Chronic progressive sclerosing inflammatory dermatosis of unknown origin that results in white plaques with epidermal atrophy and scarring…… Lichen sclerosus. Penile Lichen sclerosus (LS) is the preferred term for Balanitis Xerotica Obliterans.

1. BALANITIS XEROTICA OBLITERANS
By
Dr. Muhammad Saifullah
Post-Graduate Resident
Department of Urology & Renal Transplantation
Allied Hospital, Faisalabad.

3. INTRODUCTION
•Chronic progressive sclerosing inflammatory
dermatosis of unknown origin that results in white
plaques with epidermal atrophy and scarring……
Lichen sclerosus
•Penile Lichen sclerosus (LS) is the preferred term
for Balanitis Xerotica Obliterans.

4. INTRODUCTION
Lichen Sclerosus has Extragenital and Genital
manifestations like
a) Lichen Sclerosus et atrophicus
(Dermatological Literature)
b) Balanitis Xerotica Obliterans (Glans
penis presentation)
c) Kraurosis Vulvae (Vulvar presentation)

5. GENITAL LICHEN SCLEROSUS
BALANITIS XEROTICA
OBLITERANS
KRAUROSIS VULVAE

6. IMPORTANCE
• Genital presentations of Lichen Sclerosus (both
penile and vulvar) outnumber the Extragenital
presentations by more than 5:1
• 83 % patients show genital involvement.
• Increased risk of squamous cell carcinoma in
Genital disease has been noted although rare.

7. EPIDEMIOLOGY
• International incidence is 1 in 300-1000.
• In men, peak incidence is usually between 30-50
years. However any age group can be affected.
• Commonly seen in uncircumcised and incompletely
circumcised men and boys. (98 %)

8. EPIDEMIOLOGY
AGE (In Years)

9. EPIDEMIOLOGY
• In women Incidence is bimodal, with first peak before
puberty and another peak in postmenopausal age group.
• No racial association has been noted yet, however familial
clustering has been apparent.
• Male to female ratio is 1:6, which reveals that the females
are more commonly affected.

10. PATHOPHYSIOLOGY
• Inflamation and altered fibroblast function in
papillary dermis  Fibrosis of the upper dermis.
• Increased GLUT-1 (Glucose transporter) and
decreased VEGF expression in affected skin supports
that hypoxia and ischemia has a role in initial cellular
and vascular damage.

11. ETIOLOGY
•Multifactorial
• Uncircumcised state / Late Circumcision.
Foreskin  Chronic irritation & serve to maintain
a friendly environment some infectious agent 
Inflammation.

12. ETIOLOGY
• Hormonal factors.
Testosterone  Decreased serum levels of free
testosterone, androstenedione, and
dihydrotestosterone compared with control subjects.
• Genetic factors.

13. ETIOLOGY
• Autoimmune disease
Autoantibodies (including antinuclear, thyroid
antimicrosomal, antigastric parietal cell, anti-adrenal
cortex, antismooth muscle, and antimitochondrial
antibodies) have been detected in patients with lichen
sclerosus.
Vitiligo, thyroid disease, diabetes, and alopecia areata
have also been commonly reported in association with
lichen sclerosus.

14. ETIOLOGY
• Presence of Human Papillomaviruses
Patients with penile lichen sclerosus alone have
NOT been demonstrated to have a higher
incidence of HPV infection.

15. SIGNS &
SYMPTOMS

16. CLINICAL PRESENTATION
• Usually Asymptomatic
having mild observable
skin changes on Glans
and Penis.
• Itching (although not
usual)

17. CLINICAL PRESENTATION
• Symptoms occurring with time and progression of
penile lichen sclerosus are as follows:
 Pruritus
 Burning
 Hypoesthesia of the glans penis
 Dysuria
 Painful erection with altered sexual function
 Decrease in urinary force or stream caliber
 Urethritis with or without discharge

18. CLINICAL PRESENTATION
On clinical Examination:
•Early penile lichen sclerosus 
mild, nonspecific erythema; mild
hypopigmentation.
•As the condition progresses, single
or multiple discrete erythematous
papules or macules progress and
coalesce into atrophic ivory, white,
or purple-white patches or plaques.

19. CLINICAL PRESENTATION
On clinical Examination:
•Lesions most commonly affect the
glans and prepuce. The frenulum,
urethral meatus, fossa navicularis,
penile shaft, and perianal areas may
become involved.
•A sclerotic white ring at the tip of
the prepuce is diagnostic at this
stage.

20. CLINICAL PRESENTATION
•Uncircumcised patients can
present with:
 Phimosis (inability to
retract the foreskin over
the glans)
 Paraphimosis (inability
to return an already
retracted foreskin back
over the glans)

21. CLINICAL PRESENTATION
•With further disease progression,
the glans may become adherent to
the prepuce.
•The coronal sulcus and frenulum
may be sclerotically destroyed.
•The urethral meatus may narrow
to the point of urinary retention.
•Renal Insufficiency.

22. CLINICAL PRESENTATION
•Squamous Cell Carcinoma of the penis arising
from BXO alone has also been noted.
•Urethral stone manifesting as a stop valve has
been reported.
•Older patients should be examined to see if they
have BXO if they have symptoms of difficulty
with urination.

23. CLINICAL PRESENTATION
• Vulvar lichen Sclerosus usually presents with
progressive pruritus, dyspareunia, dysuria or genital
bleeding.

24. INVESTIGATION
S

25. LABORATORY STUDIES
• Rapid protein reagin test
helps exclude syphilis.
• Biopsy & histopathology.

26. HISTOPATHOLOGICAL
FINDINGS
• Histopathologic changes of genital lichen sclerosus are
similar to those of non-genital lichen sclerosus.
• Epidermal findings include
 Orthokeratosis
 Hyperkeratosis with follicular plugging
 Hyperkeratosis without follicular plugging
 Stratum malpighii atrophy
 Basal layer hydropic degeneration
 Dermoepidermal clefting

27. HISTOPATHOLOGICAL
FINDINGS
• Significant dermal edema and homogenization of the
collagen in the upper dermis occurs, with dilatation of
blood and lymph vessels and a loss of elastic fibers.
• The immune cells moving into areas of BXO include
lymphocytes, plasma cells, and histiocytes in the mid
dermis. The inflammatory infiltrate is less pronounced
in long-standing lesions.

28. HISTOPATHOLOGICAL
FINDINGS

29. MEDICAL
MANAGEMEN
T

30. MEDICAL CARE
• No consistently effective treatment.
• Topical and intralesional steroids
(Clobetasol & Mometasone)….. BXO
limited to the prepuce in boys with
minimal scar formation.
• Intraurethral steroids provide
efficacious therapy for stricture
disease in patients with biopsy-proven
BXO before invasive surgery.

31. MEDICAL CARE
• Steroid-based creams 
ineffective in persons with
established scarring.
• Successful therapy with topical
steroid application and skin
stretching on prepubertal boys
with unretractable foreskin and
phimosis.

32. MEDICAL CARE
•Topical tacrolimus…..
Calcineurin Inhibitor. Relapse
rate was lower after topical
tacrolimus therapy than with
betamethasone therapy.
•Acitretin….. Aromatic retinoid

33. MEDICAL CARE
•Intralesional adalimumab…..
Injectable protein which blocks
TNF- α
•Oral and intramuscular
penicillin  softening of the
skin and pruritus, tenderness.

34. MEDICAL CARE
•Carbon dioxide laser
treatment has been found
effective.

35. MEDICAL CARE
•Treatment of circumcised
patients, is more
challenging.

36. SURGICAL
OPTIONS

37. SURGICAL CARE
•In uncircumcised patients,
Circumcision is usually
Therapeutic
•Regular follow-up to
observe any suspicious
malignant changes.

38. SURGICAL CARE
•Foreskin preputioplasty
combined with intralesional
triamcinolone might be a
alternative as against
circumcision to treat BXO.

39. SURGICAL CARE
•BXO-induced urethral stricture can be treated with
Buccal mucosal graft (BMG) urethroplasty.
• BXO-related strictures with a viable urethral plate, 1-stage
dorsal onlay buccal mucosal urethroplasty achieves superb
medium-term results. They also state that the intervention
created a normal, wide-caliber, slitlike glans, and a 2-stage
procedure provides effective treatment but is associated with
a higher revision rate.

40. SURGICAL CARE
• Buccal mucosa appears to be a durable source of
nongenital tissue for urethral replacement.
• Attention to detail in terms of graft harvest, graft
preparation, and graft fixation helps to avoid major
postoperative complications.
• Onlay grafts appear to be preferable to tube grafts, and
patients with a diagnosis of BXO do not appear to be
candidates for the 1-stage urethral reconstruction using
buccal mucosa.

41. SURGICAL CARE

42. SURGICAL CARE
•Circumferential laser vaporization for severe meatal
stenosis secondary to BXO reportedly is effective.

43. COMPLICATION
S

44. COMPLICATIONS
•Phimosis & Paraphimosis
•Urinary retention
•Retrograde damage to the posterior urethra,
bladder, and kidneys. Long-standing BXO can
cause renal impairment.
•Painful erections  limits sexual function.

45. COMPLICATIONS
• Malignancies (rare). Common signs and symptoms of
penile malignancy include
a. Nodule or tumor growth
b. Ulceration & blistering
c. Hematuria
d. Pain
e. Purulent discharge
f. Lymphadenopathy
g. Failure to respond to treatment for presumptive
inflammatory or infectious balanitis.

46. PREVENTION

47. PREVENTION
•Early circumcision may decrease
the risk of developing male genital
lichen sclerosus (balanitis xerotica
obliterans BXO]); nearly all cases
have been reported in
uncircumcised patients

48. PROGNOSIS

49. PROGNOSIS
• Male genital lichen sclerosus is chronic and often
progressive. Regression or improvement of atrophic areas is
unexpected.
• Malignancies have been reported (rare); most common
cancers are
a.Squamous cell carcinoma (SCC)
b.Adenosquamous carcinoma
c.Verrucous carcinoma.
• The average time between diagnosis of lichen sclerosus and
subsequent diagnosis of penile malignancy was 17 years.