Balanitis xerotica obliterans (BXO) is a dermatological (skin) condition affecting the male genitalia. It was first described by Stuhmer in year 1928. The exact pathophysiology of balanitis xerotica obliterans is unknown. Balanitis xerotica obliterans (BXO) commonly occurs on foreskin and glans penis. Patients with BXO usually present with atrophic white patches with indurated (hardened) whitish ring near the tip of penis. Definitive diagnosis is provided by cutaneous biopsy. Prognosis is usually good with treatment. Treatment options for balanitis xerotica obliterans (BXO) include both medical and surgical modalities.

In 1928, Stuhmer for the first time in medical literature has described lichen sclerosus on penis as balanitits xerotica obliterans.^[1]

There is no established classification system for balanitits xerotica obliterans.

The exact pathophysiology of balanitits xerotica obliterans is unknown. Studies have shown that multiple factors were associated with development of BXO. These include:^{[2][3][4][5][6][7][8][9]}

Histopatholgy findings in BXO include the following:^[1]

• Moderately heavy lymphocytic infiltrate found in basal epidermis and superficial dermis in early stages of the lesion.

• Epidermis becomes atrophic with surface hyperkeratosis and thickened basement membrane
• Broad zone of subepidermal oedema with homogenization of collagen, which becomes sclerotic over time
• In few cases, epidermis is detached from dermis resulting in formation of haemorrhagic bullae

There are no comprehensive studies studying the incidence and prevalence in general population. A recent study conducted in an unselected cohort of 153,432 patients presenting to an outpatient clinic in Brookes Army Medical Center in the United States reported the incidence of BXO at 0.07%.

BXO commonly affects middle age group, with men in their twenties were found to be at twice the risk on comparison with other age groups.^[10]

On comparison with white men, BXO is more prevalent in black and hispanic men.^[11]

There are no established screening guidelines for BXO.

If left untreated, BXO may involve the penile skin, scrotum, and entire urethra leading to the complications such as phimosis and urinary retention.^[12]

Complication of BXO include:^{[13][14][15][16][17][18]}

• Phimosis
• Painful erection
• Reduced urinary flow
• Urinary retention
• Risk of malignant transformation into squamous cell carcinoma (long-term prospective studies are needed to determine the real risk of malignant transformation)

Prognosis is usually good with treatment.^[19]

Patients with BXO could be asymptomatic or symptomatic presenting with:^[20]

• Whitening or reddening of penile region
• Difficulty in retracting foreskin
• Painful erection
• Reduced urinary flow
• Urinary retention

• Burning sensation (paraesthesia)
• Purple rash in the genitial region(purpura)
• Small red or purple clusters, often spidery in appearance, on penis(telangiectases)
• Itching(pruritus) of the genitalia
• Discomfort in urination(dysuria)

Physical examination findings include:^[21]

• Whitening or reddening of glans penis, foreskin(prepuce) and coronal sulcus
• Induration of glans and foreskin
• Phimosis
• Purpura
• Telangiectases

Cutaneous biopsy will provide a definitive diagnosis of BXO.^[22]

Treatment of BXO include both surgical and medical modalities, these include:^{[23][24][25][26][27][26][28][29]}

There are no established preventive measures for preventing BXO. Studies have shown that circumcision in males can help in reducing the risk of having BXO.^[30]

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