Balanitis Xerotica Obliterans

Balanitis xerotica obliterans is lichen sclerosus of the penis: a chronic, scarring, inflammatory skin disease of the glans, prepuce and frenulum that can extend into the meatus and urethra.

It occurs mainly in uncircumcised men, with a peak at 30 to 50 years, and in boys, where it is found in a substantial minority of those with pathological phimosis.

The disease is progressive without treatment. It causes phimosis, meatal stenosis and urethral stricture, and carries a small risk of penile squamous cell carcinoma.

Pathophysiology. The cause is not settled. An autoimmune basis is supported by the association with HLA-DQ types and other autoimmune disease. Chronic occlusion and contact of the glans with urine in the preputial space act as a trigger.

Associated conditions are diabetes mellitus, obesity and previous genital trauma or surgery. Histology shows epidermal atrophy with hyperkeratosis, basal cell vacuolation, homogenised collagen in the upper dermis, and a band of lymphocytes beneath it.

Reported lifetime risk of penile squamous cell carcinoma is in the order of 2 to 9% in lichen sclerosus. Urethral stricture develops in roughly 10 to 20% of affected men.

White, atrophic or sclerotic plaques on the glans and prepuce, with loss of the coronal sulcus and frenulum, fissuring, purpura, and pigment loss. Symptoms are itch, soreness, dyspareunia, painful erection from tight skin, bleeding, and a progressively non-retractile foreskin. Meatal involvement causes a narrowed meatus, spraying and a weak stream.

Urinary retention, a non-healing ulcer, a raised, pigmented or warty area, or an erythematous patch that fails to respond to treatment needs urgent biopsy for malignancy.

• Clinical diagnosis in typical disease.
• Biopsy for atypical or erosive disease, hyperkeratotic, pigmented or raised areas, non-healing ulcers, and failure of 3 months of treatment.
• Swab for Candida and bacteria when there is inflammation or discharge. Screen for STI when risk is present.
• HbA1c, and thyroid function and autoantibody tests when clinically suggested.
• Uroflowmetry and post-void residual for voiding symptoms. Retrograde urethrography and urethroscopy when stricture is suspected.

Differential diagnosis.

• Lichen planus
• Candidal or bacterial balanitis
• Plasma cell (Zoon) balanitis
• Psoriasis or eczema of the glans
• Penile intraepithelial neoplasia and squamous cell carcinoma
• Vitiligo
• Scarring after previous circumcision or trauma

• Potent topical corticosteroid: clobetasol propionate 0.05% ointment, a thin layer (about one fingertip unit, 0.5 g) applied once daily at night for 4 weeks, then on alternate nights for 4 weeks, then twice weekly or as the skin needs. Review at 3 months. Adverse effects are skin thinning, candidiasis and local irritation. Avoid occlusive dressings.
• Emollient and soap substitute for washing, and avoidance of irritants. Treat candidal infection (clotrimazole 1% cream 2 to 3 times daily for 1 to 2 weeks) and bacterial infection by culture.
• Steroid sparing agents when steroids are unsuitable: tacrolimus 0.1% ointment twice daily, or pimecrolimus 1% cream twice daily. Evidence is weaker, and local burning is common.
• Circumcision, with removal of all affected preputial tissue, cures disease limited to the prepuce in most patients. Continue topical steroid if the glans or meatus is involved.
• Meatal stenosis: meatotomy or meatoplasty. Urethral stricture: urethroplasty with buccal mucosa graft. Do not use genital skin for grafts, because lichen sclerosus recurs in it. Dilation or urethrotomy has high failure rates.
• Children: clobetasol propionate 0.05% ointment under specialist direction, once daily at night for 4 weeks then reduced, with circumcision for refractory preputial disease.
• Optimise glycaemic control in diabetes.

Monitoring. Review at 3 months, then yearly for life, even when symptom free. Biopsy any non-healing, ulcerated, raised, pigmented or newly thickened area. Uroflowmetry yearly when meatal or urethral disease is present.

Referral and escalation. Refer to urology or dermatology for atypical disease, failure of treatment, meatal stenosis or stricture. Urgent referral for suspected carcinoma or retention.