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Urology Dec 2017To characterize the physical features and reconstructive outcomes of a series of idiopathic urethral strictures (IUS) in an effort to elucidate the nature of this common...
OBJECTIVE
To characterize the physical features and reconstructive outcomes of a series of idiopathic urethral strictures (IUS) in an effort to elucidate the nature of this common yet poorly understood entity.
PATIENTS AND METHODS
We retrospectively reviewed our urethroplasty database to identify men undergoing initial urethral reconstruction from 2007 to 2014 at 1 of 3 hospitals (N = 514). Patients were stratified by stricture etiology, including IUS, acute trauma, iatrogenic, hypospadias, balanitis xerotica obliterans, and radiation. IUS that had a known history of subacute or repetitive blunt force to the perineum (horseback riding, avid cycling, motocross, etc.) were subclassified as subacute or repetitive perineal trauma (SRPT).
RESULTS
Among 466 men undergoing initial reconstruction with available data, 215 (46%) were IUS cases. The median delay between IUS diagnosis and urethroplasty was 5.2 years, during which time men underwent a median of 2 endoscopic treatments. A total of 51 (24%) IUS cases recalled a distinct history of SRPT. Men with SRPT were slightly younger (median 43 vs 48 years, P = .01) but were remarkably similar in terms of urethral stricture length (2 vs 2 cm, P = .15), location (bulbar 96% vs 89%, P = .41), and treatment success (92% vs 88%; P = .61). Bulbar (-)SRPT and (+)SRPT IUS had similar clinical and morphometric features as those with known acute bulbar trauma with excellent 24-month stricture recurrence-free survival rates (93% vs 92% vs 97%, P = .19).
CONCLUSION
IUS have clinical features suggesting that many may be related to unrecognized or repetitive perineal trauma. Although treatment tends to be delayed, IUS have excellent urethroplasty success because most are short bulbar strictures amenable to anastomotic urethroplasty.
Topics: Adult; Humans; Male; Middle Aged; Perineum; Retrospective Studies; Urethral Stricture; Urologic Surgical Procedures, Male; Wounds and Injuries
PubMed: 28755966
DOI: 10.1016/j.urology.2017.07.022 -
Canadian Urological Association Journal... May 2018Circumcision is one of the most widely performed procedures in the world. One of the indications for circumcision is lichen sclerosis (LS). The natural history of LS in...
INTRODUCTION
Circumcision is one of the most widely performed procedures in the world. One of the indications for circumcision is lichen sclerosis (LS). The natural history of LS in children is not as well-documented as in adult patients. Surgeons use the appearance of the foreskin or meatus to predict the diagnosis of LS. Indeed, if the diagnosis of LS is made in childhood, does it change management in the long-term? Pathological analysis of the excised foreskin is routinely done if there is suspicion of LS. Our aim is to assess the concordance between the clinical and pathological diagnosis of suspected LS and to assess the need for sending the foreskin for pathological examination.
METHODS
We conducted a retrospective chart review of 64 of 420 boys who underwent circumcision in a tertiary children's hospital from June 2005 to June 2014, and who had their foreskin sent for pathology due to the clinical suspicion of LS. Demographics, presenting symptoms, presumed clinical diagnosis, pathological findings, and followup data were collected and analyzed.
RESULTS
Over the review period, 64 patients underwent circumcision for presumed LS. The mean age of the children was 9.7 years (range 3-16.5). All the children who had circumcision for presumed LS diagnosis were symptomatic. LS was confirmed in 47 of 64 foreskins (73.5%). Balanitis xerotica obliterans (BXO) was clinically suspected in 40 (85%) of the 47 patients. The mean followup was 10 months (range 1-15), with seven recurrences (15%) during that period. The recurrences required revision surgery in two patients and five were managed with steroids only.
CONCLUSIONS
In our series, the clinical diagnosis correlated with the pathological diagnosis in most cases. A clinical suspicion of LS without routine foreskin pathological assessment will reduces the overall cost to the healthcare system. Appropriate counselling of the patient/parents and their primary caregiver is imperative, as recurrence is common.
PubMed: 29405913
DOI: 10.5489/cuaj.4331 -
European Journal of Pediatric Surgery :... Apr 2015Idiopathic urethritis (IU) in children is of unknown etiology and treatment options are limited. We aim to report our experience with steroid instillation in IU in...
PURPOSE
Idiopathic urethritis (IU) in children is of unknown etiology and treatment options are limited. We aim to report our experience with steroid instillation in IU in children.
METHODS
Retrospective data collection of all male children diagnosed with IU over a period of 8 years. Patients with balanitis xerotica obliterans (BXO) and positive urine culture at presentation were excluded from the study. Data were collected on patient demographics, laboratory and radiological investigations, cystoscopy findings, management, and outcomes.
RESULTS
A total of 16 male children were diagnosed with IU. The mean age was 11.6 (7-16) years. Presenting symptoms included dysuria in 10; frank hematuria in 7; loin pain in 5; and scrotal pain in 2 patients. Serum C-reactive protein and full blood count was tested in 13 patients and was within normal limits in all of them. Endoscopy findings included posterior urethritis in 12, anterior urethritis in 2, and urethral stricture with inflammation in 2 patients. Ten patients required more than one episode of steroid instillation. Mean follow-up was 19.4 (1-74) months. Complete resolution of symptoms and signs occurred in 15 (93.6%) patients and improvement of symptoms and signs noted with ongoing treatment in 1 (6.4%) patient.
CONCLUSION
IU in children can be successfully managed with steroid instillation. In our series, 93.6% of children had complete resolution of symptoms.
Topics: Adolescent; Anti-Inflammatory Agents; Child; Cystoscopy; Drug Administration Schedule; Endoscopy; Glucocorticoids; Humans; Male; Methylprednisolone; Retrospective Studies; Triamcinolone; Urethritis
PubMed: 24683102
DOI: 10.1055/s-0034-1368800 -
Arab Journal of Urology Dec 2017To evaluate the presence of balanitis xerotica obliterans (BXO), clinically and pathologically, in the urethra of boys with failed previous hypospadias repair and where...
OBJECTIVES
To evaluate the presence of balanitis xerotica obliterans (BXO), clinically and pathologically, in the urethra of boys with failed previous hypospadias repair and where surgical management was planned.
PATIENTS AND METHODS
Between February 2010 and March 2015, boys with failed distal penile hypospadias repair who were planned for surgical management were evaluated for the presence of clinical and pathological evidence of BXO. Samples were obtained from the urethral plate and fossa navicularis, after obtaining informed consent and ethical approval. The samples were fixed, sectioned, and haematoxylin and eosin stained for light microscopic examination.
RESULTS
In all, 157 boys were enrolled in our study, with a mean (SD) age of 6.4 (2.8) years. All the boys had a history of failed hypospadias repair surgeries (once or more). The presentation was fistula in 34 boys (21.7%), meatal stenosis in 45 (28.7%), urethral stricture in 28 (17.8%), and total dehiscence in 50 (31.8%). BXO was detected clinically in 46 boys (29.3%). The total number of biopsies taken was 314, of which 124 (39.5%) were pathologically BXO-positive samples. Of the 157 boys, BXO-positive cases were clinically associated with fistula in seven boys (4.5%), meatal stenosis in 18 (10.8%), urethral stricture in seven (4.5%), and total dehiscence in 15 (9.6%). Of the 314 pathological samples, pathologically BXO-positive samples were associated with fistula in 20 samples (6.4%), meatal stenosis in 40 (12.7%), urethral stricture in 22 (7%), and total dehiscence in 42 (13.4%).
CONCLUSIONS
In failed hypospadias cases BXO should be considered, especially for cases with multiple failures, meatal stenosis, and total dehiscence. Urethral plate and fossa navicularis biopsies are important in planning a proper approach for subsequent repair.
PubMed: 29234536
DOI: 10.1016/j.aju.2017.08.002 -
Dermatologic Therapy Nov 2020Ultrapotent topical corticosteroids and circumcision are usually effective for male genital lichen sclerosus (MGLSc); however, refractory cases are often referred to our...
Ultrapotent topical corticosteroids and circumcision are usually effective for male genital lichen sclerosus (MGLSc); however, refractory cases are often referred to our Male Genital Dermatology Unit. Treatment with autologous platelet-rich plasma (TPRP) has recently been advocated as a safe and effective treatment option, but there have been no prospective studies in men to date. The objective of this study is to assess the safety and efficacy of TPRP for MGLSc resistant to conventional therapy. A prospective, open-label, single-arm, therapeutic study was carried out in this study. Inclusion criteria: resistant to conventional therapy for at least 6 months. Procedure: infiltration of 0.1 mL/cm PRP every 8 weeks. Monthly data recording: visual appearance with photographs and external scoring by an expert using Investigator's Global Assessment Scale (IGA scale 0-5), symptoms (scale 0-5), quality of life (QoL; Dermatology Life Quality Index [DLQI]), and complications. No. of patients included was n = 5. No. of patients excluded during treatment was n = 1. Mean initial IGA: 3.6. Mean initial DLQI: 6. TPRP n = 34 (range: 2-9; average: 6.8 per patient). Mean IGA at 18 months: 3.25. Mean DLQI at 18 months: 1.25. All patients reported being completely asymptomatic at 10 months. No. of patients with complications is n = 1 (balanitis). TPRP seems to be safe and effective, regarding symptom control and improvement in QoL; however, visual changes were minimal.
Topics: Circumcision, Male; Humans; Lichen Sclerosus et Atrophicus; Male; Platelet-Rich Plasma; Prospective Studies; Quality of Life
PubMed: 32683770
DOI: 10.1111/dth.14032 -
International Journal of Molecular... Sep 2016Balanitis xerotica obliterans (BXO) is a chronic inflammatory skin disorder of unclear etiology. The etiology and the exact molecular mechanisms underlying the disease...
Balanitis xerotica obliterans (BXO) is a chronic inflammatory skin disorder of unclear etiology. The etiology and the exact molecular mechanisms underlying the disease are still unknown. The human transglutaminase (TG) family consists of several proteins with catalytic activity essential for biological processes. In the present research we investigated the transcript levels of three TGs in patients operated on for congenital phimosis without or with histologically confirmed BXO; Thirty children with acquired phimosis were enrolled. The removed foreskins were sent both for histological diagnosis and for quantitative real-time PCR to evaluate the transcript levels of keratinocyte (TG1), tissue (TG2), and epidermal (TG3) transglutaminase; We observed a decrease in TG1 and TG3 transcripts by about 70% (p < 0.001) in foreskins from patients with BXO (n = 15) in comparison with patients without BXO (n = 15) and an increase in TG2 mRNA levels by 2.9 folds (p < 0.001); Reduced expression of both TG1 and TG3 was associated with the altered structure of the foreskin in BXO and can be a consequence of damage to keratinocytes. Increased expression of TG2 can be the result of chronic inflammation. TG2 overexpression can play a pivotal role in triggering and maintaining the inflammatory response in BXO patients.
Topics: Adolescent; Balanitis Xerotica Obliterans; Blotting, Western; Cadherins; Child; Child, Preschool; Foreskin; Gene Expression Profiling; Gene Expression Regulation, Enzymologic; Humans; Interferon-gamma; Isoenzymes; Male; Phimosis; Reverse Transcriptase Polymerase Chain Reaction; Transglutaminases
PubMed: 27649154
DOI: 10.3390/ijms17091551 -
Urology Annals 2015Penile lichen sclerosus (LS) is a nagging condition and its progression result in devastating urinary and sexual problems and reduction in the quality-of-life. This...
PURPOSE
Penile lichen sclerosus (LS) is a nagging condition and its progression result in devastating urinary and sexual problems and reduction in the quality-of-life. This study has been carried out to present our experience about this disease with simultaneous review of the available literature.
MATERIALS AND METHODS
This retrospective study has been done at a tertiary care center of eastern India. The data of 306 patients affected with LS were analyzed for clinical presentation, physical examination, investigations, and treatment offered.
RESULTS
Presenting symptoms were non-specific. The prepuce was most commonly involved location followed by glans and meatus. Urethral involvement was not isolated as the primary site. Circumcision was done in 237 patients, while 63 patients underwent meatotomy. Thirty-six of 39 cases of LS induced stricture were treated with buccal mucosal graft (BMG) either in one stage or in two stages.
CONCLUSION
LS varies from being a highly aggressive disease of the penis and anterior urethra to a burnt out condition affecting just the meatus and surrounding glans. Early diagnosis and treatment are required to prevent its complication and associated morbidity. Management depends on the anatomical location of lesion, extent of involvement, rapidity of progression and its severity. Use of BMG in LS induced urethral stricture has shown encouraging results.
PubMed: 26229314
DOI: 10.4103/0974-7796.150490 -
Archivio Italiano Di Urologia,... Jun 2018To evaluate the outcome of circumcised patients with balanitis xerotica obliterans (BXO) using uroflowmetry (UF).
INTRODUCTION
To evaluate the outcome of circumcised patients with balanitis xerotica obliterans (BXO) using uroflowmetry (UF).
METHODS
Between 2011 and 2013, 180 children underwent a circumcision for phimosis. The foreskin was examined on microscopy. Patients with an histological diagnosis of BXO were included in the study. Patients with BXO underwent UF two weeks after surgery and treatment with clobetasol propionate ointment. Patients were re-evaluated at 6, 12, 18 and 24 months postoperatively clinically and using UF.
RESULTS
75 of 180 circumcised patients (41.6%) were included. At two weeks, Thirtytwo of 75 patients (42.7%) displayed a pathological UF. At six months, 15 patients (20%) had pathological UF and a new cycle of clobetasol was prescribed. At one year, 10 patients (13.3%) displayed patholgocial UF and underwent progressive urethral dilatation or meatoplasty. At 18 months, 71 patients (94.7%) displayed regular UF, 3 underwent a meatoplasty and one a staged urethroplasty for a severe urethral stenosis. At two years, UF was normal in 74 out of 75 (98.7%).
CONCLUSIONS
We recommend to send for hystological examination all foreskins excised after circumcision. We believe that a clinical and uroflowmetric follow-up of pediatric patients with BXO is mandatory for a prompt identification of post-voiding dysfunction.
Topics: Adolescent; Balanitis Xerotica Obliterans; Child; Child, Preschool; Circumcision, Male; Clobetasol; Follow-Up Studies; Foreskin; Glucocorticoids; Humans; Male; Retrospective Studies; Rheology; Treatment Outcome; Ureteral Obstruction; Urodynamics; Urologic Surgical Procedures
PubMed: 29974722
DOI: 10.4081/aiua.2018.2.123 -
Journal of Cutaneous Pathology Jan 2015Evolving lesions of lichen sclerosus (LS) pose a diagnostic challenge owing to an absence of classic findings of epidermal atrophy, dermal sclerosis, a band-like...
BACKGROUND
Evolving lesions of lichen sclerosus (LS) pose a diagnostic challenge owing to an absence of classic findings of epidermal atrophy, dermal sclerosis, a band-like lymphocytic infiltrate and the presence of eosinophils.
METHODS
Retrospective specimens of LS were reviewed. Demographic information, biopsy vs. excision and the following histopathological characteristics were noted: presence and number of eosinophils, epidermal hyperplasia, spongiosis, early/transitional LS, well-developed LS and coexisting squamous cell carcinoma (SCC). Linear regression analysis was performed.
RESULTS
The data consisted of 66 biopsies (36 male [M], 30 female [F]), from 53 individuals (33M, 20F), including 57 genital and 9 extragenital biopsies. Seven biopsies showed SCC, 28 showed epidermal hyperplasia and 14 exhibited spongiosis. Thirty-five specimens were early/transitional LS and commonly exhibited epidermal hyperplasia (57%), epidermotropism of lymphocytes (97%) and basement membrane thickening (97%). Thirty-five biopsies (53%) contained eosinophils (23 early/transitional lesions). Male gender (p = 0.074) was associated with increased eosinophils. The presence of SCC (p = 0.014) was a significant predictors of eosinophil number.
CONCLUSIONS
Epidermal hyperplasia, epidermotropism of lymphocytes and basement membrane thickening are helpful features in identifying early LS. Eosinophils are not an uncommon finding in LS and are most common in male genital lesions and in LS associated with SCC.
Topics: Adult; Aged; Aged, 80 and over; Biopsy; Eosinophils; Female; Humans; Lichen Sclerosus et Atrophicus; Male; Middle Aged; Retrospective Studies; Young Adult
PubMed: 25404144
DOI: 10.1111/cup.12445 -
JRSM Open Jun 2017We observed whether general practitioners are referring more appropriately for balanitis xerotica obliterans in regards to circumcision, especially at a time of clinical...
OBJECTIVES
We observed whether general practitioners are referring more appropriately for balanitis xerotica obliterans in regards to circumcision, especially at a time of clinical concern, and whether their discriminative abilities were affected by age. We also aimed to explore if balanitis xerotica obliterans was over-diagnosed by surgeons potentially leading to unnecessary circumcisions of healthy foreskins.
DESIGN
Cross-sectional descriptive study.
SETTING
Leicester Royal Infirmary.
PARTICIPANTS
All children less than 16 years of age were included and were subsequently split into two categories: those less than or equal to five years and those above five years. Circumcision was justified if surgeon found pathology under foreskin commissioning guidelines set by the Royal College of Surgeons of England. After clinical diagnosis of balanitis xerotica obliterans, the pathological database was searched for histological confirmation.
MAIN OUTCOME MEASURES
Has diagnostic accuracy improved amongst general practitioners for balanitis xerotica obliterans and is there a high clinical to histological confirmation.
RESULTS
Of the total patients, 14.5% were diagnosed clinically with balanitis xerotica obliterans. Only 66.7% of cases were histologically confirmed with chronic inflammation found in the rest; 5.5% of all boys referred had balanitis xerotica obliterans on histology; and 8.2% of children <5 had clinical balanitis xerotica obliterans with 1.7% confirmed histologically. This was in contrast with 18.1% and 9.2% found in the older cohort.
CONCLUSION
There remains a high diagnostic inaccuracy amongst general practitioners when referring for balanitis xerotica obliterans. This is greatest in those under five years. Although balanitis xerotica obliterans was over-diagnosed, no healthy foreskin underwent unnecessary circumcision.
PubMed: 28620502
DOI: 10.1177/2054270417692731