Effect of Lichen Sclerosis on Success of Urethroplasty

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Key points

  • Lichen sclerosis is a chronic inflammatory skin disease with a variable presentation commonly affecting the anogenital area in both men and women.

  • Management of urogenital lichen sclerosis is predicated on the extent of disease.

  • Most patients can be treated with conservative therapies consisting of minimally invasive surgical techniques and potent topical steroids.

  • Surgical intervention may be indicated when the disease process is extensive or recalcitrant to conservative therapy.

  • Perineal

Presentation

Genital involvement with LS may present with local pruritus, dysuria, phimosis, paraphimosis, fissures, whitish skin, and bothersome lower urinary tract symptoms (LUTS) when the urethra is involved (Fig. 1). Riddell and colleagues5 reported common symptoms in patients diagnosed with LS. Tight foreskin was noted in 25.8%, pruritus in 18%, painful erections in 13.6%, and cracking and bleeding in 9.1%. Up to 19.7% of patients reported difficulty passing urine, which raises concern for either

Pathogenesis

LS is characterized microscopically by the presence of hyperkeratosis, thinning of the epidermis, loss of rete pegs, and collagen deposition in the dermis (Fig. 2). A histiocytic or lymphocytic infiltrate is also noted and has led to the theory of an inflammatory cause.6, 7 A variety of precipitating factors, including autoimmune processes, infections, and trauma, have also been suggested to contribute to the development of LS.

Epidemiology

The true prevalence of LS in men is likely underreported, because many affected individuals will have minimally symptomatic disease. In children presenting with phimosis for circumcision, pathologic analysis has shown that LS may be present in up to 20% to 30% of patients.23, 24, 25 An estimated 28% of men seen in an outpatient clinic diagnosed with LS by physical examination were asymptomatic.5 In 1971, Wallace26 reported an estimated prevalence of LS between 1 in 300 and 1 in 1000 in a cohort

Evaluation for penile/urethral disease

Although the diagnosis of LS is often from history and physical examination (see Fig. 1; Fig. 3), several skin disorders, such as scleroderma, penile intraepithelial neoplasia (previously known as erythroplasia of Queyrat and Bowen disease), leukoplakia, and Zoon balanitis, may present with similar signs and symptoms. Therefore, the authors think a confirmatory biopsy is imperative to rule out malignant and premalignant penile lesions and further guide therapy.4 Moreover, because the external

Management of genital lichen sclerosis

The 3 overarching goals of management are alleviation of symptoms, prevention and treatment of urethral stricture disease, and prevention and detection of malignant transformation. In their practice, the authors have developed 3 additional goals to also address improving quality of life:

  • 1.

    Unobstructed voiding

  • 2.

    Painless intercourse

  • 3.

    Adequate cosmesis32

As a result, the authors have shifted their paradigm in the management of LS. Most patients can be treated with minimally invasive therapies, including

Two-stage repair

Extensive cases of urethral stricture disease due to LS with an inadequate native urethral plate for primary one-stage repair represent a reconstructive challenge. In these cases, a staged surgical approach often yields better outcomes than single-stage reconstruction.41

The first stage of this approach, as described by Barbagli, through a midline penile incision, involves complete excision of all affected urethra and full opening of the glans. Buccal mucosa is harvested and grafted to the

Recurrence after 2-stage repairs

The success rates for 2-stage repairs are traditionally lower when compared with uncomplicated urethral reconstruction, due to a variety of factors, including the extensive nature of preoperative urethral stricture disease and the recurrent nature of LS. Kulkarni and colleagues43 demonstrated a recurrence rate of 27% at a mean follow-up time of 43 months for 2-stage buccal urethral reconstruction.

Peterson and colleagues44 reported a series of 63 patients with LS, 19 who underwent first-stage

Perineal urethrostomy

Perineal urethrostomy (PU) is a recognized alternative for proximal diversion in the nonsalvageable urethra. PU as the final point in management of an obstructed lower urinary tract is becoming more acceptable in men with LS and is an attractive option for patients with extensive urethral LS who may be unwilling or medically unfit to proceed with a 2-stage repair. Prior reports suggest patient satisfaction with a PU is acceptable.41, 44 Barbagli and colleagues45 recently reported their

Recurrence with perineal urethrostomy

There is a wide range of reported recurrence for PU (72%–100%).43, 44 In his series of 173 patients, Barbagli reports a 70% success rate. Even though some patients needed up to 5 additional procedures, nearly all (97%) were satisfied with PU and would choose it again.45 Peterson and colleagues44 found that almost half of planned 2-stage repairs (8/19, 42%) elected to not proceed to the second stage, rendering them with a functional PU without significantly affecting quality of life.

Morey and

Summary

LS is a progressive disease with a varied presentation and can be a challenging problem to manage. Localized disease to the foreskin and glans can be treated with potent topical steroids or circumcision. Urethral involvement occurs in 20% of patients. The extent of urethral involvement ranges from meatal only to panurethral. Intraurethral steroids with self-calibration may provide symptomatic relief to a large proportion of patients. Urethroplasty in this population has a higher risk of

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References (46)

  • A.F. Morey et al.

    Fossa navicularis reconstruction: impact of stricture length on outcomes and assessment of extended meatotomy (first stage Johanson) maneuver

    J Urol

    (2007)
  • L.A. Levine et al.

    Buccal mucosa graft urethroplasty for anterior urethral stricture repair: evaluation of the impact of stricture location and lichen sclerosus on surgical outcome

    J Urol

    (2007)
  • C.K. Patel et al.

    Outcomes for management of lichen sclerosus urethral strictures by 3 different techniques

    Urology

    (2016)
  • A.C. Peterson et al.

    Heroic measures may not always be justified in extensive urethral stricture due to lichen sclerosus (balanitis xerotica obliterans)

    Urology

    (2004)
  • G. Barbagli et al.

    Clinical outcome and quality of life assessment in patients treated with perineal urethrostomy for anterior urethral stricture disease

    J Urol

    (2009)
  • D. French et al.

    The “7-flap” perineal urethrostomy

    Urology

    (2011)
  • New nomenclature for vulvar disease

    Obstet Gynecol

    (1976)
  • S. Das et al.

    Balanitis xerotica obliterans–a review

    World J Urol

    (2000)
  • L. Riddell et al.

    Clinical features of lichen sclerosus in men attending a department of genitourinary medicine

    Sex Transm Infect

    (2000)
  • R.M. Azurdia et al.

    Lichen sclerosus in adult men: a study of HLA associations and susceptibility to autoimmune disease

    Br J Dermatol

    (1999)
  • C.W. Laymon

    Lichen sclerosus et atrophicus and related disorders

    AMA Arch Derm Syphilol

    (1951)
  • M. Bjekic et al.

    Risk factors for genital lichen sclerosus in men

    Br J Dermatol

    (2011)
  • A.R. Cantwell

    Histologic observations of pleomorphic, variably acid-fast bacteria in scleroderma, morphea, and lichen sclerosus et atrophicus

    Int J Dermatol

    (1984)
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    Disclosure Statement: There are no conflicts of interest. No sources of external funding to be reported.

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