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International Journal of Surgical... Aug 2020Since the seminal study of Hart and Helwig in 1975, there are few detailed pathological studies of lichen sclerosus (LS). The aims of this study were to provide a...
Since the seminal study of Hart and Helwig in 1975, there are few detailed pathological studies of lichen sclerosus (LS). The aims of this study were to provide a detailed histopathological description of penile LS, as well as to explore its relationship with penile intraepithelial neoplasia (PeIN) or invasive carcinoma. We evaluated 200 patients and designed a topographical approach for the histological evaluation focusing in alterations of the following anatomical layers: squamous epithelium, lamina propria, dartos, and corpus spongiosum. We documented the quantity and topographical location of stromal lymphocytes. The prevalent lesions found were epithelial hyperplasia, atrophy, PeIN, basal cell vacuolization, lamina propria sclerosis, and variable patterns of lymphocytic infiltration. Various unique patterns of stromal sclerosis were described: perivascular, globular, linear, and solid fibrosis/hyalinization; any of them were found to be diagnostic for LS. The variation in the topography and density of lymphocytes was determinant for the identification of LS morphological variants: lichenoid, band-like, lymphocytic depleted, and mixed. A major finding was the identification of the variant designated as lymphocytic depleted LS, which we considered as the morphological prototype of LS associated with penile neoplasia. The detailed description of this complex lesion presented in this study may help pathologists in practice to identify and better define LS. The identification of the special variants suggests a role of the stromal lymphocytes in the process of carcinogenesis. Confirmation of the observations with more studies is necessary to determine the significance of these findings.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Balanitis Xerotica Obliterans; Humans; Lichen Sclerosus et Atrophicus; Male; Middle Aged; Penile Neoplasms; Precancerous Conditions; Young Adult
PubMed: 31969038
DOI: 10.1177/1066896920901333 -
European Journal of Pediatrics Jan 2020Lichen sclerosus (LS) is a severe, chronic, dermatosis characterised by inflammatory, sclerotic, pruritic lesions that causes significant morbidity in patients of all... (Review)
Review
Lichen sclerosus (LS) is a severe, chronic, dermatosis characterised by inflammatory, sclerotic, pruritic lesions that causes significant morbidity in patients of all genders and ages. In boys, the lesions typically affect the foreskin and glans (termed balanitis xerotica obliterans (BXO)), leading to phimosis and potentially meatal stenosis. The incidence of the disease is not well reported but the average age of affected boys is 8 years (range 1-16). Diagnosis can often be made clinically, although histological study remains important to rule out important differential diagnoses. Complications include genital scarring, urinary and sexual dysfunction as well as the development of carcinomas in adult life. Circumcision has been regarded as definitive management of BXO in boys, but this may be supplemented with medical therapies such as topical steroids, immune modulators, intralesional triamcinolone and ozonated olive oil. Supportive measures including emollients, avoidance of irritants, surveillance of complications and recurrence as well as education and counselling remain important.Conclusion: BXO remains an important cause of phimosis in boys. The frequency of this condition appears unclear but seems likely to be less than 1% of males. Treatment generally involves circumcision, with some evidence that topical steroids or immunomodulators may decrease the incidence of recurrent meatal stenosis.What is Known:• Surgical circumcision is considered the definitive management of BXO• Many aspects of BXO are still in contention or require further study including the epidemiology and aetiology.What is New:• There is increasing awareness of non-surgical modalities that may be used in adjunct to surgery including topical corticosteroids, immune modulators, intralesional triamcinolone and ozonated olive oil• Awareness of meatal stenosis-related BXO has led to the development of surgical techniques such as preputioplasty as well as buccal mucosal inlay grafts.
Topics: Adolescent; Anti-Inflammatory Agents; Balanitis Xerotica Obliterans; Child; Child, Preschool; Circumcision, Male; Europe; Humans; Infant; Male; Prognosis; United States
PubMed: 31760506
DOI: 10.1007/s00431-019-03516-3 -
Urology Jan 2020To elucidate current understanding on the pathophysiological mechanism of genital lichen sclerosus (LS), urologic manifestations, and treatment options.
OBJECTIVE
To elucidate current understanding on the pathophysiological mechanism of genital lichen sclerosus (LS), urologic manifestations, and treatment options.
MATERIALS AND METHODS
The Medline/PubMed and Embase databases were systematically reviewed for publications pertaining to LS. After applying inclusion and exclusion criteria, references were assessed for relevance to the pathophysiology, presentation, and treatment of LS by title and abstract review by 2 independent reviewers, yielding 186 articles for assessment.
RESULTS
The contemporary understanding of the epidemiology and histology of LS is reviewed herein. Additionally, we explore in detail the 3 hypotheses regarding the pathophysiological mechanism contributing to disease presentation: infectious etiology, primary immune dysregulation, and the isotraumatopic response. We summarize the available biological evidence supporting each hypothesis. This discussion provides context for understanding LS morbidity and may spur new avenues of research. For the clinician, we review the clinical presentation of disease, including the risk of progression to squamous cell carcinoma. The current medical and surgical treatment options are also detailed.
CONCLUSION
LS remains a potentially insidious disease which may lead to debilitating urinary and sexual dysfunction. Cross disciplinary research should aim for earlier detection, as well as more effective and durable treatment. The exact cause of LS remains unknown.
Topics: Administration, Topical; Balanitis Xerotica Obliterans; Biopsy; Circumcision, Male; Diagnosis, Differential; Disease Progression; Female; Glucocorticoids; Humans; Lichen Sclerosus et Atrophicus; Male; Penis; Prevalence; Treatment Outcome; Vulva; Vulvar Lichen Sclerosus
PubMed: 31605681
DOI: 10.1016/j.urology.2019.09.034 -
The Surgeon : Journal of the Royal... Jun 2020Symptomatic phimosis is a common childhood urology complaint. Circumcision was traditionally the treatment of choice, but its popularity in cases of non-scarred phimosis...
BACKGROUND
Symptomatic phimosis is a common childhood urology complaint. Circumcision was traditionally the treatment of choice, but its popularity in cases of non-scarred phimosis has been superseded by more conservative methods like preputioplasty. We sought to examine outcomes of preputioplasty for the treatment of non-scarred pathological phimosis in two UK paediatric surgery tertiary centres.
METHODS
Retrospective case series selecting cases performed in both departments over a 4 year period (January 2012-December 2015).
INCLUSION CRITERIA
non-scarred pathological phimosis treated with preputioplasty.
EXCLUSION CRITERIA
diffuse scarring of foreskin or presence of balanitis xerotica obliterans (BXO), preputioplasty performed as part of hypospadias repair. Outcome measure was treatment success as evidenced by fully retractile prepuce at follow up. Follow up occurred between 3 and 24 months.
RESULTS
We identified 126 patients, 6 were excluded due to the above criteria. Median age was 13.4 years (range 10 months-18 years). Median follow up was 13 months (range 3-24 months). 115 patients (96%) had successful treatment as evidenced by satisfactory post-operative cosmesis and complete resolution of phimosis at follow up. Recurrence of phimosis occurred in 5 patients (4%). Mean time of recurrence was 6 months, with a median age of recurrence of 15.3 years (range 10.7-16.7 years). All patients with recurrence were successfully treated with circumcision.
CONCLUSION
Foreskin conserving methods like preputioplasty are a valid option in the treatment of non-scarred pathological phimosis.
Topics: Adolescent; Child; Child, Preschool; Circumcision, Male; Humans; Infant; Male; Patient Satisfaction; Phimosis; Plastic Surgery Procedures; Recurrence; Retrospective Studies; Treatment Outcome
PubMed: 31548120
DOI: 10.1016/j.surge.2019.08.004 -
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 -
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 -
Journal of Pediatric Urology Dec 2018The importance of the pathology of the dartos fascia in hypospadias and buried penis is still debatable. Understanding the properties of connective tissue of dartos... (Comparative Study)
Comparative Study
INTRODUCTION
The importance of the pathology of the dartos fascia in hypospadias and buried penis is still debatable. Understanding the properties of connective tissue of dartos fascia in hypospadias and buried penis may give a clue to the underlying mechanism.
OBJECTIVE
This study aimed to compare connective tissue and vascularization of dartos fascia between normal penis, buried penis, and hypospadias.
STUDY DESIGN
We conducted this prospective study from May 2013 to November 2016. We collected dartos fascia specimens from three groups: buried penis, hypospadias, and normal penis as control. All of the patients underwent primary surgery in all groups. Patients with penile abnormalities, such as phimosis or Balanitis Xerotica Obliterans (BXO) were excluded from the normal penis group. We compared the fibers between these groups using Masson trichrome histochemical staining, Gomori's silver impregnation staining, Weigert resorcin-fuchsin staining, and CD31 immunohistochemistry staining for evaluation of collagen fibers, reticulin fibers, elastin fibers, and endothelial cells of blood vessels, respectively. The collagen fibers, reticular fibers, elastic fibers, and vascular vessels were counted with ImageJ and manually calibrated and counted and were analyzed using the one-way ANOVA test. The assessment conducted by two pathologists was blinded, without knowing the clinical diagnosis of patients.
RESULTS
There was a total of 60 patients with 20 patients in each group. Collagen fibers for most cases of buried penis and hypospadias showed thicker but fewer collagen fibers than the normal penis. There was a reduction of total collagen and elastin of dartos fascia in hypospadias and buried penis cases. On the other hand, the ratio of reticulin fibers, which represents collagen type III to total collagen, was increased compared to normal penis.
DISCUSSION
Although the dartos fascia in buried penis and hypospadias is thick and inelastic when palpated or during traction/counter traction, it is well-vascularized tissue. This inelastic dartos fascia tissue is an abnormal tissue, but its characteristics are not similar to fibrotic tissue. However, further study with a larger sample is warranted and should differentiate the degree of chordee in patients with hypospadias and buried penis.
CONCLUSIONS
There was a difference between connective the tissue of dartos fascia in buried penis and patients with hypospadias compared with normal penis. Inelastic dartos fascia tissue in patients diagnosed with buried penis and hypospadias is an abnormal tissue. Therefore, it is suggested that this tissue is excised during reconstructive surgery. Further research is needed to unveil the pathophysiology of the condition.
Topics: Adolescent; Child; Child, Preschool; Cross-Sectional Studies; Fascia; Humans; Hypospadias; Infant; Male; Penis; Prospective Studies
PubMed: 30554609
DOI: 10.1016/j.jpurol.2018.04.034 -
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 -
Central European Journal of Urology 2018Buried penis is a condition that causes the penis to become hidden beneath the skin. It has a significant impact on quality of life and can present in a variety of ways,... (Review)
Review
INTRODUCTION
Buried penis is a condition that causes the penis to become hidden beneath the skin. It has a significant impact on quality of life and can present in a variety of ways, with lower urinary tract symptoms and erectile dysfunction being common. Whilst there are several causes, obesity is the most common in adults. Due to the burden that obesity is increasingly presenting to healthcare, buried penis may become more common in the future.The purpose of this article is to provide an overview of the causes, presentation and surgical management of this condition in adults.
MATERIAL AND METHOD
A literature review was conducted using urological and plastic surgery articles from PubMed, Embase and Medline. Eighteen studies, published between 1982 and 2016, were included.
RESULTS
Original research trials discussed the treatment of buried penis in lymphoedema and balanitis xerotica obliterans (BXO), new techniques for fat removal, comparison of grafts and postoperative dressings. Several studies provided broad overviews, although focused on management rather than cause and presentation. Overall, studies suggest that, whilst some causes can only be treated with surgery, others can be modified by lifestyle changes and medical management.
CONCLUSIONS
Buried penis is a complex condition that may take years to treat. Several surgical techniques are available, with patients likely requiring a combination of techniques to treat this problem. This review aims to provide a comprehensive overview of the causes, presentation and surgical management of this condition, in order to further the understanding of clinicians who may be faced with this problem more commonly in the future.
PubMed: 30386659
DOI: 10.5173/ceju.2018.1676 -
International Journal of Dermatology Jul 2019Balanitis xerotica obliterans (BXO), or penile lichen sclerosus, is a progressive sclerosing inflammatory dermatosis of the glans penis and foreskin. It is associated... (Review)
Review
Balanitis xerotica obliterans (BXO), or penile lichen sclerosus, is a progressive sclerosing inflammatory dermatosis of the glans penis and foreskin. It is associated with significant morbidity and may result in impaired urinary and sexual function. It was initially described by Stuhmer in 1928, named after its pathological features, and is considered the male equivalent of vulvar lichen sclerosis (LS). The etiology of BXO is uncertain; however, autoimmune disease, local trauma, and genetic and infective causes have been proposed. BXO occurs most commonly on the prepuce and glans penis. It is considered to have premalignant potential to transform into squamous neoplasia. This postulation rests on retrospective studies and parallels drawn with vulvar LS and squamous cell carcinoma (SCC) development. Histologically, BXO and vulvar LS are considered the same disease. There is a paucity of evidence-based guidelines to assist with appropriate follow-up for patients with BXO.
Topics: Administration, Topical; Balanitis Xerotica Obliterans; Carcinoma, Squamous Cell; Circumcision, Male; Dermatology; Diagnosis, Differential; Glucocorticoids; Humans; Male; Penile Neoplasms; Penis; Phimosis; Practice Guidelines as Topic; Precancerous Conditions; Sexual Dysfunction, Physiological; Urination Disorders
PubMed: 30315576
DOI: 10.1111/ijd.14236