Balanitis Xerotica Obliterans Clinical Presentation

Updated: Nov 11, 2019
  • Author: Amira M Elbendary, MD, MBBCh, MSc; Chief Editor: William D James, MD  more...
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Early in its course, penile lichen sclerosus (balanitis xerotica obliterans [BXO]) is relatively asymptomatic with only mild visually observable changes of the penis and glans. Physical changes occur over months or years and may include color or textural changes. Early symptoms are more prevalent in uncircumcised patients.

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

Symptoms occurring in late penile lichen sclerosus (in uncircumcised patients) are as follows:

  • Phimosis (inability to retract the foreskin over the glans)

  • Paraphimosis (inability to return an already retracted foreskin back over the glans)

The development of multifocal squamous cell carcinoma (SCC) in persons with lichen sclerosus et atrophicus of the penis and hepatitis C virus infection has been reported. SCC of the penis arising from BXO alone has also been noted.

A urethral stone manifesting as a stop valve, a rare complication of BXO, has been reported.

In older patients, BXO with phimosis can be a cause of difficulty with urination; thus, older patients should be examined to see if they have BXO in they have symptoms of difficulty with urination. [26]


Physical Examination

Early penile lichen sclerosus (balanitis xerotica obliterans [BXO]) demonstrates only subtle physical findings (eg, 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. 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. Erosions, fissures, petechiae, serous and hemorrhagic bullae, and telangiectasias of the glans have been reported, albeit uncommonly. It runs a relapsing and remitting course, with periods of quiescence, but is nonetheless progressive.{ref41]

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. Urinary retention may be severe enough to cause retrograde damage to the posterior urethra and to the bladder and kidneys. Significant urethral meatal narrowing has led to sloughing of the distal half centimeter of the urethra. Phimosis and paraphimosis of uncircumcised patients may occur at this late stage. Chronic disease may lead to atrophy of the glans. [27]

Seventeen percent of lichen sclerosus cases are extragenital, beginning as mild, nonspecific erythema with mild hypopigmentation.

In one case report [28] , BXO in a middle-aged man involved the entire anterior urethra and the scrotum. It manifested as a palpable nodular scrotal mass and caused obstructive voiding symptoms. He was treated with a staged urethroplasty.



Phimosis, paraphimosis, painful erection, urethral stenosis, urinary retention, and altered flow are the most common complications. [29]

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.

Malignant transformation is estimated to occur in 4-8% of cases. A 2017 retrospective review found that 13.6% of patients with balanitis xerotica obliterans (BXO) had evidence of penile intraepithelial neoplasia. [6] Another retrospective study in Paraguay that examined surgical specimens for invasive squamous cell carcinoma found that 33% of cases had associated BXO. [30] A similar study in London found that 28% of 155 patients with penile squamous cell carcinoma had BXO. [31]

A long lag time has been observed between symptoms of BXO and diagnosis of penile squamous neoplasia, with Nasca et al reporting between 10 and 23 years. [25]

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 (BXO) resulting in renal impairment in a child that lead to a persistent but improved renal impairment after circumcision has been noted. [32]