Frequency of lichen sclerosus in children presenting with phimosis: A systematic histological study



      The incidence of preputial lichen sclerosus (PLS) among children presenting with phimosis varies from 10 to 95%, depending on the age, the protocol for the treatment of pediatric phimosis, the method of diagnosis (clinical versus histological), and case mix (congenital versus acquired phimosis).


      PLS may not be clinically obvious. Our aim is to show that a systematic histological examination of the prepuce may diagnose PLS in clinically unsuspected cases.


      Prospective observational study of the histology of all prepuces resected from boys undergoing circumcision for phimosis but not clinically suspected to have PLS.


      PLS was diagnosed histologically in 22 boys (32%). Boys with PLS were significantly older (mean 8.4 versus 4.7 years old). Diagnosis of PLS was not related to the degree of phimosis (summary figure). In three patients (grade 4 phimosis) glans discoloration was observed during surgery, and all had PLS. Follow up for boys found to have PLS ranged from 1 to 10 years. One patient developed recurrent phimosis, attributed to inappropriate conservative resection, and required further surgery. There were no cases of meatal stenosis.


      Subtle cases of PLS may be difficult to detect clinically. Children are frequently asymptomatic, except for being unable to retract the prepuce. Physical examination has a low negative predictive value for the diagnosis of PLS. Complete removal of the prepuce with permanent glans exposure is regarded as essential to cure PLS and to avoid recurrent phimosis, but our patients were treated with partial circumcisions for cultural reasons. Only one needed reoperation for recurrent phimosis.


      Summary Figure
      Graphical AbstractAge tends to be higher in preputial lichen sclerosus) PLS cases, but the degree of phimosis is not related to the histological diagnosis of the condition.



      PLS (preputial lichen sclerosus), PPV (positive predictive value), NPV (negative predictive value)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Pediatric Urology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Johnsen N.V.
        • Brown E.T.
        • Rynolds W.S.
        • Kaufman M.R.
        • Milam D.F.
        • Dmochowski R.R.
        Diagnosis and management of male genital lichen sclerosus.
        Curr Bladdr Dysfunct Rep. 2016; 11: 234-241
        • Clouston D.
        • Hall A.
        • Lawrentschuk N.
        Penile lichen sclerosus (balanitis xerotica obliterans).
        Br J Urol. 2011; 108: 14-19
        • Freeman C.
        • Laymon C.W.
        Balanitis xerotica obliterans.
        Arch Dermatol Syphilol. 1941; 44: 547-561
        • Caterall R.D.
        • Oates J.K.
        Treatment of balanitis xerotica obliterans with hydrocortisone injections.
        Br J Vener Dis. 1962; 38: 75-77
        • Meuli M.
        • Briner J.
        • Haniman B.
        • Sacher P.
        Lichen sclerosus et atrophicus causing phimosis in boys: a prospective study with 5-year follow up after complete circumcision.
        J Urol. 1994; 152: 987-989
        • Nguyen A.T.M.
        • Holland A.J.A.
        Balanitis xerotica obliterans: an update for clinicians.
        Eur J Pediatr. 2020; 179: 9-16
        • Ghidini F.
        • Virgone C.
        • Pulvirenti R.
        • Trovalusci E.
        • Gamba P.
        Could a careful clinical examination distinguish physiologic phimosis from balanitis xerotica obliterans in children?.
        Eur J Pediatr. 2021; 180: 591-595
        • Celis S.
        • Reed F.
        • Murphy F.
        • Adams S.
        • Gillick J.
        • Abdelhhafez A.H.
        • et al.
        Balanitis xerotica obliterans in children and adolescentes: a literature review and clinical series.
        J Pediatr Urol. 2014; 10: 34-39
        • Bochove-Overgaauw D.M.
        • Gelders W.
        • de Vylder A.M.A.
        Routine biopsies in pediatric circumcision: (non)sense?.
        J Pediatr Urol. 2009; 5: 178-180
        • Naji H.
        • Jawad E.
        • Ahmed H.A.
        • Mustafa R.
        Histopathological examination of the prepuce after circumcision: is it a waste of resources?.
        Afr J Pediatr Surg. 2013; 10: 164-166
        • Kiss A.
        • Kiraly L.
        • Kutasy B.
        • Mrksz M.
        High incidence of balanitis xerotica obliterans in boys with phimosis: a prospective 10-year study.
        Pediatr Dermatol. 2005; 22: 305-308
        • Kuehhas F.E.
        • Miernik A.
        • Weibl P.
        • Schoenthaler M.
        • Sevcenco S.
        • Schauer I.
        • et al.
        Incidence of balanitis xerotica obliterans in boys younger than 10 years presenting with phimosis.
        Urol Int. 2013; 90: 439-442
        • Huntley J.S.
        • Phil D.
        • Bourne M.C.
        • Munro F.D.
        • Wilson-Story D.
        Troubles with the foreskin: one hundred consecutive referrals to pediatric surgeons.
        J Roy Soc Med. 2003; 96: 449-451
        • Aguayo C.
        • Clavarro A.E.H.
        • Irastorza C.M.
        Balanitis xerotica obliterans, underdiagnosed pathology of clinical relevance.
        Cir Pediatr. 2015; 28: 133-136
        • Pilatz A.
        • Altinkilic B.
        • Schormann
        • Maegel L.
        • Izykowski N.
        • Bckcr J.
        • et al.
        Congenital phimosis in patients with and without lichen sclerosus: distinct expression pattern of tissue remodeling associated genes.
        J Urol. 2013; 189: 268-274
        • Yardley I.E.
        • Cosgrove C.
        • Lambert A.W.
        Paediatric preputial pathology: are we circumcising enough?.
        Ann R Coll Surg Engl. 2007; 89: 62-65
        • Mattioli G.
        • Repetto P.
        • Carlini C.
        • Granata C.
        • Gambini C.
        • Jasonni V.
        Lichen sclerosus et atrophicus in children with phimosis and hypospadias.
        Pediatr Surg Int. 2002; 18: 273-275
        • Das S.
        • Tunuguntla H.S.
        Balanitis xerotica obliterans – a review.
        World J Urol. 2000; 18: 382-387
        • Gargollo P.C.
        • Kozakwich H.P.
        • Bauer S.B.
        • Borr J.G.
        • Peters C.A.
        • Retik A.B.
        • et al.
        Balanitis xerotica obliterans in boys.
        J Urol. 2005; 174: 1409-1412
        • Villanueva C.E.
        • Gander R.
        • Royo-Gomes G.
        • Ezzeddine M.
        • Lopez-Paredes M.
        • Asensio-Llorente M.
        Treatment of balanitis xerotica obliterans in pediatric patients.
        Cir Pediatr. 2020; 33: 79-83
        • Homer L.
        • Buchanan K.J.
        • Nasr B.
        • Losty P.
        • Corbett H.
        Meatal stenosis in boys following circumcision for lichen sclerosus (balanitis xerotica obliterans).
        J Urol. 2014; 192: 1784-1788