Balanitis Xerotica Obliterans (Lichen Sclerosus of Penis)


The International Society for the Study of Vulvar Disease recommends use of the term “lichen sclerosus” (LS) for males and females (1).


  • Balanitis xerotica obliterans (BXO) is the historical term for LS affecting the male genitalia, primarily the penis.
  • BXO is associated with destructive inflammation, phimosis, urethral stricture disease, and squamous cell carcinoma (SCC). The disease is more common in uncircumcised males, and the diagnosis is confirmed by biopsy. BXO is the male equivalent of LS atrophicus in females.
  • There are specific histologic features of LS/BXO.


  • The prevalence is 1 in 300 to 1 in 1,000 men. Peak incidence appears to be 21 to 30 years of age (2).
  • Neonatal circumcision appears to prevent development of BXO. However, circumcision later in childhood may not be protective; affects foreskin and glans in 57–100%, meatus in 4–37% with involvement of urethra in about 20%

Etiology and Pathophysiology

The exact cause of BXO is unknown. Several theories have been proposed to account for male BXO.

  • Autoimmune theory: One of the most accepted theories is immune dysregulation. Organ-specific antibodies as well as an increased incidence of other autoimmune conditions, such as diabetes mellitus, vitiligo, and alopecia, have been identified in patients with LS (3).
  • Role of Borrelia and Epstein-Barr virus have been studied. Chronic exposure to urine has been proposed to be a causative factor.

Risk Factors

BXO has a predilection for the warm, moist, urine-exposed environment that exists under the foreskin. Depasquale et al. noted recurrence of BXO when there was redundant skin postcircumcision; recurrence was also common when there were redundant skin folds due to obesity. There appears to be an increased risk for family members to develop LS, suggesting a genetic component to the etiology.

General Prevention

  • Neonatal circumcision appears to be protective.
  • Early diagnosis may allow for earlier treatment to prevent anatomic changes, such as stricture, and prevent malignant change (1).
  • Many advocate that treatment of even asymptomatic patients should occur to prevent disease progression and possible malignancy (1).
  • Currently, there is no curative treatment, and long-term follow-up is needed because of the risk of malignancy.

Commonly Associated Conditions

BXO typically occurs in the uncircumcised penis and appears to spare those who underwent newborn circumcision, but circumcision later in childhood does not appear to be protective.

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