Dr. Debasis Maity

Remember:

• Lichen sclerosus (LS) is the preferred term for what was previously known as balanitis xerotica obliterans (BXO).
• Lichen sclerosus is a chronic inflammatory disorder of the skin of uknown origin. The glans penis and foreskin are usually affected.
• LS is a scarring disorder characterized by tissue pallor, loss of architecture and hyperkeratosis.
• Incidence of LS in the western population is 1 in 300.
• LS is 6 to 10 times more prevalent in women than in men, generally presenting around the time of menopause.
• In men, LS seems to peak between the ages of 30 to 50; but it may occur in all ages; from infants to the elderly.
• LS is commonly found at the time of circumcision when performed beyond the neonatal period.
• LS is the most common cause of meatal stenosis, appears as a whitish plaque that may involve the prepuce, glans penis, urethral meatus and fossa navicularis. If only the foreskin is involved, circumcision may be curative.
• LS usually begins as a meatal or perimeatal process in the circumcised patient but it may involve other areas of the preputial space in the uncircumcised patient.
• In uncircumcised men, the prepuce becomes edematous and thickened, and often may be adherent to the glans.
• The peak ages of recognition in women are bimodal, with many cases noted before puberty but with another peak presenting in postmenopausal women.
• BXO= m/c cause of strictures of fossa navicularis and penile urethra, starts at glans and preputial skin, causing meatal stenosis and/or phimosis.
• Urethral stricture occur due to inflammation or infection of the periurethral glands of Litter (“Littritis”) secondary to high pressure voiding related to meatal stenosis & perhaps microabscesses and deep spongiofibrosis.
• Panurethral stricture can also occur in BXO.

Etiology:

No specific mechanism has been elucidated, possibilities are:

• Autoimmune disease
• Reactive oxidative stress contributed to the sclerotic, immunologic and carcinogenic process in LS.
• Infections (chronic infection by a spirochete, Borrelia burgdorferi).
• Koebner phenomenon relates the development of LS to trauma to an affected area.
• Genetic origin, based on the observation of a familial distribution of cases.
• Concomitant existence of the disease in identical twins.

BXO changes involving glans and prepuce. (Bagnan, Howrah)	BXO changes involving glans and prepuce. (Berhampur, Murshidabad)
BXO changes with phimosis (Bolpur, Birbhum)	BXO changes with meatal stenosis (Tamluk, Midnapur)

Diagnosis:

• Diagnosis is made through biopsy.
• LS has specific histologic features, including-
  • Basal cell vacuolation
  • Epidermal atrophy
  • Dermal edema
  • Collagen homogenization
  • Focal perivascular infiltrate of the papillary dermis
  • Plugging of the ostia of follicular and eccrine structures

Management:

• The combination of topical steroids and antibiotics may help stabilize the inflammatory process.
• Conservative therapy may be warranted in patients whose meatus can easily be maintained at 14 to 16 French.
  • In these cases, intermittent catheterization with lubrication of the catheter
  • and meatal dilator with 0.05% clobetasol (brand name Temovate) for 3 months may be adequate treatment.
• Long-term antibiotic (Tetracycline, erythromycin, penicillin) therapy may also be helpful to improve the inflammation, because secondary infection of the inflamed tissue may occur.
• A recent European, multicenter, phase II trial also supported the safety and efficacy of topical tacrolimus in the treatment of long standing LS.
• In young patients with severe meatal stenosis, surgery is indicated. Because patients with long-standing meatal stenosis often have severe proximal urethral stricture disease, retrograde urethrography should be performed before the initiation of therapy.
• Long-standing cases with a long length of urethral stricture are amenable to techniques of reconstruction but are very challenging.
• It is becoming clear that except in the case of urethral stricture disease confined only to the meatus and fossa navicularis, staged oral graft (buccal mucosal graft-BMG) reconstruction, at least in the short to mid term, seems to provide superior durable results.
• In some patients with severe urethral stricture disease, ideal treatment is perineal urethrostomy.