What is the likely diagnosis and treatment for a patient with distal penile pain, redness, and wrinkling, negative Urinary Tract Infection (UTI) and Sexually Transmitted Disease (STD) tests, who is circumcised?

Likely Diagnosis and Management

The most likely diagnosis is lichen sclerosus (LS) of the glans penis, which requires biopsy confirmation followed by ultrapotent topical corticosteroid therapy, with circumcision reserved for cases unresponsive to medical treatment. 1

Clinical Presentation Consistent with Lichen Sclerosus

The triad of distal penile pain, redness, and wrinkling in a circumcised male with negative infectious workup strongly suggests lichen sclerosus:

• Porcelain-white appearance with wrinkling is pathognomonic for LS, though early disease may present with erythema and inflammation before the classic white plaques develop 1
• Pain and redness indicate active inflammatory disease, which can manifest as erythematous patches before progressing to the characteristic sclerotic changes 1
• Circumcision does not eliminate LS risk - the disease can affect the glans and coronal sulcus even in circumcised men, though it is less common than in uncircumcised males 1

Diagnostic Approach

Biopsy is essential for definitive diagnosis, particularly to exclude penile intraepithelial neoplasia (PeIN) or squamous cell carcinoma (SCC):

• Perform punch, excisional, or incisional biopsy of the most suspicious areas, especially any well-defined erythematous, erosive, ulcerated, or nodular lesions 1
• Biopsy is indicated for persistent lesions that do not respond to initial treatment, as LS carries a 2-9% risk of malignant transformation to penile SCC 1
• The main indications for penile biopsy are to exclude malignancy and resolve diagnostic uncertainty 2

Initial Treatment Protocol

First-line therapy is ultrapotent topical corticosteroids:

• Initiate treatment with ultrapotent topical corticosteroid (e.g., clobetasol propionate 0.05%) applied to affected areas 1
• Treatment duration should be adequate (typically several weeks to months) before considering surgical intervention 1
• Follow-up at 3 months after initiating topical steroid therapy to assess response, record urinary and sexual symptoms, and examine for residual disease 1, 3, 4

When to Consider Surgical Intervention

Circumcision or other surgical procedures are reserved for specific indications:

• Persistent disease unresponsive to topical steroids at 3 months warrants consideration of surgical options 1, 4
• Urinary symptoms (difficulty voiding, decreased stream) suggest urethral involvement or meatal stenosis requiring urological referral for flow rate and postvoid residual volume measurement 1
• Surgical options include division of coronal adhesions, frenuloplasty, or glans resurfacing with split-skin grafting for refractory cases 1

Alternative Diagnoses to Consider

While LS is most likely, other differential diagnoses in circumcised males include:

• Zoon balanitis (plasma cell balanitis) - presents with well-demarcated, shiny, red-orange plaques, but occurs almost exclusively in uncircumcised men 5
• Bacterial balanitis - though cultures were negative, consider Staphylococcus haemolyticus or other coagulase-negative staphylococci that can cause erosive balanitis even in circumcised males 6
• Psoriasis or lichen planus - can affect the glans in circumcised men, though less commonly than in uncircumcised males 5
• Penile intraepithelial neoplasia (PeIN) - presents as erythematous plaques and must be excluded by biopsy, particularly given the association with LS 1

Critical Follow-Up and Monitoring

Long-term surveillance is essential due to malignancy risk:

• If disease responds well to topical steroids, review again at 6 months, then discharge if remission continues 1, 4
• Provide written information about symptoms suggesting disease relapse or malignant change (persistent erythema, erosion, ulceration, papule, or nodule) 1
• Patients with active ongoing disease require long-term follow-up with assessment at each visit for changes suggestive of PeIN or SCC 1, 4
• LS can recur after many years of remission, so discharged patients must be counseled to seek re-referral if symptoms return 1, 4

Common Pitfalls to Avoid

• Do not delay biopsy in persistent or atypical cases - early detection of malignant transformation is critical 1
• Do not perform circumcision without adequate trial of topical steroids first - many cases respond to medical management 1
• Do not assume circumcision status eliminates LS risk - the disease can affect the glans and coronal sulcus in circumcised men 1
• Do not discharge patients without clear instructions on when to return if symptoms recur or worsen 1, 4