ Campus G, Ena P, Scuderi N (April 1984). "Surgical treatment of balanitis xerotica obliterans". Plast Reconstr Surg 73 (4): 652–7. doi:10.1097/00006534-198404000-00024. PMID 6538689. 
  43. ^ Pasieczny TAH. (1977). "The treatment of balanitis xerotica obliterans with testosterone propionate ointment" (Reprint:The CIRP Circumcision Reference Library). Acta Derm Venerol 57 (3): 275–7. PMID 71837.