Balanitis Xerotica Obliterans Phimosis

Tight Foreskin due to lichen sclerosis atrophicus

What is Balanitis Xerotica obliterans (BXO) foreskin?

BXO is a thin white crinkly patches appear on the foreskin. It can be troublesome if this is not treated. This causes tight foreskin in children and adults. This is also known lichen sclerosis atrophicus or a Csillag’s Disease or white spot disease.

Who gets the BXO

BXO is disease can affect uncircumcised male ranging from young boys to adolescent and men. But BXO is rare under 5 years of age. This is the commonest disease of tightening of the foreskin (BXO phimosis)

What causes the BXO?

The exact cause of BXO is not known. Sometimes it is associated with diseases in which the body’s immune system attacks normal tissues. Despite the tendency to affect the genital skin, BXO is not an infection – the disease is not contagious, so sexual partners cannot pick it up. Rarely, BXO can occur in relatives.

What are the symptoms of BXO?

Many patients have none, but the most common symptom of BXO is itching. As a rule the patches on the foreskin itch and can also hurt if the skin breaks down or cracks. In the genital area, the scar-like process can tighten the skin, and this can interfere with sexual intercourse in affected men. BXO can make the foreskin tight and difficult to retract, and can even partly block the flow of urine.

What does BXO look like?

On the main areas of the foreskin, the spots of BXO look like small ivory-coloured slightly raised areas, which can join up to form white patches. Some have tiny yellowish horny plugs within the pale areas. After a while the surface of the spots can look like wrinkled tissue paper. The most common sites are the bends of the wrists, the upper trunk, around the breasts, the neck and armpits. Sometimes this causes no symptoms and they may not even know it is there. The white thin, fragile areas, sometimes surrounding the foreskin in a figure of eight pattern, have a crinkly surface; their fragility may lead to easy bruising and erosions. Later on, the foreskin opening can shrink, leading to pain with intercourse. Less often BXO can develop in children. It can make retraction of the foreskin difficult and interfere with passing water and sexual activities. BXO can be confused with thrush infection.

How will BXO be diagnosed?

The diagnosis of BXO can usually be made from the typical appearance of the condition. This will be confirmed after the examination of the foreskin skin (a biopsy) under the microscope.

Can the BXO be cured?

No treatment is likely to reverse the changes of BXO completely, but the symptoms and signs of the disease can usually be well controlled with a steroid application.

How can BXO be treated?

A variety of treatments are available for BXO. Your symptoms can be relieved by the use of steroid creams or ointments. Bland moisturisers help to soften and protect the skin. In adults, tightening of the foreskin will often respond to steroid ointments; if not, a circumcision may be worth considering. In children, circumcision is usually required.

The fragile skin of BXO may be more susceptible than normal skin to infection with Candida yeasts (thrush) or bacteria, and may split or even bleed. We will treat these problems if they arise. 

What can YOu do?

Cancer of the penis may be a little more likely to occur in BXO that has been present for many years than in normal skin. If you have any lumps or non-healing sores in that area you should ask your doctor to look at them. It is very important to follow to your GP or Urologist if BXO persist even after circumcision and treatment.

Price for adult circumcision with frenuloplasty £625 with Glue or with staplers £750

Tight foreskin - Phimosis in adult and children. Is this associated with Balanitis Xerotica Obliterans (BXO) and what is best evidence based management?

“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.

1.      Topical and intralesional steroids have been used. Topical steroids can offer a reliable option only in the management of mild or early 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.

2.      Circumcision with frenuloplasty in adult and children with BXO

3.      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.

4.      A variety of surgical techniques can be used to treat more severe penile BXO. 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.

5.      Consider surgical intervention for symptoms or signs of urethral meatal stenosis.

6.      Buccal mucosal graft for BXO ­induced urethral stricture can work.

7.      Consider consultation with Dr. Khan  for the following reasons:

  • Therapeutic circumcision

  • Circumcision for symptomatic phimosis or paraphimosis

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

  • In some cases of male genital lichen sclerosus (BXO), painful erections may limit sexual function.”

Source: (Accessed  on 19 June 2017)

London circumcision Centre, Leyton and Thornhill clinic, Luton are the best circumcision clinic for management of tight foreskin with penile BXO. 


1. Assessment and advice for option of treatment like steroid cream, circumcision or further operations   

2. Consultation before the circumcision  

3. Circumcision with glue because glue circumcision is better than stitches

4. Aftercare advice following the circumcision  

5. To send the biopsy to confirm diagnosis and exclude any malignancy 

6. Further treatment after 6 weeks of circumcision  

7. Advice to follow up to your GP or at our clinic with Dr Khan   

8. Long term follow up required if biopsy proven BXO found after the circumcision  

Please contact us for specialist and professional opinion.

PS: This information is only for guidance. This is not a replacement for professional medical advice. Please Dr. Khan for free telephone advice +447527314081 without any obligation.