HISTORY
A 59-year-old uncircumcised man is referred by his primary care provider for evaluation of what he deems a “yeast infection” of the distal penis and foreskin. Numerous OTC creams (eg, tolnaftate, clotrimazole, hydrocortisone cream) have been tried, over a period of months, with no improvement in the condition. Now, the patient is experiencing increasing discomfort, not only with the rash itself, but also with actual urinary obstruction. Urination, he reports, has been “difficult” and “messy.”

EXAMINATION
The patient’s foreskin is bound down so tightly that it cannot be retracted without pain. Only a tiny opening remains through which the patient can urinate (with difficulty). The surface of the foreskin is atrophic, dry, and shiny. There is little, if any, redness or swelling, but focal areas of purpura are noted over the area.

DISCUSSION
Penile conditions are problematic for several reasons, not the least of which is the location. Many clinicians are not inclined to even look at the area, pleading ignorance of what they might see and preferring to stay in the diagnostic dark. It is certainly true that a provider would do well to have some idea of what he/she might see when examining a particular area of the body—a principle that applies just as much to elbows and fingernails as to penises.

This patient’s condition is called balanitis xerotica obliterans (BXO), a diagnosis of sufficient obscurity to almost guarantee initial misdiagnosis as “yeast infection” or “herpes.” One treatment failure after another eventually leads to referral to a provider familiar with BXO, which is the male version of lichen sclerosus et atrophicus (LS&A) and usually affects the glans, foreskin, and distal shaft.

The causes of these conditions are as yet unknown. However, much is known about how they present, how they look under a microscope, and how to treat them.

LS&A in women itches terribly and presents with whitish atrophic skin changes that affect the perivaginal and perianal areas, sharply sparing the perineum, which gives it a figure-eight or butterfly look. Localized trauma can produce areas of purpura or even bullae. LS&A is not uncommon in children (females > males), in whom the associated focal purpura can be mistaken for a sign of sexual abuse.

Treatment entails use of the most powerful topical steroid ointments, which are so effective that they have completely replaced previous treatment options (eg, testosterone ointment). While a cure is unlikely, control is a realistic goal. If it is left untreated, not only are affected women miserable, but also the condition can lead to stenosis of the introitus and/or meatal stenosis and eventual urinary blockage.

BXO, as in this case, can also cause urinary obstruction, both from the overlying foreskin and from actual meatal stenosis. This is why advanced cases need referral to urology for possible circumcision. As with many penile diagnoses (eg, squamous cell carcinoma or condyloma), BXO is far more common in the uncircumcised.

Other conditions that belong in the differential include seborrhea, psoriasis, dermatophytosis, candidiasis, Bowen’s disease, and irritant/contact dermatitis. Biopsy is typically needed to confirm the diagnosis.

A more common presentation of BXO is a focally atrophic finish to the glans penis, with whitish highlights and a notably dry feel to the affected skin. But, as in this case, it can also affect the foreskin, leading to inflammation and adhesion of the foreskin to the shaft and glans.

In relatively uncomplicated cases, class 1 steroid ointments, such as clobetasol, are prescribed for twice-daily use in the beginning, with a reduction to once-daily use within about two weeks, and then finally to occasional use as the situation demands. Normally, a class 1 steroid would not be used on a thin-skinned area, but BXO responds quite well to it (and lower-strength steroids usually fail). Once control is achieved, the frequency of application is, of course, limited to as-needed use.

TAKE-HOME LEARNING POINTS
1. There is a differential for penile conditions that includes a number of items beyond “yeast infection”: squamous cell carcinoma, psoriasis, seborrheic dermatitis, contact dermatitis, lichen planus, and balanitis xerotica obliterans (BXO).

2. Dermatology is the relevant initial specialty for these patients, not urology, although the ultimate resolution for balanitis is often surgical.

3. The female counterpart to BXO is called lichen sclerosus et atrophicus (LS&A); it is far more common but equally mysterious to providers unacquainted with it.

4. Biopsy—safe and easy to perform—is often necessary to establish the correct diagnosis. For example, a 3-mm punch biopsy, performed under local anesthesia and closed with a single polyglactin stitch, would provide an adequate specimen. Other things being equal, the use of lidocaine-containing epinephrine is perfectly acceptable (and often necessary!) in this area.

5. BXO/LS&A are now routinely treated with class 1 steroid ointments, such as clobetasol, which has almost totally supplanted older choices (eg, testosterone ointment).

Man has very uncomfortable problem