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Journal of Pediatric Surgery Nov 2018To determine whether treatment of lichen sclerosus et atrophicus (LS), with topical steroids reduces the rate of circumcision.
PURPOSE
To determine whether treatment of lichen sclerosus et atrophicus (LS), with topical steroids reduces the rate of circumcision.
METHODS
Two independent reviewers performed a literature search of studies reporting treatment of LS with topical steroids using EMBASE and MEDLINE database(s).
INCLUSION CRITERIA
boys aged 0-18 years, clinical diagnosis of LS, treatment with topical steroids. Literature reviews, studies of phimosis without LS and adult patients were excluded. Data analysed for each paper included age, duration of treatment, length of follow up and outcome, notably circumcision or no surgery.
RESULTS
The original search identified 26 titles. Application of exclusion criteria left 6 articles for inclusion in the study. Eighty nine patients with LS were treated with topical corticosteroids. Circumcision was avoided in 31/89 (35%; range 0-100%). Median patient age was 6.5 years (1 month-15 years). Median duration of treatment was 2 months (1-23 months); median follow-up 4 months (6 weeks-5 years).
CONCLUSIONS
Treatment of LS with topical steroids reportedly avoided circumcision in 35% of boys. Duration of medical therapy and patient follow up in analysed studies were, however, short. A prospective randomised trial would provide a definitive answer.
TYPE OF STUDY
Systematic review.
LEVEL OF EVIDENCE
III.
Topics: Administration, Topical; Adolescent; Balanitis Xerotica Obliterans; Child; Child, Preschool; Circumcision, Male; Humans; Infant; Infant, Newborn; Lichen Sclerosus et Atrophicus; Male; Steroids
PubMed: 29395150
DOI: 10.1016/j.jpedsurg.2017.12.021 -
Molecules (Basel, Switzerland) Mar 2018Balanitis xerotica obliterans (BXO) is a chronic inflammatory skin disorder, considered the male genital variant of lichen sclerosus. Anti-inflammatory drugs are... (Observational Study)
Observational Study
Balanitis xerotica obliterans (BXO) is a chronic inflammatory skin disorder, considered the male genital variant of lichen sclerosus. Anti-inflammatory drugs are commonly used in BXO. We evaluated the effects of an innovative formulation of ozonated olive oil with vitamin E acetate (OZOILE) on the inflammatory status and tissue remodeling in male children with BXO. The mRNA transcripts of proteins involved either in inflammation or in dynamics of tissue regeneration were analyzed by quantitative real-time PCR, in foreskins affected by BXO removed from patients untreated or treated with OZOILE cream for 7 days before circumcision. We found a significant reduction in mRNA levels of IL-1β, TNF-α, INF-γ, transglutaminase 2 and NOS2 in foreskins treated with OZOILE in comparison to untreated ones ( < 0.001). No significant differences were observed in NF-κB activation in the specimens obtained from treated and untreated patients. Hence, OZOILE treatment up-regulated hypoxia-inducible factor (HIF)-1alpha, vascular endothelial growth factor (VEGF) and E-cadherin gene expression ( < 0.001). The treatment with OZOILE showed effective results in children affected by BXO by reducing the inflammatory process and stimulating mechanisms for tissue regeneration of the foreskin. A randomized clinical trial on a large number of children affected by BXO might be useful to verify the efficacy of topical treatment with OZOILE.
Topics: Administration, Topical; Adolescent; Anti-Inflammatory Agents; Balanitis Xerotica Obliterans; Child; Circumcision, Male; Cytokines; Drug Combinations; GTP-Binding Proteins; Gene Expression Profiling; Gene Expression Regulation; Humans; Hypoxia-Inducible Factor 1, alpha Subunit; Male; Nitric Oxide Synthase Type II; Olive Oil; Protein Glutamine gamma Glutamyltransferase 2; Transglutaminases; Treatment Outcome; Vascular Endothelial Growth Factor A; Vitamin E
PubMed: 29534008
DOI: 10.3390/molecules23030645 -
Journal of Pediatric Surgery May 2024We describe meatal outcomes for boys undergoing circumcision to treat Lichen Sclerosus (LS/BXO) with a focus on those who underwent meatotomy/meatoplasty at circumcision...
PURPOSE
We describe meatal outcomes for boys undergoing circumcision to treat Lichen Sclerosus (LS/BXO) with a focus on those who underwent meatotomy/meatoplasty at circumcision and factors associated with post-circumcision meatal intervention.
METHODS
Retrospective review of patients undergoing circumcision for histologically confirmed LS between 2011 and 2020. Statistical testing was by Chi2 and multivariate analysis.
RESULTS
382 patients underwent circumcision at a mean of 9.1 years (SD 2.9). At circumcision, LS on the glans was documented in 213/365 (58%). Meatal involvement was documented in 74/382 (19%); 25/382 (6.5%) had a meatotomy, 94/382 (25%) had meatal calibration/dilatation and 234/367 (64%) were prescribed post-operative topical steroids. Patients with LS glans or meatal involvement were more likely to have a meatotomy (p = 0.0013) and to receive post-operative steroids (OR 5, p = 0.0001). Post circumcision, 40/382 (10%) required a median of 1 subsequent procedure (range 1-5), 10 (2.6%) underwent dilatation, 30 (7.4%) had a meatotomy. Patients undergoing meatotomy at circumcision had an odds ratio (OR) of 1.2 for subsequent meatotomy (p = 0.027). Analysis based on requirement for any subsequent procedure identified an OR of 3.1 for having had a meatotomy at circumcision (p = 0.022) and an OR of 6.0 of receiving post-operative steroids (p=<0.001).
CONCLUSIONS
Meatal stenosis following circumcision for LS requiring meatal intervention affected 10% of boys. Meatotomy at circumcision increased the likelihood of subsequent meatal intervention and is therefore not recommended.
LEVEL OF EVIDENCE
Level III.
PubMed: 38862295
DOI: 10.1016/j.jpedsurg.2024.05.010 -
Asian Journal of Surgery May 2021
Topics: Balanitis Xerotica Obliterans; Child, Preschool; Foreskin; Hand, Foot and Mouth Disease; Humans; Male
PubMed: 33752984
DOI: 10.1016/j.asjsur.2021.02.014 -
The Journal of Urology Jun 2016We investigated outcomes of the contemporary practice of administering intraurethral steroids to treat stricture disease in patients with biopsy proven lichen sclerosus.
PURPOSE
We investigated outcomes of the contemporary practice of administering intraurethral steroids to treat stricture disease in patients with biopsy proven lichen sclerosus.
MATERIALS AND METHODS
We performed an institutional review board approved review of the records of patients with biopsy proven lichen sclerosus stricture disease from October 2010 to September 2015. Study inclusion criteria were age 18 years or greater and male gender. Extracted data included patient demographics, comorbidities, location of lichen sclerosus, previous therapies and need for further interventions. Management was considered successful when there was no need for subsequent escalation of therapy. The intraurethral steroid regimen consisted of applying clobetasol cream to the affected urethra to lubricate a calibration device such as a urinary catheter or meatal dilator. The initial phase of therapy included twice daily application for 2 to 3 months, at which point the frequency was decreased by the clinician, enabling the patient to titrate medication use as needed.
RESULTS
We identified 40 patients with biopsy proven lichen sclerosus who had urethral stricture as part of the disease state. Of these patients 28 received the intraurethral steroid regimen and success was achieved in 25 (89%). Mean followup was 24.8 months. No patient who was started on the intraurethral steroid regimen proceeded to urethroplasty.
CONCLUSIONS
Based on our outcomes we have developed a stepwise treatment algorithm for patients with biopsy proven lichen sclerosus stricture disease that uses intraurethral steroids before initiating plans for invasive surgery.
Topics: Administration, Topical; Clobetasol; Glucocorticoids; Humans; Lichen Sclerosus et Atrophicus; Male; Middle Aged; Retrospective Studies; Treatment Outcome; Urethra; Urethral Stricture
PubMed: 26707511
DOI: 10.1016/j.juro.2015.12.067 -
Journal of Pediatric Surgery Apr 2020Lichen sclerosus (LS), (balanitis xerotica obliterans), causes pathological phimosis. Many boys present with obstructive symptoms, the cause is usually obvious on...
BACKGROUND
Lichen sclerosus (LS), (balanitis xerotica obliterans), causes pathological phimosis. Many boys present with obstructive symptoms, the cause is usually obvious on examination so ultrasound scans (USS) of the urinary tract are not routinely indicated. We review a series of abnormal USS in boys with LS.
METHODS
Retrospective note review for boys undergoing surgical treatment for LS between 2000 and 2017. Seventy-eight boys had a USS prior to surgery, those with abnormal USS form the study population. Boys with neuropathic bladder or congenital urinary tract abnormalities were excluded.
RESULTS
Nineteen of 78 boys (24%), mean age 9 years, were included. Seventeen had obstructive symptoms, 13 had culture proven UTIs, 12 had new onset incontinence. On USS 3 (17%) had acute retention, 8 (78%) had an isolated post-void residual volume (PVR) >10% of estimated bladder capacity (EBC); 3 had bladder wall thickening +/- PVR >10%, 5 had upper tract changes. Symptoms resolved with successful treatment of LS. Six boys had post treatment USS, abnormalities resolved in 5.
CONCLUSIONS
Clinicians should consider LS in boys presenting with UTIs, new onset incontinence and obstructive urinary tract symptoms. Routine USS are not indicated though should be considered in those with an atypical history or examination.
TYPE OF STUDY
Case Series.
LEVEL OF EVIDENCE
Level 4.
Topics: Adolescent; Balanitis Xerotica Obliterans; Child; Child, Preschool; Humans; Male; Phimosis; Retrospective Studies; Ultrasonography; Urinary Bladder Neck Obstruction; Urinary Incontinence; Urinary Retention
PubMed: 31455543
DOI: 10.1016/j.jpedsurg.2019.07.020 -
Journal of Pediatric Urology Feb 2019Circumcision has long been the mainstay of management for genitourinary lichen sclerosus et atrophicus (LS); however, there has been growing interest in surgical...
INTRODUCTION
Circumcision has long been the mainstay of management for genitourinary lichen sclerosus et atrophicus (LS); however, there has been growing interest in surgical techniques that preserve the foreskin.
OBJECTIVE
The aim of this study was to assess population-based surgical management of LS in England and determine surgical outcomes.
STUDY DESIGN
Cases of LS treated in English NHS trusts (2002-2011) were extracted from the Hospital Episode Statistics (HES) Database. Cases were identified by both an ICD-10 code for LS and either an OPCS4.6 code for circumcision or preputioplasty (with/without injection of steroid). Subsequent admissions were analysed for related complications/procedures. Data are presented as median (interquartile range) unless otherwise stated.
RESULTS
7893 patients had surgery for LS, of whom 7567 (95.8%) underwent circumcision (Table). Primary preputioplasty was performed in 326 (4.1%) in 44/130 centres; of these 151/326 had concomitant injection of steroid. Age at surgical intervention was 9 (6-11) years. There were no postoperative bleeds following preputioplasty. Of those treated with preputioplasty, 74 (22%) had subsequent circumcision at a median of 677 (277-1203) days post operation. Concomitant steroid injection reduced the risk of subsequent circumcision (21/151 (14%) vs. 53/175 (30%), p < 0.001). More children underwent a second operative procedure following preputioplasty than those having had a primary circumcision (27.9% vs. 7.9%, p < 0.001).
CONCLUSION
Although circumcision is the predominant treatment for LS, these data suggest that preputioplasty is a valid option in management, albeit with a higher re-intervention rate. Selection bias may play a role and a randomized controlled trial is needed. Preputioplasty combined with steroid injection appears to reduce the chance of completion circumcision.
Topics: Child; Cohort Studies; England; Humans; Lichen Sclerosus et Atrophicus; Male; Male Urogenital Diseases; Practice Patterns, Physicians'; Time Factors; Treatment Outcome; Urologic Surgical Procedures, Male
PubMed: 30482498
DOI: 10.1016/j.jpurol.2018.02.027 -
Journal of Clinical and Diagnostic... Jul 2017Penile carcinoma is considered a delayed sequel of lichen sclerosus. It is important to recognize this not so uncommon complication in time as survival of patients with...
Penile carcinoma is considered a delayed sequel of lichen sclerosus. It is important to recognize this not so uncommon complication in time as survival of patients with Squamous Cell Carcinoma (SCC) depends on early diagnosis and treatment. We describe a case of a 49-year-old male presenting with urethral stricture due to lichen sclerosus. He was treated for stricture disease and later on developed SCC penis after ten years of presentation.
PubMed: 28892974
DOI: 10.7860/JCDR/2017/26330.10254 -
Journal of Clinical and Diagnostic... Jul 2016The penile circular fasciocutaneous flap (FCF) is employed in the successful single stage reconstruction of long segment complex anterior urethral strictures especially...
The penile circular fasciocutaneous flap (FCF) is employed in the successful single stage reconstruction of long segment complex anterior urethral strictures especially when buccal mucosa is unavailable due to various reasons. A 65-year-old gentleman, chronic smoker and tobacco chewer, hypertensive on treatment, presented with obstructive lower urinary tract symptoms for 8 months. He had no prior urethral catheterization. On examination, he had circumcised penis, with stenosis of the external urethral meatus. Glans had no changes suggesting balanitis xerotica obliterans. Suprapubic cystostomy was done as he developed acute urinary retention during evaluation. Retrograde urethrogram (RGU) showed pan-anterior urethral stricture. He was planned for substitution urethroplasty. On oral cavity examination, he had moderate trismus with oral submucous fibrosis. As buccal mucosal graft was unavailable, he was planned for FCF. A ventral onlay tubularization FCF urethroplasty from meatus to bulbar urethra based on dartos dorsal pedicle was done. His postoperative recovery was uneventful. Pericatheter RGU did not show extravastion and he voided well with Qmax 14 ml/second. He is doing well at follow-up.
PubMed: 27630900
DOI: 10.7860/JCDR/2016/20404.8117 -
The Journal of Urology Mar 2019
Topics: Balanitis Xerotica Obliterans; Constriction, Pathologic; Humans; Lichen Sclerosus et Atrophicus; Male; Urethra; Urethral Stricture
PubMed: 30759653
DOI: 10.1097/01.JU.0000553682.80153.32