The rate of lichen sclerosus (BXO) was significantly higher among male patients with acquired than congenital phimosis

Balanitis Xerotica Obliterans (BXO) in acquired Phimosis in male patients

BXO is thin white dry patches that 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 as lichen sclerosus

If any male patients who has tight foreskin recently , we must exclude BXO phimosis. Literature showed that it is more likely to due to BXO

Following advice will be given

1. Topical 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.

2. Circumcision with frenuloplasty in adults and children with BXO may be required if there is no improvement in the tight foreskin with steroids

3. Further treatment, or treatment of circumcised patients, is more challenging. Topical steroids will require in patients after circumcision who has BXO on glans (head) penis 

4. Steroids injection provides efficacious management for urinary stricture disease in patients with biopsy ­proven BXO before invasive surgery.

Care Quality Commission has given "Good" rating to London Circumcision Centre in all five domains

This service is rated as

Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

CQC carried out an announced comprehensive inspection at the London Circumcision Centre. This inspection was conducted as part of CQC inspection programme of independent health providers.

The provider is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

CQC key findings of our clinic were:

• The service had systems in place which kept patients safe. These included checks on patients attending the service and risk assessments conducted to ensure staff and patients were safe whilst attending the centre.

• Staff at the service had the skills and knowledge to provide effective care.

• Feedback on the provider and service revealed high levels of patient satisfaction.

• Provision of services at the clinic considered patient demand and included timely access appointments which included face-to-face, telephone and video consultations.

• There was a focus on innovative, learning and improvement.

Good Ratings for London Circumcision Centre

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Good Ratings for London Circumcision Centre -

CQC inspected and Rated Good

The scarred foreskin due to balanitis xerotica obliterans requires prompt treatment

Lichen sclerosus of men genitalia is usually called balanitis xerotica obliterans (BXO). This is progressive scarring with inflammatory disease of the head of the penis (also called glans penis) and foreskin. It may cause tight foreskin (called phimosis).  BXO has a significant abnormality which sometimes associated with urinary obstruction and sexual dysfunction. Medical treatment with steroids may require in early BXO.  Circumcision is indicated in the case of the tight foreskin (phimosis) due to BXO or foreskin trapped beyond the head of the penis during sexual activity (paraphimosis).

The following pathway should be adopted in the management of lichens sclerosis (BXO) phimosis

• Assessment and advice will require for the different option of treatments of BXO by our specialist Urologist 

• Consultation is important before the circumcision and other surgical procedures to know about the management. 

• Circumcision, biopsy and urethroplasty are surgical options.

• Follow up advice following the circumcision is an important part of the long-term advice. 

• Good practice to send a foreskin biopsy to confirm the diagnosis and exclude any skin cancer 

• Further steroid treatment may require treating the remaining BXO over the head of the penis after 4-6 weeks of circumcision

• Long term follow-up is required if biopsy proven BXO found after the circumcision   

Disclaimer: This information is not the replacement of medical professional advice. Please contact us for professional consultation.

Reference: Kwok R, Shah TT, Minhas S. Recent advances in understanding and managing Lichen Sclerosus. F1000Research. 2020;9.

Cracks on the foreskin

Cracked foreskin presents with mild burning, itching, swelling and red patches, and with tight foreskin (phimosis)

Cracks or fissures on the foreskin may be due to Inflammatory conditions of the foreskin (called posthitis) or head of the penis (balanitis) or both (balanoposthitis). These cracks could be painful and associated with fungal or bacterial infection, scarring conditions called lichen sclerosus (BXO), and tight foreskin (phimosis and Paraphimosis).

Fungal infections are usually responsible, most commonly involving the yeast called Candida albicans, which is associated with a bacterial infection. Foreskin yeast infection is generally called “candidiasis” or “thrush” and is not common in healthy individuals but in cancer, immunocompromised, and diabetic individuals.

Bacterial infections, especially Streptococcus organisms, are the second most common cause of balanitis. The sexual health clinic needs to exclude sexually transmitted infections (STIs). The most common STIs are Chlamydia trachomatis, genital mycoplasmas, and Neisseria gonorrhoeae. These can produce cracks and red foreskin.

Poor hygiene due to a tight foreskin can cause cracks on the foreskin and irritant balanitis.

Diabetic patients with uncircumcised men have a high (35%) prevalence of balanitis, which gives them cracks to the foreskin. Among men with an acquired tight foreskin, 26% had a history of diabetes. Tight foreskin (phimosis) in men with diabetes increases the risk of infection of the foreskin and glans.

Balanitis xerotica obliterans (BXO) is a chronic, progressive, and sclerosing inflammatory foreskin disease of unknown cause. BXO will produce scars and cracks.

Treatment of the cracks is medical (antifungal, antibiotics and steroids) and surgical (dorsal slit, preputioplasty or circumcision). Control of sugar in diabetes patients is critical to managing the above treatment.

If cracks of freoskin are associated with tight foreskin (phimosis)

The treatment of phimosis depends on several factors, including age and the degree of tightness. Here are the available options:

1. Steroid Cream or Ointment: These reduce inflammation and improve foreskin elasticity.

2. Stretching Exercises: Beneficial, especially in the early stages of Phimosis.

 3. Stretching Rings (Phimostretch): Devices that aid gentle foreskin stretching.

If cracks of freoskin are associated with diseased freoskin (BXO)

We provide circumcision, dorsal slit or preputioplasty at our centre
Please get in touch with us for professional and expert advice by calling the mobile number below to the doctor directly.

Please call us at +447527314081 to discuss this further and get advice from our specialist team.

• Dr Nkwam: Consultant Urologist

• Dr Sanndher: Consultant Urologist

• Dr Khan: Paediatric Surgeon/Urologist

• Dr Safdar: Experienced Surgeon

London Circumcision Centre, Leyton and South Woodford Clinics, London