Male genital lichen sclerosus associated with urological interventions and microincontinence: a case series of 21 patients

Abstract

Summary Background Male genital lichen sclerosus (MGLSc) is an acquired, chronic, inflammatory cutaneous disease associated with significant morbidity and squamous cell carcinoma of the penis. Consideration of all of the evidence suggests that chronic exposure of susceptible epithelium to urinary occlusion by the foreskin is the most likely pathomechanism. MGLSc never occurs in men who were circumcised at birth, and has been associated with trauma, instrumentation and anatomical abnormalities, e.g. frank hypospadia that results in microincontinence. Aim To describe 21 patients who developed MGLSc following urological diagnoses and procedures. Methods We conducted a retrospective review of patients with a diagnosis of MGLSc whose symptoms related to urological procedures who attended or saw one of the authors (CBB) privately during the period June–October 2018. Results In total, 21 patients (mean age 59 years) were identified. The referrals came from the local urology departments, primary care or extramural dermatology services. Most of the patients were uncircumcised men. All had developed symptoms and signs of MGLSc within 5 years following their urological procedure; on examination, 30% of the patients were found to have damp penile skin due to microincontinence. Of the 21 patients, 10 had undergone radical prostatectomy for prostate cancer, 4 had a diagnosis of Peyronie disease, 4 had undergone multiple cystoscopies and urethroscopies, 2 had undergone surgery on the bladder neck and 1 had undergone implantation of a penile prosthesis to treat erectile dysfunction. Conclusion This case series further strengthens the urinary occlusion hypothesis for the causation of MGLSc. It is important to recognize that urological interventions can create incompetence of the naviculomeatal valve post voiding. In uncircumcised men, this creates a risk factor for MGLSc that was not previously present. Occlusion, the phenomenon of koebnerization and currently unelucidated epithelial susceptibility factors lead to inflammation, sclerosis and cancer. Patients and urologists should be aware of these possibilities and preventative measures instituted, e.g. adaptive voiding habits and barrier protection.

Male genital lichen sclerosus, microincontinence and occlusion: mapping the disease across the prepuce

“…Even though several causative factors have been proposed (such as genetic predisposition, autoimmunity, infectious agents, physical trauma and obesity), there is little published evidence to support them 4,7,8 . Over the years, our team has compiled and published compelling evidence to suggest that occluded exposure to urine is central to the pathogenesis of MGLSc 4–6 . This report adds further evidence to the urinary occlusion hypothesis.…”

“…The frenulum can be a particular target, manifesting sclerosis or undergoing complete obliteration. 1,2,[4][5][6] Typical histological signs include epidermal atrophy (effacement and loss of rete ridges), basal keratinocyte degeneration, superficial dermal sclerosis, chronic lichenoid inflammation and areas of zoonoid inflammation. 1,2 Treatment is either medical (with ultrapotent topical steroids, soap substitutes and barrier creams) or surgical (circumcision).…”

“…1,2,4,5 Consequently, MGLSc is generally a disease of uncircumcised men, and is associated with penile trauma, instrumentation and anatomical abnormalities (such as hypospadias) that are responsible for urinary microincontinence. [4][5][6] The diagnosis of MGLSc is usually made on clinical grounds but the spectrum of presentation is broad. Male dyspareunia, pruritus and rash are the predominant symptoms.…”

“…Meatal involvement may be subtle with encroachment and blunting of the architecture or more overt with pinhole narrowing of the urethral meatus. The frenulum can be a particular target, manifesting sclerosis or undergoing complete obliteration 1,2,4–6 …”

Have been the incidence and consequences of penile lichen sclerosus still underestimated?

“…Penile LS is a chronic and fibrotic dermatosis which often occurs on the prepuce and glans of the penis. Etiopathogenesis is unknown, but nowadays authors are more likely to suggest that occlusion and irritating effects of urine could be the main reason for LS formation (2)(3)(4). Moreover, microdribling incontinence in occlusion conditions could provide to higher gene expression of proinflammatory cytokines such as interleukin 1-A (IL-1A), interleukin 6 (IL-6) and interferongamma (INF-γ) which may confirm this hypothesis (2).…”