Balanitis Xerotica Obliterans Treatment & Management

Updated: Nov 11, 2019
  • Author: Amira M Elbendary, MBBCh, MSc; Chief Editor: William D James, MD  more...
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Treatment

Medical Care

No consistently effective treatment has been developed for penile lichen sclerosus (balanitis xerotica obliterans [BXO]); however, the therapies described below have varying degrees of reported success.

Topical and intralesional steroids have been used. Topical steroids can offer a reliable option only in the management of mild BXO limited to the prepuce in boys with minimal scar formation. Patients and their families must have realistic expectations with regard to the success of such treatments. Steroid-based creams are ineffective in persons with established scarring. Studies have shown that applying a potent topical steroid improves BXO in the histologically early and intermediate stages of disease and may inhibit further worsening in the late stages. Kiss [35] questioned the utility of topical steroid-based creams for the treatment of clinical BXO. Differences in success rates may relate to an unwillingness to use superpotent corticosteroids.

Ghysel et al reported on successful therapy with topical steroid application and skin stretching on prepubertal boys with unretractable foreskin and phimosis. [36]

Successful treatment of BXO with topical tacrolimus has been reported.

Etretinate therapy has been used, but it is no longer available; acitretin is the current equivalent.

Carbon dioxide laser treatment has been used. [37]

An interesting report notes the successful use of intralesional adalimumab, a medication for psoriasis among other things, for BXO. [38]

Ebert et al, [39] in a retrospective analysis of 13 children with BXO published in 2007, reported that the relapse rate was lower after topical tacrolimus therapy than with betamethasone therapy.

In a case series of 3 patients, 2 had softening of the skin and pruritus, tenderness, and inflammatory change resolution within 3 weeks of receiving oral and intramuscular penicillin. Dirithromycin at 500 mg/d abated BXO in a third patient; the BXO returned when dirithromycin was discontinued but it improved again upon resumption of therapy.

Further treatment, or treatment of circumcised patients, is more challenging.

Intraurethral steroids provide efficacious therapy for stricture disease in patients with biopsy-proven BXO before invasive surgery. [40]

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Surgical Care

A variety of surgical techniques can be used to treat more severe penile lichen sclerosus (balanitis xerotica obliterans [BXO]).

Circumcision is indicated when phimosis or paraphimosis impair function. Topical steroids are recommended to be continued postoperatively, and there should be a low threshold to rebiopsy if any concerns arise regarding squamous neoplasia development. Complete circumcision is recommended, as partial circumcision is associated with recurrent disease in 50% of cases. [41]

Uncircumcised patients usually benefit from therapeutic circumcision. Provide regular follow-up care to observe any changes in involved areas suggestive of malignancy.

Foreskin preputioplasty combined with intralesional triamcinolone might be a tenable alternative as against circumcision to treat BXO. [42]

Consider surgical intervention for symptoms or signs of urethral meatal stenosis. Buccal mucosal graft (BMG) for BXO-induced urethral stricture can work. [29]

Dubey et al [43] report that in 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.

Full-thickness skin grafts from eyelids to penis, plus split-thickness grafts in chronic BXO have been reported.

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.

Circumferential laser vaporization for severe meatal stenosis secondary to BXO reportedly is effective.

In 2007, Levine et al [44] reported on buccal mucosa graft urethroplasty for anterior urethral stricture repair. They evaluated the impact of stricture location and lichen sclerosus on surgical outcome. When lichen sclerosus affects the penis, complete excision of the diseased urethra with multistage repair decreases the rate of stricture recurrence associated with a 1-stage repair.

Palminteri et al [45] treated 17 patients, performing y resurfacing or reconstruction of the glans penis for benign, premalignant, and malignant penile lesions (5 glans skinning and resurfacing; 5 glans amputation and reconstruction of the neoglans, and 7 partial penile amputation and reconstruction of the neoglans). Four patients had lichen sclerosus. Glans resurfacing and reconstruction were performed with the use of a skin graft harvested from the thigh. Patients who received glans resurfacing reported glandular sensory restoration and complete sexual ability. Patients receiving glansectomy or partial penectomy with neoglans reconstruction maintained sexual function and activity, albeit with reduced sensitivity secondary to glans/penile amputation. Palminteri et al concluded that glans resurfacing or reconstruction can ensure a normal-appearing and functional penis, without jeopardizing cancer control.

A review published in 2013 found that BXO likely is more common than believed, and, while circumcision is its primary treatment, topical or intralesional treatments can be co-adjuvants of treatment. [46]

Simsek et al in 2014 performed circular buccal mucosal urethroplasty in 15 males for BXO related to anterior urethral strictures. [47] Urethral catheter removal occurred within 2 weeks, and, during subsequent visits, cosmetic outcome, symptoms assessment, and uroflowmetry over 20.5 months (range, 4-96 mo) were measured. The 15 men manifested no recurrent stricture, a normal meatus, and no chordee or erectile dysfunction. Excellent functional and cosmetic results were achieved in all 15 patients. They concluded that for surgical treatment of meatal strictures, a circular mucosal graft technique restores a functional and cosmetic penis.

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Consultations

Consider consultation with urologists for the following:

  • Therapeutic circumcision

  • Circumcision for symptomatic phimosis or paraphimosis

  • Significant narrowing or obstruction of the urethral meatus or changes in urinary flow

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Activity

In some cases of male genital lichen sclerosus, painful erections may limit sexual function.

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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.

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Long-Term Monitoring

Provide regular follow-up care to observe any changes in involved areas suggestive of malignancy.

Regular follow-up is necessary in patients treated with topical steroids to ensure maintenance of normal skin texture and color and detection of any signs of steroid-related atrophy.

Regular follow-up post therapeutic circumcision is recommended to detect recurrence of the lesion. A low threshold to perform a biopsy on any concerning lesion is recommended to detect early squamous neoplasia.

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.

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