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Urology Feb 2021To assess the accuracy of clinical diagnoses and the true incidence of lichen sclerosus (LS) in patients with phimosis.
OBJECTIVE
To assess the accuracy of clinical diagnoses and the true incidence of lichen sclerosus (LS) in patients with phimosis.
MATERIALS AND METHODS
The 92 adult male patients who were qualified for circumcision due to phimosis, were included in the study. The patients were diagnosed clinically by a urologist and dermatologist before the surgical procedure. After the circumcision, the resected foreskins were examined by 2 independent uropathologists.
RESULTS
Preoperative clinical diagnosis of LS was established in 54 patients (58.7%); healthy-looking skin in 26 (28.3%) and other penile diseases in 12 (13.1%) patients. After histopathological examination, the diagnosis of LS was established in 62 patients (67.4%), but only in 44 patients with previous LS clinical diagnosis. LS was histopathologically confirmed in 18 other patients with clinically diagnosed healthy skin (n = 17) or lichen planus (n = 1). Healthy skin was histopathologically confirmed in 10 cases in patients diagnosed clinically before as LS. Other 15 histopathological diagnoses were Zoon balanitis (n = 3), nonspecific balanitis (n = 5), lichen planus (n = 1), psoriasis (n = 1), invasive penile cancer (n = 3), Bowen's disease (n = 1), penile intraepithelial neoplasia 2 usual type (n = 1).
CONCLUSION
LS has been revealed as the most common histopathological diagnosis in patients undergoing circumcision in our study. Histopathological examination seems to be necessary to exclude this disease.
Topics: Balanitis Xerotica Obliterans; Circumcision, Male; Humans; Male; Middle Aged; Missed Diagnosis; Phimosis; Postoperative Period; Preoperative Period; Prospective Studies; Young Adult
PubMed: 33248142
DOI: 10.1016/j.urology.2020.11.027 -
European Journal of Pediatrics Feb 2021The diagnosis of balanitis xerotica obliterans (BXO) in children may be challenging, since clinical examination only could lead to an underestimation of its incidence....
The diagnosis of balanitis xerotica obliterans (BXO) in children may be challenging, since clinical examination only could lead to an underestimation of its incidence. The aim of this retrospective and single-centre study is to assess the diagnostic performance of clinical examination, together with clinical history, in identifying BXO. Ninety-seven children underwent circumcision for phimosis from 2015 to 2019. Histology was routinely performed. Cohen's kappa coefficient, sensitivity, specificity, predictive values, likelihood ratios and accuracy of macroscopic appearance of the foreskin, steroid administration and past medical history were estimated. Forty-eight patients (50%) were affected by BXO; 31 of them (69%) presented with suggestive clinical signs. A strictured or whitish urethral meatus was detected during surgery in nine cases (19%); this was associated to allergic or immune diseases (p = 0.046). Foreskin appearance alone mildly correlated with histology (k = 0.494; p < 0.001) and it showed a diagnostic accuracy of 75%. The specificity and positive predictive value of abnormal macroscopic findings at examination, together with a positive clinical history for other allergic or immune diseases, and/or for balanitis, were 100% and the positive likelihood ratio was greater than 10. Conversely, sensitivity decreased to 4.5% (95% CI 0-11%).Conclusion: Foreskin appearance together with clinical history could predict BXO with certainty. However, since the absence of a positive medical history could not exclude the diagnosis, foreskin histology is still highly recommended. What is Known: • Occurrence of balanitis xerotica obliterans may be underestimated in children and it could lead to long-term complications. • The diagnostic accuracy of clinical examination is controversial. What is New: • Clinical signs together with patients' medical history present high specificity and positive predictive values but low sensitivity. • When suggestive clinical aspects are present, patient should be referred to surgery avoiding prolonged conservative treatment; and preputial histology is highly recommended.
Topics: Balanitis Xerotica Obliterans; Child; Foreskin; Humans; Lichen Sclerosus et Atrophicus; Male; Phimosis; Retrospective Studies
PubMed: 33230719
DOI: 10.1007/s00431-020-03881-4 -
The Journal of Urology Dec 2020We evaluated the success of minimally invasive management of lichen sclerosus with topical and intraurethral clobetasol, as defined by improvement in patient reported...
PURPOSE
We evaluated the success of minimally invasive management of lichen sclerosus with topical and intraurethral clobetasol, as defined by improvement in patient reported outcome measures and nonprogression to surgery.
MATERIALS AND METHODS
We conducted a review of our prospective ongoing quality improvement study to determine outcomes of our current standard practice for males with penile and urethral biopsy proven lichen sclerosus. Data were collected between 2011 and 2019, and included patient demographic information, medical and surgical histories, and location and extent of lichen sclerosus related pathology. The primary outcomes for this study were voiding function and voiding related quality of life, and were assessed using the AUASS (American Urological Association Symptom Score) and quality of life bother index, respectively.
RESULTS
We identified 42 patients with biopsy proven lichen sclerosus related urethral stricture disease. Of these patients 85.7% were treated with intraurethral steroids alone and did not require surgical intervention. Median AUASS significantly improved from 12 to 8, and median quality of life bother index improved from 4 ("mostly dissatisfied") to 2 ("mostly satisfied"). Average stricture length of those with penile urethral disease and bulbar urethral disease was 4.8 cm (SD 3.0) and 16.2 cm (SD 6.5), respectively. Median followup was 8.4 months (IQR 2.6-26.4).
CONCLUSIONS
Lichen sclerosus related urethral stricture disease can be effectively managed with intraurethral steroids. This minimally invasive management strategy improves patient reported voiding symptoms and voiding quality of life.
Topics: Administration, Topical; Adult; Biopsy; Clobetasol; Follow-Up Studies; Humans; Lichen Sclerosus et Atrophicus; Male; Middle Aged; Patient Reported Outcome Measures; Patient Satisfaction; Penis; Prospective Studies; Quality of Life; Retrospective Studies; Skin Cream; Treatment Outcome; Urethra; Urethral Stricture; Urination
PubMed: 32717158
DOI: 10.1097/JU.0000000000001304 -
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 -
Paediatrics & Child Health Jun 2020Within the paediatric population, changing patterns of circumcisions have confounded the epidemiology and presentation of lichen sclerosus (LS). We sought to evaluate...
Within the paediatric population, changing patterns of circumcisions have confounded the epidemiology and presentation of lichen sclerosus (LS). We sought to evaluate the incidence, demographics, and clinical features of patients presenting to a single Albertan paediatric urologist with LS. This retrospective descriptive analysis evaluated all paediatric patients referred for phimosis to a single paediatric urologist in Edmonton, Alberta. Chief complaints/symptoms, date of birth, and date of circumcision were identified. The primary outcome of interest was the proportion of circumcisions with pathologically confirmed LS. From July 2006 to March 2016, 4,163 patients were seen for phimosis of the approximate 12,000 new referrals. Hundred phimosis patients had clinically suspected LS. Of those adequately reported, 81 (81/83) were microscopically confirmed to be LS with a mean age of 9.6 years and median age of 8.9 years (range 4.1 to 16.1 years). This cohort represented 2.0% of phimosis referrals and approximately 0.7% of all referrals to our paediatric urologist. When compared to physiologic phimosis, these patients had higher rates of dysuria (n=28, 34.6% versus n=1, 1.0%, P<0.0001) and urinary retention (n=18, 22.2% versus n=1, 1.0%, P<0.0001) as presenting complaints. LS of the paediatric male genitalia is an uncommon, albeit clinically significant disease entity. The clinical diagnosis for the trained practitioner is very accurate.
PubMed: 32549740
DOI: 10.1093/pch/pxy172 -
F1000Research 2020Lichen sclerosus (LS), or balanitis xerotica obliterans as it was previously known, is a chronic inflammatory lymphocyte-mediated scarring dermatosis that often affects... (Review)
Review
Lichen sclerosus (LS), or balanitis xerotica obliterans as it was previously known, is a chronic inflammatory lymphocyte-mediated scarring dermatosis that often affects the preputial skin and glans, leading to phimosis and urethral strictures if left untreated. We present a narrative review of the literature assessing its aetiology and pathogenesis and discuss its links to penile cancer and its medical and surgical management. Possible hypotheses for the development of LS include chronic exposure to trapped urine, leading to changes in the epithelial structure. This is supported by the fact that circumcision is often curative in the early stages of the disease. Although circumcision can be curative, the use of topical steroids is typically the first-line treatment and may preserve the foreskin and forgo the need for circumcision altogether. Patients should be made aware of a possible association with penile cancer. Although the majority of cases can be treated by medical therapy and circumcision, a significant number of patients may also require penile reconstructive procedures.
Topics: Balanitis Xerotica Obliterans; Circumcision, Male; Humans; Lichen Sclerosus et Atrophicus; Male; Penile Neoplasms; Penis
PubMed: 32518626
DOI: 10.12688/f1000research.21529.1 -
The American Journal of Dermatopathology Nov 2020We describe the association of balanitis xerotica obliterans and differentiated penile intraepithelial neoplasia (PeIN) with dermal elastosis and "bramble-bush" elastic...
Balanitis Xerotica Obliterans Associated With Differentiated Penile Intraepithelial Neoplasia and "Bramble-Bush" Elastic Fibers Accumulation: A Finding Not Specific for Penicillamine Intake.
We describe the association of balanitis xerotica obliterans and differentiated penile intraepithelial neoplasia (PeIN) with dermal elastosis and "bramble-bush" elastic fibers in a diabetic patient with no history of penicillamine intake. An 84-year-old man presented with urethral obstruction syndrome that required postectomy, meatotomy, and foreskin excision. Histopathological examination revealed changes of lichen sclerosus and differentiated PeIN. Orcein staining showed striking dermal elastosis and transepidermal elimination of elastic fibers. At higher magnification, multiple serrations and buds arising from the borders of the elastic fibers were observed giving the so-called bramble-bush appearance. Balanitis xerotica obliterans is considered a premalignant disease, and 14% of patients have evidence of PeIN. The differentiated subtype can be difficult to diagnose because of the minimal basal cell atypia, so a striking dermal elastosis, which may even occur before the neoplasm becomes invasive, may facilitate its diagnosis. The term "acquired perforating dermatosis" seems appropriate to describe those cases of perforating elastosis that occurs in adults with systemic diseases. The bramble-bush appearance of elastic fibers is not specific for penicillamine-induced elastopathy, and it may occur in other diseases, such as diabetes mellitus. This peculiar morphology of elastic fibers may be related to the enzymatic imbalance between matrix metalloproteinases and lysyl oxidase, an enzyme required for the cross-linking of elastic fibers.
Topics: Aged, 80 and over; Balanitis Xerotica Obliterans; Carcinoma in Situ; Diabetes Mellitus, Type 1; Elastic Tissue; Humans; Male; Penicillamine; Penile Neoplasms
PubMed: 32472770
DOI: 10.1097/DAD.0000000000001692 -
Urology Jul 2020We present an unusual case of isolated urethral tuberculosis. The patient had a history of urethral strictures and persistent discharge from two peno-scrotal fistulas...
We present an unusual case of isolated urethral tuberculosis. The patient had a history of urethral strictures and persistent discharge from two peno-scrotal fistulas which was confirmed on urethrogram. He was treated with antitubercular treatment and a two stage urethroplasty.
Topics: Balanitis Xerotica Obliterans; Cutaneous Fistula; Humans; Male; Middle Aged; Tuberculosis, Urogenital; Urethral Diseases; Urinary Fistula
PubMed: 32325139
DOI: 10.1016/j.urology.2020.04.035 -
Cirugia Pediatrica : Organo Oficial de... Apr 2020Balanitis xerotica obliterans (BXO) is a chronic inflammatory disease with a little known incidence in pediatric population. The objective of this work was to describe...
OBJECTIVES
Balanitis xerotica obliterans (BXO) is a chronic inflammatory disease with a little known incidence in pediatric population. The objective of this work was to describe our experience in the treatment of BXO.
MATERIALS AND METHODS
Retrospective study carried out in 419 patients undergoing circumcision surgery between January 2014 and January 2017. Demographic, clinical, therapeutic, and anatomical and pathological variables, as well as complications during follow-up, were analyzed.
RESULTS
Of the 419 patients, 41 (9.78%) were diagnosed with BXO. 6 patients were excluded owing to lack of follow-up, so 35 patients were analyzed. Mean age at diagnosis was 8.6 years. Suspicion diagnosis was clinical at physical exploration in 17 patients (48.6%), and at surgery in 18 patients (51.4%). Anatomical and pathological confirmation was performed in a total 35 patients (100%). During follow-up, 6 patients (17.14%) had lesions in the glans, 3 (8.57%) in the urethra, and 9 (25.71%) in both. 6 meatotomies (17.14%) and 5 new circumcisions (14.28%) had to be carried out. Mean recurrence time was 32.43 months. In 19 patients (54.28%), topical corticoids - ointment - were applied, and 1 patient (2.85%) received topical immunosuppressants.
CONCLUSIONS
A close follow-up of patients with clinical or anatomical and pathological diagnosis of BXO is required given its high morbidity. The complications described in pediatric population include meatal and urethral stenosis, as well as recurrent phimosis, unless a sufficient amount of foreskin is resected.
Topics: Adolescent; Balanitis Xerotica Obliterans; Betamethasone; Child; Child, Preschool; Circumcision, Male; Dexamethasone; Follow-Up Studies; Glucocorticoids; Humans; Male; Penis; Phimosis; Recurrence; Reoperation; Retrospective Studies; Tacrolimus
PubMed: 32250071
DOI: No ID Found -
Asian Journal of Urology Jan 2020Urethral stricture is a highly prevalent disease and has a continued rising incidence. The global burden of disease keeps rising as there are significant rates of...
OBJECTIVE
Urethral stricture is a highly prevalent disease and has a continued rising incidence. The global burden of disease keeps rising as there are significant rates of recurrence with the existing management options with the need for additional repeat procedures. Moreover, the existing treatment options are associated with significant morbidity in the patient. Long segment urethral strictures are most commonly managed by augmentation urethroplasty. We explored the potential for the application of an acellular tissue engineered bovine pericardial patch in augmentation urethroplasty in a series of our patients suffering from urethral stricture disease. The decreased morbidity due to the avoidance of harvest of buccal mucosa, decreased operative time and satisfactory postoperative results make it a promising option for augmentation urethroplasty.
METHODS
Nine patients with long segment anterior urethral strictures (involving penile and/or bulbar urethra and stricture length >4 cm) were included in the study after proper informed consent was obtained. Acellular tissue engineered indigenous bovine pericardial patch was used for urethroplasty using dorsal onlay technique.
RESULTS
A total of nine patients underwent tissue engineered indigenous pericardial patch urethroplasty for long segment urethral strictures, mostly catheter injury induced or associated with balanitis xerotica obliterans. Median follow-up was 8 months (range: 2-12 months). Out of nine patients, eight (88.9%) were classified as success and one (11.1%) was classified as failure.
CONCLUSION
Our study brings a product of tissue engineering, already being used in the cardiovascular surgery domain, into the urological surgery operating room with satisfactory results achieved using standard operating techniques of one stage urethroplasty.
PubMed: 31970073
DOI: 10.1016/j.ajur.2019.05.001