May 1984.

Carbon dioxide laser treatment of balanitis xerotica obliterans

John Louis Ratz, M.D. Cincinnati, OH

A case of balanitis xerotica obliterans unresponsive to topical therapy is presented. The condition was successfully corrected following epithelial vaporization with the carbon dioxide laser, the patient remaining free of recurrence for 21 months postoperatively. (J AM ACAD DERMATOL 10:925-928, 1984.)
[CIRP note: This file does not include three photographs.]

Balanitis xerotica obliterans (BXO) is a chronic and often painful condition of the glans penis. Its histology is similar to that of lichen sclerosus et atrophicus (LSA), and indeed, it probably does represent LSA of the glans. Many modalities have been used in the treatment of this condition but not always with success.

A patient came to our office with a histologic diagnosis of BXO that had been unresponsive to topical therapy. The involved area was treated with CO2 laser vaporization and has remained free for 21 months after treatment.


A 39-year-old white man came to the surgical unit and laser treatment center of the Department of Dermatology of the University of Cincinnati Medical Center in September, 1981, with a biopsy-proved diagnosis of BXO of at least 2 years duration. The patient had experienced pain for some time before that and eventually had developed an inability to retract his foreskin, necessitating a circumcision that was performed in 199.

Following this procedure the patient was left with a raw, erosive, exquisitely painful glans penis. After 2 years of unsuccessful management, primarily with topical antibiotics and potent corticosteroids, he was referred for other treatment considerations.

Physical examination at the time of his initial visit revealed a superficial, hemorrhagic erosion of most of the surface of the glans penis (Fig. 1). The meatus and corona were free of involvement, and the remainder of the cutaneous examination was unremarkable.

The biopsy specimens were reviewed and coincided with the clinical diagnosis of BXO.

On September 30, 1981, with the patient under regional anesthesia, the involved area was vaporized through the handpiece of the articulating CO2 laser, which was operating at 20 W of power output in the continous mode. The CO2 laser spot size was 2 mm, and the power density delivered was approximately 600 W/cm2. This resulted in a dry, somewhat charred glans penis (Fig. 2) The entire affected area was vaporized to margins of apparently normal epithelialization. The wound was allowed to reepithelialize from these normal margins, with the thought that the resulting epithelium would remain uninvolved.

Once regional anesthesia was no longer effective, the patient experienced a syncopal episode and was hospitalized for observation. Application of topical lidocaine jelly relieved the symptoms, and the patient return to his home the next day. He was instructed to cleanse the area twice daily with hydrogen peroxide and to immediately apply an antibacterial ointment (Polysporin).

Occasional burning pain was still present to a minima degree until 3 weeks postoperatively. He has remained free of disease since that time, which is 21 months postoperatively (fig. 3).


Fig. 1. Preoperative appearance of BXO, involving most of the glans penis.


Fig. 2. Postoperative appearance of glans immediately following CO2 laser vapororization.


Fig. 3. Appearance of glans after completion of reepithelialization and healing.


Treatment of LSA may depend on its extent, location, symptoms, etc. Although not always successful, suggested modes of therapy have included topical or intralesional corticosteroids,1 oral or topical estrogens,2 topical antibiotics,2 topical or intralesional androgens,3 cryosurgery,4 and, when the glans penis is involved, excision of the affected area.5 When more extensive involvement is present, meatotomy has been performed, but may believe that this procedure is rarely effective for any length of time.6,7 Urethroplasty has been suggested as a possible treatment of choice,6 and a combination of circumcision, meatal dilatation, and meatoplasty has also been suggested.7

Most observers agree that the condition can be, and usually is, progressive and that symptoms can include difficulty with micturition, nonretractable foreskin, urinary retention, and pain and difficulty during intercourse.7 Our patient had not had intercourse since before his circumcision, 2 years before his initial visit to our unit.

Some reports indicate that development of leukoplakia can take place in LSA,4 and squamous cell carcinoma has been reported to occur in areas of involvement of BXO.8,9 Radiation therapy might be a factor in the development of such tumors, however.8,10

One report of CO2 laser treatment is present in the urologic literature,11 but the technique differed slightly from ours, and no mention was made of follow-up. The exact physics of CO2 laser vaporization as employed here can be found in our earlier paper on treatment of port-wine stains.12 Although the details of the treatment are the same, we are finding with time, that the power output for successful vaporization is probably much less than in much of our original work. Most CO2 laser vaporization in our unit is now carried out at power outputs of between 5 and 10 W.


It has been gratifying to us to be able to effect curative therapy for our patient after he had had several years of unsuccessful treatment. It is important to note that this patient never experienced any meatal edema or difficulty in micturition postoperatively. This can be attributed tto the mode of therapy and has been discussed in our earlier papers.12-14 It is also important to note that he was restored to completely normal sexual function 3 months postoperatively, this after a hiatus of more than 2 years.

Although pain is generally not a factor following CO2 laser surgery, it was quite prominent for a short time in this patient and must always be considered as a possible sequela.

We believe that CO2 laser vaporization, as presented, represents an attractive alternative to conventional therapy for what is often a chronic, progressive, and difficult to treat entity. Its use may successfully obviate the need for more rigorous surgery at a later date and should be considered when other modes of therapy have failed.


  1. Poynter JH, Levy J: Balanitis xerotica obliterans: Effective treatment with topical and sublesional steroids. Br J Urol 39:420425, 1967.
  2. Laude TA, Narayanswamy G, Rajkumar S: Lichen sclerosus et atrophicus in an eleven year old girl: Report of a case. Cutis 26:78-80
  3. Pasieczny TA: The treatment of balanitis xerotica obliterans with testosterone propionate ointment. Acta Derm Venereol (Stockh) 57:275, 1977.
  4. August PJ, Milward TM: Cryosurgery in the treatment of lichen sclerosus et atrophicus of the vulva. Br J Dermatol 103:667-670, 1980.
  5. Mikhail GR: Cancers, precancers, and pseudocancers on the male genitals: a review of clinical appearances, histopathology, and management. J Dermatol Surg Oncol 6:1027-1035, 1980.
  6. Staff WG: Urethral involvement in balanitis xerotica obliterans. Br J Urol 42:234-239, 1970.
  7. Khezri AA, Dounis A, Dunn M: Balanitis xerotica obliterans. Br J Urol 51:229-231, 1979.
  8. Bingham JS: Carcinoma of the penis developed in lichen sclerosus et atrophicus. Br J Vener Dis 54:350-351, 1978.
  9. Bart RS, Kopf AW: Tumor conference No. 18: Squamous cell carcinoma arising in balanitis xerotica obliterans. J Dermatol Surg Oncol 4:556-558, 1978.
  10. Norris HJ, Helwig EB: Relation of lichen sclerosus et atrophicus to the development of carcinoma. Obstet Gynecol 45:369-377, 1975.
  11. Rosenberg SK, et al: Continuous wave CO2 treatment of balanitis xerotica obliterans. Urology 19:539-541, 1982.
  12. Ratz JL, Bailin PL, Levine HL: CO2 laser treatment of port-wine stains: a preliminary report. J Dermatol Surg Oncol 8:1039-1044, 1982.
  13. Bailin PL, Ratz JL, Lutz-Nagey L: CO2 laser modification of Mohs’ surgery. J Dermatol Surg Oncol 7:621-623, 1981.
  14. Bailin PL, Ratz JL, Levine HL: Removal of tattoos by CO2 laser. J Dermatol Surg Oncol 6:997-1001, 1980.

From the Department of Dermatology, University of Cincinnati Medical Center.

Reprint requests to: Dr. John Louis Ratz, Department of Dermatology, Cleveland Clinic Foundation, 9500 Euclid Avenue., Cleveland, OH 44106.

(File revised 19 May 2007)

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