Lichen Sclerosus – Balanitis Xerotica Obliterans – BXO

Lichen sclerosus of the penis and urethra is also known as Lichen Sclerosis, Lichen Sclerosus et Atrophicus and Balanitis Xerotica Obliterans (BXO). This is generally an acquired disease of the penis and urethra. It is not cancer and is not contagious or sexually transmitted. The cause is unknown. Men who develop this chronic and often debilitating disease are generally found to have one or more abnormalities on physical exam including white penile skin color change, especially along the skin towards the head (glans) of the penis, a smoothing of the indentation between the head of the penis and the shaft of the penis often with the appearance of penile skin fusion to the head of the penis, also called phimosis, and/or a urethral opening more towards the undersurface of the penis with induration and narrowing. The changes can vary from subtle to dramatic. Patients with this disease often have associated urethral stricture disease, and the strictures can be short and limited to the urethral opening, or can involve the entire anterior urethra. It is not unusual for patients to have this condition for years without a diagnosis, even though this can usually be diagnosed within 10 seconds during an examination of the penis when Lichen Sclerosis is suspected. This section discusses the penile and urethral changes that occur with Balanitis Xerotica Obliterans and the treatment.

Pictures of Balanitis Xerotica Obliterans with Subtle Skin Changes

The following 4 patients are of a patient recently referred to the Center for Reconstructive Urology from out-of-state for treatment of a long urethral stricture. In general, when a man has meatal stenosis or very long stricture without a history of prior Urologic surgery, we always suspect Balanitis Xerotica Obliterans. Initial inspection of the penis suggested completely normal penile skin and the only abnormality was a narrowing of the urethral opening. However, on closer inspection, there was a whitish line along the undersurface of the penis that was very close to the glans penis and the scar associated with prior circumcision is generally farther away from the head of the penis and darker in color. In many cases the scar is very hard to detect. Further close inspection of the penis as the skin was retracted revealed classic smoothing over of a portion of the coronal sulcus which is the groove between the head of the penis and the shaft of the penis. This change is classic for BXO. This patient was found, despite having mild skin changes, to have severe urethral stricture disease involving the entire anterior urethra (as shown below)

Normal appearing penis, initial inspection
Narrow urethral opening
White circumcising scar towards glans
Smoothing of groove along coronal sulcus

Pictures of Severe Balanitis Xerotica Obliterans – BXO

In more severe cases, there can be shrinkage of the penis and deformity with migration of the urethral opening towards the undersurface of the penis. Some circumcised patient appears uncircumcised because the penile skin fuses to the glans penis and can not be retracted.


Urethral Strictures Caused by Balanitis Xerotica Obliterans

These are retrograde urethrograms (RUGs) of 2 patient who were diagnosed with Lichen Sclerosis where there was early detection. Only the very distal urethra was involved.

BXO stricture limited to the most distal urethra
BXO stricture extending into the penile urethra

This next example is the patient who presented with a long history of slow urination and mild penile skin changes. Although he had areas of normal urethral size, the majority of the penile urethra was extremely narrow, the distal bulbar urethra (just deep to the base of the penis) was very narrow, and the most proximal bulbar urethra (the portion of the anterior urethra closest to the external sphincter) was also very narrow.

Retrograde urethrogram demonstrating severe disease
Voiding study (VCUG) of the same patient

The following films are 2 examples of extensive BXO strictures that have damaged the entire anterior urethra. These patients had a long history of narrowing of the urethra managed with dilations over a period of years. It is likely that their strictures were initially short and progressed over time. However, this could not be confirmed because they were treated repeatedly without first having diagnostic imaging.


Balanitis Xerotica Obliterans Treatment

When patients with BXO are referred to the Center for Reconstructive Urology or are diagnosed for the first time during the physical examination, our initial approach is to first evaluate the urethra and then discuss treatment options. The initial test is a simple calibration of the size of the opening which is easily and painlessly measured using instruments called Bougies. We then perform cystoscopy. If there is any narrowing that prevents easy passage of the scope, urethral imaging is then performed to assess the exact length and location and severity of the stricture disease.

The skin changes often respond favorably to topical steroid cream, such as Temovate 0.05%, but this does not cure any associated strictures. It has been stated on internet health information websites that circumcision is a standard treatment. In selected cases where there is redundant diseased skin, circumcision may be beneficial. However, in many cases, circumcision could lead to a skin deficiency. In some cases, when there is adequate skin length buy narrowing and pinching of the distal skin, Dr. Gelman has used a novel technique with success. This technique involves making longitudinal incisions and transverse closures. This penile skin revision surgery adds width where needed without removing skin. The approach to this condition should be individualized and a treatment plan is best formulated by a Urologist with expertise in male urethral and penile disorders.

When BXO is associated with urethral stricture disease, observation and dilation is generally not recommended. The best management for very short strictures is a meatotomy or extended meatotomy and the most appropriate treatment for longer strictures is urethroplasty (open urethral reconstruction).

The most complex strictures are pan-urethral strictures involving the entire anterior urethra, and these can be greater than 22cm in length. Although these are complex strictures, we have successfully reconstructed many patients with this problem. Our preferred approach to urethral reconstruction, also called urethroplasty, is to reconstruct the bulbar urethra in one stage using bilateral buccal mucosa grafts. Options for the remainder of the urethra include a one-stage repair using penile skin when there is redundant normal penile skin available, or a two-stage repair using split-thickness skin grafts harvested from the thigh. During the first stage, the skin graft is placed adjacent to the urethra. After this surgery, the opening of the urethra is at the base of the penis. During the following 4-6+ months, the graft becomes more supple and can then be rolled into a tube to reconstruct the urethra during the second stage repair.

In the past, it was reported that when penile skin was used as a tissue to augment the narrow urethra, the late recurrence rate was high. It was then suggested that this was because the disease is known to involve the penile skin, and perhaps the recurrence was due to the disease progressing to involve the skin. It was proposed that if distant tissues (buccal mucosa, extra-genital skin grafts) instead, perhaps the long-term success rate would be higher. However, we have occasionally noted areas of whitish color change after first stage repairs as the grafts are visible to the eye. Biopsy confirmed Lichen Sclerosis in both skin grafts and buccal grafts indicating that the use of distant tissues may not always be protective. Although our technical success rate is very high, we recognize the risk of late recurrence with this disease in particular given that the surgery addresses the obstruction but does not cure the disease. Therefore, life long follow-up is especially important when a patient is diagnosed with Lichen Sclerosis.