eMedicine Specialties > Dermatology > Diseases of the Dermis

Balanitis Xerotica Obliterans: Follow-up

Author: Noah S Scheinfeld, MD, JD, FAAD, Assistant Clinical Professor, Department of Dermatology, Columbia University; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Private Practice
Coauthor(s): George C Keough, MD, Chief, Clinical Assistant Professor, Department of Medicine, Dermatology Service, Eisenhower Army Medical Center; Daniel S Lehman, MD, Fellow in Minimally Invasive Urology/Oncology, Department of Urology, Columbia University Medical Center
Contributor Information and Disclosures

Updated: Jan 7, 2010

Follow-up

Further Outpatient Care

  • Provide regular follow-up care to observe any changes in involved areas suggestive of malignancy.
  • Consider surgical intervention for symptoms or signs of urethral meatal stenosis.
  • Patients can be taught to dilate the urethral meatus at home if the penile lichen sclerosus (balanitis xerotica obliterans [BXO]) involves the meatus; this sometimes is useful.

Deterrence/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.

Complications

  • As the disease progresses, urinary retention may be sufficient to lead to retrograde damage to the posterior urethra, bladder, and kidneys.
  • As previously noted, painful erections in some cases of male genital lichen sclerosus may limit sexual function.
  • Malignancies have been reported to occur in penile lesions (rare). 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. For this reason, close follow-up care is indicated in order to quickly diagnose any malignant changes.
  • Long-standing penile lichen sclerosus (balanitis xerotica obliterans [BXO]) resulting in renal impairment in a child that lead to a persistent but improved renal impairment after circumcision has been noted.18

Prognosis

  • Male genital lichen sclerosus is chronic and often progressive. Regression or improvement of atrophic areas is unexpected.
  • Malignancies have been reported to arise in penile lichen sclerosus lesions (rare); most common cancers are squamous cell carcinoma (SCC),19 adenosquamous carcinoma, and verrucous carcinoma. 
    • A study of 86 uncircumcised men with genital lichen sclerosus revealed malignant changes (3 SCC, 1 SCC in situ, and 1 verrucous carcinoma) occurring in 5 (5.8%) subjects. The average time between diagnosis of lichen sclerosus and subsequent diagnosis of penile malignancy was 17 years.20
    • Notably, 4 of the 5 patients with malignant changes were found by polymerase chain reaction to have evidence of HPV-16 in their tissue specimens. It has been suggested that lichen sclerosus may promote HPV infection and perhaps the development of SCC.21

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose male genital lichen sclerosus (balanitis xerotica obliterans [BXO]) early is a potential pitfall. 
    • Delay in diagnosis or follow-up of patients with urinary symptoms may lead to irreversible damage to the urinary system.
    • No singularly effective therapy exists; however, treatment with surgical and/or medical techniques should be quickly instituted upon diagnosis of this often progressive condition.
  • Failure to provide regular follow-up care is a potential pitfall. Care should include biopsy of ulcerating or nonhealing areas to detect malignancies (rare) developing from lesions of male genital lichen sclerosus.

Special Concerns

  • Men with genital lichen sclerosus may delay presenting to a physician because of fear or embarrassment. Accurate diagnosis, aided with appropriate biopsy, helps calm anxiety.
  • Goolamali and Pakianathan22 reported penile carcinoma arising in BXO in a 46-year-old white man; thus, if BXO is suspected or has occurred in the past, penile carcinoma should be excluded during the examination.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous Chief Editor, William D. James, MD, to the development and writing of this article.



More on Balanitis Xerotica Obliterans

Overview: Balanitis Xerotica Obliterans
Differential Diagnoses & Workup: Balanitis Xerotica Obliterans
Treatment & Medication: Balanitis Xerotica Obliterans
Follow-up: Balanitis Xerotica Obliterans
Multimedia: Balanitis Xerotica Obliterans
References
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Further Reading

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Keywords

balanitis xerotica obliterans, BXO, penile lichen sclerosus, male genital lichen sclerosus, lichen sclerosus et atrophicus, LS, penile LS, sclerosing inflammatory dermatosis, Koebner phenomenon, vitiligo, thyroid disease, diabetes, alopecia areata, pseudoepitheliomatous keratotic and micaceous balanitis, PKMB

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Contributor Information and Disclosures

Author

Noah S Scheinfeld, MD, JD, FAAD, Assistant Clinical Professor, Department of Dermatology, Columbia University; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Private Practice
Noah S Scheinfeld, MD, JD, FAAD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Optigenex Consulting fee Independent contractor

Coauthor(s)

George C Keough, MD, Chief, Clinical Assistant Professor, Department of Medicine, Dermatology Service, Eisenhower Army Medical Center
George C Keough, MD is a member of the following medical societies: American Academy of Dermatology and American Medical Association
Disclosure: Nothing to disclose.

Daniel S Lehman, MD, Fellow in Minimally Invasive Urology/Oncology, Department of Urology, Columbia University Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Mark W Cobb, MD, Consulting Staff, WNC Dermatological Associates
Mark W Cobb, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and American Society of Dermatopathology
Disclosure: Nothing to disclose.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey Meffert, MD, Assistant Clinical Professor of Dermatology, University of Texas Health Science Center-San Antonio
Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society
Disclosure: Nothing to disclose.

CME Editor

Catherine M Quirk, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania
Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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