Browse the corpus

Balanitis xerotica obliterans, a subtype of lichen sclerosus, is an inflammatory disorder of unknown etiology that presents as white, atrophic papules and plaques affecting the male genitalia, primarily the foreskin, glans, and urethral meatus. Lichen sclerosus can affect both male and female patients, but the condition is specifically termed "balanitis xerotica obliterans" when it involves the foreskin and glans penis in men. Involvement of the foreskin causes atrophic skin changes with dyspigmentation and constriction, which may result in phimosis. In the glans, these changes result in the characteristic whitish patches and meatal stenosis. The diagnosis of balanitis xerotica obliterans requires a thorough clinical examination supported by histopathological analysis to confirm characteristic features such as epidermal atrophy, basal cell liquefaction, and dermal layer sclerosis. Treatment usually consists of very high-potency topical steroids, but surgery is often needed for recurrent or resistant lesions and is considered the definitive therapy. This activity for healthcare professionals is designed to enhance learners' competence in evaluating and managing balanitis xerotica obliterans. Participants gain a deeper understanding of the etiology, risk factors, pathogenesis, symptomatology, and best diagnostic and therapeutic practices for this condition. Greater proficiency enables clinicians to collaborate within an interprofessional team caring for affected individuals, improving outcomes. Objectives: Identify the etiology of balanitis xerotica obliterans. Create clinically guided diagnostic plans for balanitis xerotica obliterans. Implement personalized, evidence-based management approaches for balanitis xerotica obliterans. Collaborate with the interprofessional team to educate, treat, and monitor patients with balanitis xerotica obliterans to improve patient outcomes. Access free multiple choice questions on this topic.

Balanitis xerotica obliterans is a form of lichen sclerosus that involves the foreskin and glans penis in affected male individuals. The condition presents as white or hypopigmented macules or atrophic papules on the penis. Involvement of the foreskin leads to atrophic skin changes with depigmentation and constriction, which can result in phimosis. In the glans, these changes result in the characteristic whitish patches and meatal stenosis.[1][2][3] Balanitis xerotica obliterans was first described as a unique entity in 1928 by Stühmer and is responsible for about 85% of all cases of acquired phimosis.[4] Urethral stricture disease, phimosis, and meatal stenosis are common sequelae of balanitis xerotica obliterans.[5] For information on lichen sclerosus in women, see the companion StatPearls reference review, Lichen Sclerosus, at www.statpearls.com/point-of-care/24256.[6]

The etiology of balanitis xerotica obliterans is mainly unknown. Possible contributing etiological factors include chronic penile inflammatory conditions, atopic dermatitis, genetic predisposition, infections (such as syphilis), the Koebner phenomenon, morphea, penile trauma, hypothyroidism, diabetes, and sex hormone disorders.[7][8] Smoking, obesity, hypertension, and cardiovascular disease have also been linked to this condition.[9][10] While balanitis xerotica obliterans is closely associated with several autoimmune disorders, including alopecia areata, autoimmune thyroiditis, localized scleroderma (morphea), pernicious anemia, and vitiligo, balanitis xerotica obliterans is likely multifactorial.[11][12] For example, antithyroid antibodies and autoimmune thyroid disorders such as Graves disease and Hashimoto thyroiditis are present in about 5% of male patients with balanitis xerotica obliterans, with the frequency of hypothyroidism or hyperthyroidism more than double the incidence in the general population.[13] This finding has led some experts to recommend that screening for thyroid disease be considered in individuals with balanitis xerotica obliterans.[14][15] Other proposed etiologies of this disorder include various infections, penile trauma, and chronic inflammatory states. HLA-DR11, HLA-DR12, and HLA-DQ7 antigens are found more often in patients with balanitis xerotica obliterans or lichen sclerosus than in controls.[16][17][18] First described by Heinrich Koebner in 1876, the Koebner phenomenon refers to an isomorphic response in unaffected skin following cutaneous trauma, commonly observed in psoriasis.[19] The Koebner phenomenon's exact cause is unclear, but it appears to involve adhesion molecules, autoimmune antigens, cytokines, and stress proteins.[20] This condition is neither new nor unique to the patient but rather an activation of a preexisting cutaneous disorder.[21] For more information on the Koebner phenomenon, see the companion StatPearls reference at www.statpearls.com/point-of-care/23943. Manual retraction of the foreskin at least 5 times a month or more has also been reported to increase the risk of developing balanitis xerotica obliterans.[22] Up to 15% of males with hypospadias develop balanitis xerotica obliterans.[23]

First described by Heinrich Koebner in 1876, the Koebner phenomenon refers to an isomorphic response in unaffected skin following cutaneous trauma, commonly observed in psoriasis.[19] The Koebner phenomenon's exact cause is unclear, but it appears to involve adhesion molecules, autoimmune antigens, cytokines, and stress proteins.[20] This condition is neither new nor unique to the patient but rather an activation of a preexisting cutaneous disorder.[21] For more information on the Koebner phenomenon, see the companion StatPearls reference at www.statpearls.com/point-of-care/23943. Manual retraction of the foreskin at least 5 times a month or more has also been reported to increase the risk of developing balanitis xerotica obliterans.[22] Up to 15% of males with hypospadias develop balanitis xerotica obliterans.[23] Most inflammatory skin disorders of the male genitalia occur in uncircumcised men or boys who undergo late (postpubertal) circumcision. The foreskin may promote chronic inflammation due to the sequestration or pooling of urine under the prepuce, which may activate the Koebner phenomenon and ultimately result in balanitis xerotica obliterans.[24] Postvoid dribbling and microincontinence may contribute to the development of balanitis xerotica obliterans.[25] Over 90% of men diagnosed with balanitis xerotica obliterans have reported microincontinence, compared with only 14% in the normal control group.[26] Further evidence of this theory is demonstrated by the tendency of balanitis xerotica obliterans to affect only the skin exposed to sequestered urine, as with a phimotic foreskin, while sparing other areas, such as the anogenital region. Another theory suggests that the underlying etiology may be a hormonal disorder involving 5α-reductase, as adults with balanitis xerotica obliterans generally have lower levels of androstenedione, dihydrotestosterone, and free testosterone than controls.[27] Increased galectin-7, a proapoptotic protein and fibroblast stimulator, may also be involved.[28][29] Human papillomavirus (HPV) does not appear to be a causative factor of balanitis xerotica obliterans. However, of those cases that progress to squamous cell carcinoma, 22% demonstrate evidence of HPV infection, with HPV-16 being the most prevalent genotype.[30]

Reporting on the prevalence of this condition is challenging, as patients initially present to a wide range of physician specialties. Studies have indicated that the prevalence rates of male genital lichen sclerosus are approximately 0.1% to 0.3% (1 case per 300 to 1,000 men) overall. In children, the consensus is that the peak age of balanitis xerotica obliterans is 7 to 8 years, although the incidence in boys is thought to be significantly underestimated.[31][32][33][34] Some published reports suggest that the actual incidence is 5% to 6% and as high as 8.9% in uncircumcised boys.[35][36] In adults, balanitis xerotica obliterans is most often found in middle-aged and older men.[37] A large U.S. Department of Defense database found that the incidence of male lichen sclerosus more than doubled in adults older than 60.[38] An uncircumcised status is the strongest risk factor for developing balanitis xerotica obliterans, regardless of age. In one study, 98% of patients diagnosed with balanitis xerotica obliterans were uncircumcised.[39] While no specific racial or ethnic predilection exists, Black and Hispanic cohorts report a higher frequency of balanitis xerotica obliterans, about double that of White patients, likely due to lower circumcision rates in these populations.[40]

Clinically, balanitis xerotica obliterans is a chronic, progressive mucocutaneous autoimmune disorder characterized by hypopigmentation and skin atrophy with constriction, often resulting in phimosis or meatal stenosis. At the cellular level, this dermatological disorder involves activated T cells releasing interleukin-4 (IL-4) and transforming growth factor-β (TGF-β), leading to abnormal collagen production with fibrosis and decreased vascularity. IL-4 is a potent immune-regulating cytokine that stimulates the multiplication of fibroblasts, increasing collagen production and subsequent scarring.[41] Transforming growth factor-β (TGF-β) is a cytokine that also promotes increased collagen production, resulting in sclerosing fibrosis.)[42] Additional cytokines and cellular factors include IL-1 and IL-1 receptor antagonists; increased monoclonal CD4+ T lymphocytes, CD1a+ dendritic cells, macrophages, and mast cells; and decreased CD3+ T lymphocytes.[43] CD8+ and CD57+ lymphocytes may also be increased, along with Ki67+ and p53+ cells, resulting in keratinocytic hyperplasia.[44] Another theory has suggested that balanitis xerotica obliterans may involve widespread hyaline material deposition due to immunoglobulin G autoantibodies to extracellular matrix 1 (ECM1) protein. Though usually relatively benign, balanitis xerotica obliterans is now considered a non-HPV-related premalignant lesion and may undergo malignant squamous cell carcinoma transformation if untreated.[45][46][47][48][49][50][51][52] Progression of balanitis xerotica obliterans to squamous cell carcinoma of the penis has been reported in up to 15% of patients with penile lichen sclerosus; this malignant progression takes an average of 17 years.[53][54] Conversely, a significant percentage of patients with penile squamous cell carcinoma (28%-55%) also had histological evidence or a history of balanitis xerotica obliterans.[55][56][57]

Early balanitis xerotica obliterans is characterized by a specific histologic pattern showing a band-like lymphocytic infiltrate below a zone of dermal edema. Histology of early lesions shows a moderate lymphocytic infiltrate in the superficial dermis and basal layers of the epidermis. These features are associated with vacuolar changes in the basal epidermal layer. With progression, the papillary dermis loses elastic fibers as the epidermis becomes atrophic with superficial hyperkeratosis. A subepidermal layer of homogenized collagen and edema forms, along with cutaneous atrophy and dermal lymphocytic bands.[58] Subepidermal edema, later replaced by fibrosis, pushes the bands of lymphocytic inflammatory infiltrate deeper into the cutaneous tissues.[59] Balanitis xerotica obliterans lesions demonstrate abundant infiltrating, autoreactive, cytotoxic T lymphocytes with abnormal extracellular matrix metabolism, orthokeratotic hyperkeratosis, and epidermal atrophy. Serum levels of autoimmune antibodies to extracellular matrix proteins may be elevated.[60] The superficial dermis often has abundant homogenized collagen with a lymphoplasmacytic infiltrate. Genetically, an immune-mediated TH1-specific interferon-γ–induced phenotype predisposes patients to balanitis xerotica obliterans. MicroRNAs and tissue remodeling genes are overexpressed, and oxidative stress leads to DNA peroxidation, which promotes autoimmune reactions and carcinogenesis.

Balanitis xerotica obliterans of the penis may initially present asymptomatically. When symptomatic, the most common presentation is hypopigmentation followed, in order, by phimosis, urinary symptoms (51.6%), dysuria (23%), voiding dysfunction, narrowed urinary stream, erythema, balanitis, circumferential scarring of the foreskin, meatal stenosis (21.4%), buried penis, pain, and penile adhesions.[61] Ballooning of the foreskin during voiding and deviation of the urine stream are also frequently reported. White hypopigmented lesions, atrophic plaques, or scars on the glans, penis, or foreskin are the most common physical finding. These lesions are often associated with phimosis and meatal stenosis. Complications may develop if the condition is left untreated, including dysuria, narrowed or weakened stream, urinary retention, paraphimosis, and even renal failure. Erythematous changes may also develop, appearing as well-defined lesions around the coronal sulcus, foreskin, and meatus. Telangiectasias and purpura of the glans may be found. These lesions can progressively invade the distal urethra and fossa navicularis, resulting in urethral strictures, which may extend to the proximal urethra.[62] Perianal lesions are extremely rare in boys. Extragenital lesions may be seen in 6% of cases and may involve the back, buttocks, mouth, neck, shoulders, and thighs. Voiding dysfunction from balanitis xerotica obliterans is relatively uncommon but tends to cause significant morbidity when present. A large study from the United Kingdom demonstrated that surgical referrals for nonretractile phimosis are often made inappropriately, as over 75% of the referred patients had a normal foreskin, and surgeons discharged more than half after the first visit.[63] Other forms of balanitis xerotica obliterans often go unrecognized, and 1st-line therapy is rarely initiated in the primary care setting. Such findings suggest room for improvement at the primary care level.

In a retrospective review of 380 adult patients at the Mayo Clinic, the average delay in diagnosis was over 2 years. In a separate study, the mean diagnostic delay period for patients younger than 18 was 22 months.[64] Balanitis xerotica obliterans in male individuals is almost always seen in uncircumcised patients. The condition presents with white or erythematous areas on the glans, penis, or foreskin. A whitish, sclerotic lesion right around the distal lumen of the foreskin is characteristic of balanitis xerotica obliterans. A similar white, sclerotic area around the urethral meatus is also highly suggestive. A biopsy may be needed in questionable cases to provide an accurate diagnosis. The sample should be taken from active sclerotic lesions or erosions that have not improved after initial medical therapy.[65] Prior corticosteroid therapy may diminish characteristic histological features, and early ulcerative or erythematous areas should be avoided, as they will likely demonstrate only unspecified features.[66][67] Guidelines from the British Association of Dermatologists for the management of lichen sclerosus have suggested the following indications for a histological examination in male balanitis xerotica obliterans: [68] Atypical clinical features Pigmented lesions Failure of 1st-line therapy if surgical excision is not performed Extragenital lichen sclerosus mimicking a morphea is present Suspicion of neoplastic changes Confirmation of lichen sclerosus and exclusion of penile intraepithelial neoplasia (PeIN) after a circumcision Urethral stricture involvement should be suspected in patients with voiding dysfunction (ie, weak stream) who do not have meatal stenosis and in individuals with symptoms unrelieved by meatotomy surgery. Evaluation of these patients may necessitate cystoscopy and retrograde urethrography, while uroflowmetry may be used for screening and follow-up tracking. The diagnosis of balanitis xerotica obliterans does not require specific laboratory tests. However, a serum test for syphilis and thyroid function may be helpful in selected cases.

Both conservative (medical) and surgical options are available for balanitis xerotica obliterans treatment. As a general guide, topical steroids are used in balanitis xerotica obliterans with meatal stenosis, while circumcision is more likely to be recommended for adult patients with symptomatic phimosis or a history of paraphimosis.[69] Asymptomatic patients do not require therapy. Conservative Treatment Topical steroids are the main treatment for symptomatic lichen sclerosus, starting initially with very high-potency compounds (see below).[70] Mucosal surfaces, such as the glans penis, are resistant to atrophy and other common side effects of topical steroids, making them the preferred nonsurgical modality.[71] Topical therapy is relatively ineffective in severe balanitis xerotica obliterans, which generally requires surgical treatment. Systemic oral steroids have no therapeutic benefit in balanitis xerotica obliterans cases.[72] Topical steroid therapy for balanitis xerotica obliterans usually proceeds as follows: Very high-potency topical steroids, such as clobetasol propionate 0.05%, fluocinonide 0.1%, and halobetasol propionate 0.05%, are the initial nonsurgical treatments of choice. While practical, these medications should not be used continuously for more than 3 weeks. After that period, the frequency of application should be adjusted to once or twice a week. This regimen has been successful in over 90% of pediatric patients with phimosis or mild balanitis xerotica obliterans.[73] Consider the application of clobetasol propionate 0.05% ointment once daily with a cotton swab to the urethral meatus, followed by meatal dilation, for meatal stenosis due to balanitis xerotica obliterans. This regimen should be continued for 1 to 3  months before progressing to surgical meatotomy. Medium-potency steroids, including amcinonide 0.1%, betamethasone dipropionate 0.05%, desoximetasone 0.05% to 0.25%, diflorasone diacetate 0.05%, fluticasone 0.005% to 0.05%, and triamcinolone acetonide 0.1% to 0.5%, may be used continuously for up to 3 months. Low-potency topical steroids, such as alclometasone dipropionate 0.05%, desonide 0.05%, fluocinolone acetonide 0.01%, hydrocortisone 1% to 2.5%, and triamcinolone 0.025%, as well as commercially available over-the-counter steroid creams, do not have any specified limit for routine or continuous use.

Medium-potency steroids, including amcinonide 0.1%, betamethasone dipropionate 0.05%, desoximetasone 0.05% to 0.25%, diflorasone diacetate 0.05%, fluticasone 0.005% to 0.05%, and triamcinolone acetonide 0.1% to 0.5%, may be used continuously for up to 3 months. Low-potency topical steroids, such as alclometasone dipropionate 0.05%, desonide 0.05%, fluocinolone acetonide 0.01%, hydrocortisone 1% to 2.5%, and triamcinolone 0.025%, as well as commercially available over-the-counter steroid creams, do not have any specified limit for routine or continuous use. Children should generally use topical steroids for less than the maximum duration allowed for adults.[74] Betamethasone and triamcinolone are common options and typically require twice-a-day dosing. However, higher-potency topical steroids are generally recommended for initial therapy. The patient is monitored for a response. The frequency of topical steroid applications may be reduced to every other day or every 3rd day if a good response is observed after 2 months.[75] Weekly topical steroid applications may be considered after the lesion has resolved.[76][77] Topical steroid therapy combined with foreskin stretching has been used successfully in prepubertal boys with nonretractable phimosis.[78][79] Poor responses typically result from poor compliance with the application protocol, inadequate use of highly potent topical steroids, and severe cases of balanitis xerotica obliterans with established scarring. Surgery, with or without a biopsy, should be considered in individuals resistant to topical therapy after 3 months. Circumcision is usually recommended in cases of severe phimosis affecting voiding or sexual performance to avoid the need for long-duration topical therapy. Histological examination of the foreskin is highly recommended in such patients.[80] Topical calcineurin inhibitors like pimecrolimus and tacrolimus, the oral retinoid acitretin, platelet-rich plasma, and subcutaneous intralesional injections with the tumor necrosis factor inhibitor adalimumab are considered 2nd-line treatments.[81][82][83]

Poor responses typically result from poor compliance with the application protocol, inadequate use of highly potent topical steroids, and severe cases of balanitis xerotica obliterans with established scarring. Surgery, with or without a biopsy, should be considered in individuals resistant to topical therapy after 3 months. Circumcision is usually recommended in cases of severe phimosis affecting voiding or sexual performance to avoid the need for long-duration topical therapy. Histological examination of the foreskin is highly recommended in such patients.[80] Topical calcineurin inhibitors like pimecrolimus and tacrolimus, the oral retinoid acitretin, platelet-rich plasma, and subcutaneous intralesional injections with the tumor necrosis factor inhibitor adalimumab are considered 2nd-line treatments.[81][82][83] Pimecrolimus 1% cream is as effective in relieving symptoms of balanitis xerotica obliterans as topical clobetasol propionate 0.05%.[84] This drug requires a prescription and retails for about $100 for a 30-gram tube in the U.S. The cost may be higher, and availability may be limited elsewhere. Side effects of these immune modulator creams include a mild stinging or burning sensation on initial application. Pimecrolimus and tacrolimus have a black box warning from the U.S. Food and Drug Administration about possible malignant transformation. However, this black box warning is based on oral formulations and is highly unlikely with topical use.[85][86] Intralesional injections of triamcinolone (1 to 3 mL of 10 mg/mL) have been suggested as an adjunct to preputioplasty to avoid a recurrence of phimosis and the need for a full circumcision.[87] This treatment has produced an 81% success rate with good patient satisfaction in one study of 104 patients after a median follow-up period of 14 months.[88] Other proposed conservative treatments include oral systemic retinoids (eg, acitretin, etretinate, and isotretinoin), topical testosterone, and ozonated olive oils with vitamin E. These treatments are generally not recommended due to possible side effects, such as teratogenicity, and a lack of adequate studies proving safety and efficacy.[89][90]

Other proposed conservative treatments include oral systemic retinoids (eg, acitretin, etretinate, and isotretinoin), topical testosterone, and ozonated olive oils with vitamin E. These treatments are generally not recommended due to possible side effects, such as teratogenicity, and a lack of adequate studies proving safety and efficacy.[89][90] Phototherapy, psoralen-ultraviolet A (PUVA) cream photochemotherapy, and photodynamic therapy are sometimes used in female patients with lichen sclerosus but do not appear appropriate for men, as no published studies support the efficacy or safety of these modalities in male individuals with balanitis xerotica obliterans. Surgical Therapy As sensitive, intimate anatomical areas are involved, patients may develop feelings of being mutilated, disfigured, or humiliated, requiring great sensitivity and respect from clinicians when discussing surgical options. Some surgical interventions for balanitis xerotica obliterans, such as urethral stricture treatment, may result in long recovery periods with some degree of decreased sexual function or enjoyment, disruption of daily living activities, embarrassment, pain, and swelling.[91] In addition to the usual requirement to review surgical risks, benefits, and reasonable alternatives, patient and family preferences must be carefully considered. Indications for surgery include significant symptoms inadequately relieved by conservative measures, failure of topical therapy, suspected penile cancer, diagnostic uncertainty, and patient preference over prolonged topical therapy. Surgery is considered the definitive treatment for balanitis xerotica obliterans involving the penis in men. Preliminary treatment with topical steroids may be considered to reduce inflammation before surgical intervention. Persistent voiding issues, such as a weakened stream after a successful meatotomy, suggest a urethral stricture. As a general rule, men with persistent disease, ie, significant phimosis or meatal stenosis, unresponsive to very high potency topical steroids after 3 months of treatment, are candidates for surgery.

Indications for surgery include significant symptoms inadequately relieved by conservative measures, failure of topical therapy, suspected penile cancer, diagnostic uncertainty, and patient preference over prolonged topical therapy. Surgery is considered the definitive treatment for balanitis xerotica obliterans involving the penis in men. Preliminary treatment with topical steroids may be considered to reduce inflammation before surgical intervention. Persistent voiding issues, such as a weakened stream after a successful meatotomy, suggest a urethral stricture. As a general rule, men with persistent disease, ie, significant phimosis or meatal stenosis, unresponsive to very high potency topical steroids after 3 months of treatment, are candidates for surgery. A penile malignancy is suggested by unexplained ulcerations, nodules, growth of a neoplastic lump, blistering, erythema, blisters, lymphadenopathy, and failure to respond to standard therapy. Common signs and symptoms of penile malignancy include nodule or tumor growth, ulceration, blistering, hematuria, erythema, pain, purulent discharge, bleeding, lymphadenopathy, and failure to respond to treatment for presumptive inflammatory or infectious balanitis.[92] Circumcision is often recommended when phimosis affects voiding, reduces sexual performance, or causes paraphimosis. Circumcision is almost always curative.[93] Uncircumcised children should undergo complete or radical circumcision when lichen sclerosus is suspected based on immunohistological findings of premalignant markers, such as p53 and Ki67, in affected foreskins. This precaution aims to prevent the later development of squamous cell carcinoma in adulthood. Half of all balanitis xerotica obliterans cases treated with partial or incomplete circumcision have been linked to disease recurrence.[94] Residual foreskins from a partial or incomplete circumcision often demonstrate recurrent disease about half the time. Circumcisions in patients with balanitis xerotica obliterans may be challenging due to a buried penis or extensive adhesions between the foreskin and glans. Any failure to completely separate these adhesions will negatively affect the area's cosmetic appearance and may cause problems with sexual activity.[95]

Circumcision is often recommended when phimosis affects voiding, reduces sexual performance, or causes paraphimosis. Circumcision is almost always curative.[93] Uncircumcised children should undergo complete or radical circumcision when lichen sclerosus is suspected based on immunohistological findings of premalignant markers, such as p53 and Ki67, in affected foreskins. This precaution aims to prevent the later development of squamous cell carcinoma in adulthood. Half of all balanitis xerotica obliterans cases treated with partial or incomplete circumcision have been linked to disease recurrence.[94] Residual foreskins from a partial or incomplete circumcision often demonstrate recurrent disease about half the time. Circumcisions in patients with balanitis xerotica obliterans may be challenging due to a buried penis or extensive adhesions between the foreskin and glans. Any failure to completely separate these adhesions will negatively affect the area's cosmetic appearance and may cause problems with sexual activity.[95] Scarring from balanitis xerotica obliterans often leads to a contraction of the frenulum, significantly affecting quality of life and future sexual enjoyment. A frenuloplasty is recommended in such situations as part of a complete circumcision. For more information, see the companion StatPearls reference review, Circumcision, at "www.statpearls.com/point-of-care/19567." Preputioplasty of the foreskin, together with intralesional steroid injections, has been suggested as a possible acceptable alternative to circumcision in selected boys with balanitis xerotica obliterans who wish to avoid a full circumcision. Preputioplasty involves the use of plastic surgical techniques to open the tight foreskin without resection of this part. This approach has traditionally not been recommended when sclerotic, atrophic changes suggestive of balanitis xerotica obliterans are present. However, interest has grown in combining the procedure with intralesional triamcinolone injections in treating such cases.[96]

Preputioplasty of the foreskin, together with intralesional steroid injections, has been suggested as a possible acceptable alternative to circumcision in selected boys with balanitis xerotica obliterans who wish to avoid a full circumcision. Preputioplasty involves the use of plastic surgical techniques to open the tight foreskin without resection of this part. This approach has traditionally not been recommended when sclerotic, atrophic changes suggestive of balanitis xerotica obliterans are present. However, interest has grown in combining the procedure with intralesional triamcinolone injections in treating such cases.[96] Initial reports indicate high levels of patient satisfaction with this procedure as an alternative to traditional circumcision despite a 13% recurrence rate. No data supports the use of this modality in adults with balanitis xerotica obliterans, and long-term outcomes are unavailable. The lack of research on preputioplasty with intralesional triamcinolone is a concern, as the need to remove residual premalignant tissue with circumcision after this treatment is unknown. Glans resurfacing with carbon dioxide laser or reconstruction performed using a skin graft from the thigh is possible. Such surgery has been reported to preserve sensation and normal sexual ability postoperatively.[97] A meatotomy is generally indicated for meatal stenosis that has failed topical steroid therapy or has a peak flow rate of less than 10 mL/sec.[98] Repeated dilations are usually unsuccessful long-term. Meatotomies are typically performed starting with a ventral slit. A straight clamp is placed between the ventral surface of the glans and the inferior urethra to provide initial hemostasis. The clamp is removed after several minutes. Electrocautery may be used for bleeding. The cut edges are closed with small absorbable interrupted sutures, usually 000 and 0000. A single, continuous suture is not recommended, as it may cause closure due to the purse-string effect.

Meatotomies are typically performed starting with a ventral slit. A straight clamp is placed between the ventral surface of the glans and the inferior urethra to provide initial hemostasis. The clamp is removed after several minutes. Electrocautery may be used for bleeding. The cut edges are closed with small absorbable interrupted sutures, usually 000 and 0000. A single, continuous suture is not recommended, as it may cause closure due to the purse-string effect. One technique involves a continuous suture on each meatal lip, which is then reinforced with one or more interrupted sutures. Creating a much larger surgical urethral opening than usual (extended meatotomy) or an interposition procedure is usually recommended for patients with balanitis xerotica obliterans, as the meatal orifice tends to close substantially as it heals. A dorsal slit may also need to be performed in some cases. Topical steroid therapy should be continued after meatotomy surgery.[99] The success of the surgery depends significantly on postoperative care. The routine involves at least twice-daily manual separation of the meatal lips until the site is completely healed to prevent the closure of the urethral opening. This routine should be performed for a minimum of 2 weeks or until the surgical site is completely healed. The median recurrence rate of meatal stenosis 2 years after meatotomy surgery in patients with balanitis xerotica obliterans is 40%.[100] The long-term recurrence rate has been reported to be as high as almost 90%, but much depends on postoperative care. About 20% to 47% of patients with balanitis xerotica obliterans undergoing circumcision ultimately require meatal surgery, compared to about 6% undergoing circumcisions for other reasons.[101][102] Meatotomy at the time of circumcision does not appear to improve this outcome and may even increase the risk.[103] Treatment of urethral strictures is needed in about 20% of male patients with balanitis xerotica obliterans. Strictures due to the condition typically start at the meatus and progress proximally. Such strictures are continuous and may extend as far as the proximal urethra. Urethral strictures in balanitis xerotica obliterans tend to be more difficult to manage than strictures from other etiologies due to the progressive fibrotic cutaneous process underlying this condition.[104]

Treatment of urethral strictures is needed in about 20% of male patients with balanitis xerotica obliterans. Strictures due to the condition typically start at the meatus and progress proximally. Such strictures are continuous and may extend as far as the proximal urethra. Urethral strictures in balanitis xerotica obliterans tend to be more difficult to manage than strictures from other etiologies due to the progressive fibrotic cutaneous process underlying this condition.[104] Treatment is the same as with other types of urethral strictures, but the recurrence rate is higher at almost 90%. Urethral dilation and direct-vision internal urethrotomy surgery are less successful in treating urethral stricture disease in patients with balanitis xerotica obliterans, particularly if the affected part is 2 cm or more in length, so urethroplasties are preferred.[105][106][107] Intraurethral steroid suppositories have also demonstrated some efficacy in treating urethral strictures associated with balanitis xerotica obliterans.[108] Single-stage urethroplasty using buccal mucosal grafts is now the gold-standard treatment for significant urethral strictures in patients with balanitis xerotica obliterans.[109] Single-stage urethroplasties are preferred over the 2-stage technique whenever possible.[110][111] The buccal mucosa is the preferred graft material for urethroplasties, as genital skin results in a very high late-failure rate, according to a study of patients monitored for up to 10 years.[112] Lingual and lower lip sources are recommended if buccal mucosa tissue is insufficient.[113] Split-thickness skin grafts from the thighs may also be used but give inferior long-term results when utilized in 2-stage procedures.[114][115][116] Severe, recurrent, intractable strictures may require a perineal urethrostomy, which is generally preferred over a suprapubic cystostomy. Routine follow-up is needed at least yearly since recurrences are common. Genital skin flaps or grafts with single or staged urethroplasties were frequently performed in the past and enjoyed generally good short-term success.[117] However, the recurrence rate was almost 100% after long-term follow-up, so these techniques are no longer recommended.[118][119] For more information on the management of urethral strictures, see the companion StatPearls reference review, Circumcision, at www.statpearls.com/point-of-care/30833.

Contact dermatitis can occur anywhere on the genitalia. Pruritic, erythematous skin lesions arise from direct contact with a particular substance. The affected area can appear as a red rash with cracked skin.[120][121] Leukoplakia can resemble lichen sclerosus, with both conditions presenting as white, flat plaques. Like balanitis xerotica obliterans, leukoplakia can undergo malignant transformation. Leukoplakia typically results from chronic irritation occurring between the glans and foreskin. Leukoplakia, lichen planus, penile intraepithelial neoplasia, erythroplasia of Queyrat, and scleroderma cannot be reliably differentiated from balanitis xerotica obliterans (lichen sclerosus) without a biopsy. For more information, see the companion StatPearls reference review, Penile Cancer and Penile Intraepithelial Neoplasia, at www.statpearls.com/point-of-care/26896."= Plasma cell balanitis, or Zoon balanitis, is a benign condition in older men. The condition usually presents as a flat, red plaque that sometimes has associated smaller red marks. The diagnosis requires a biopsy.[122] Psoriasis is a chronic, noncontagious disorder, presenting with scaly, red, pruritic cutaneous patches that can arise anywhere on the body. A high turnover rate of skin cells characterizes this autoimmune condition. Plaques are commonly seen and may appear on the penis.[123] The most important differentials of balanitis xerotica obliterans include the following: Atopic dermatitis Balanitis circumscripta plasmacellularis Bowen disease of the glans Candida infection Carcinoma in situ Cellulitis Contact dermatitis Erythroplasia of Queyrat Fixed drug reaction Infectious balanitis Leukoplakia Lichen planus Penile cancer (squamous and verrucous types, fibrosarcoma) Penile intraepithelial neoplasia Pseudoepitheliomatous keratotic and micaceous balanitis Psoriasis Radiation dermatitis Recurrent balanoposthitis Scleroderma Squamous cell carcinoma of the penis Syphilis Zoon balanitis A thorough clinical investigation and a careful diagnostic examination, which may include a biopsy and a histological analysis, can distinguish balanitis xerotica obliterans from mimics and guide treatment.

Penile cancer is an uncommon but dangerous male malignancy with a tumor-specific mortality of 30%.[124] As mentioned, the potentially devastating diagnosis of penile cancer occurs in up to 15% of balanitis xerotica obliterans cases but takes many years to develop.[125][126][127][128] Circumcision may reduce this risk significantly, especially in the neonatal period, as phimosis is an independent risk factor for malignant transformation.[129] In contrast, lichen sclerosus of the vulva has only a reported 5% estimated risk of progression to squamous cell carcinoma. Chronic inflammation results in genetic and epigenetic changes, as well as abnormal cellular homeostasis and cytokine activation, promoting malignant transformation.[130] A significant number of patients with penile cancer (up to 50%) report a history of balanitis xerotica obliterans. Early use of steroid creams can limit disease progression significantly, while early circumcision is curative in most clinical situations involving the foreskin.

The complications of balanitis xerotica obliterans usually arise from late diagnosis and may include disease recurrence, phimosis, paraphimosis, meatal stenosis, progression to penile cancer, urethral strictures, genital scarring, glans ulceration, frenulum contraction, and urinary retention. Balanitis xerotica obliterans is widely known to lead to squamous cell carcinoma of the penis, though this association is generally underappreciated and underestimated.[131] The following complications were noted in a 10-year retrospective study of patients with balanitis xerotica obliterans: 62.6% had foreskin scarring 47.2% had foreskin and meatus involvement 26.4% had foreskin, glans, and meatus involvement 19.8% needed an additional procedure following their circumcision or meatal dilation In addition to penile cancer, severe, chronic disease may ultimately cause glans atrophy. Renal failure has also been reported.[132] Early diagnosis and treatment can help prevent the progression of the disease and its more serious complications.

Early diagnosis, proper treatment, and regular follow-up visits are essential to avoid sexual dysfunction, urethral strictures, and penile cancers. Primary care providers or urologists should evaluate patients yearly. Patients should be immediately referred to urology if findings from follow-up exams are concerning for possible disease progression or recurrence. Patients should be counseled on proper self-genital examination. Individuals prescribed topical steroids for lichen sclerosus must strictly adhere to application schedules. Surgical intervention is warranted when topical steroids fail to correct symptoms. Circumcision is recommended as a precaution in pediatric patients suspected of having lichen sclerosus.

Autoimmune disorders, such as thyroid disorders, type 1 diabetes mellitus, rheumatoid arthritis, and scleroderma, have a higher incidence in patients with balanitis xerotica obliterans. Patients should be screened for these conditions in the presence of suggestive clinical signs or symptoms. Pathological examinations of foreskins after circumcisions should be regularly performed to identify patients with balanitis xerotica obliterans who would require follow-up examinations and are at risk of penile carcinoma, meatal stenosis, and urethral strictures. Patients identified as having balanitis xerotica obliterans should receive routine follow-up for the above reasons.

Balanitis xerotica obliterans requires the interprofessional contributions of primary care physicians, pediatricians, nurses, pharmacists, dermatologists, and urologists. Prescription high-potency topical corticosteroids are used for initial therapy in symptomatic patients. Surgery is required in a large percentage of patients who continue to have symptoms despite topical treatment, particularly if they develop phimosis. Circumcision and additional surgical interventions may be necessary. All healthcare team members should be involved in educating patients to dispel misconceptions and provide support. Follow-up with primary care physicians and consulting services is vital to prevent the malignant progression of inflammatory changes to squamous cell carcinoma of the penis or urinary difficulty from stricture disease. As balanitis xerotica obliterans involves a particularly intimate area of the male anatomy, and some treatments require prolonged therapy or surgery with extended recovery periods, healthcare team members should be aware of how emotionally sensitive the discussion and management of this condition can be and treat it with professionalism and respect. Clinicians should counsel patients about signs and symptoms to watch for. Indicators of disease progression warrant a prompt urology consultation. Increased awareness of the optimal treatment of balanitis xerotica obliterans and close coordination among the healthcare team members improve outcomes and quality of life for affected individuals.