Managing Urethral Strictures in Men From Lichen Sclerosus
Managing Urethral Strictures in Men From Lichen Sclerosus
LS in males can range in severity from mild to aggressive courses. It is most commonly found in the genital region with a 5:1 ratio of genital compared with extragenital involvement. When genital LS is present, it almost always involves the foreskin/glans and, in more serious cases, the urethra may be involved. Involved skin can appear gray or white in color with cracking or fissuring of the skin in later cases. In a retrospective review of 522 patients, Depasquale et al. found disease of the prepuce and glans only in 57% of patients and the meatus in 4%. A total of 20% had urethral involvement. When confined to the cutaneous surfaces, LS can often be treated conservatively with topical therapies or circumcision, however urethral involvement often portends a poor prognosis with need for more invasive therapies. LS can be confused with erythroplasia of Querat, lichen planus, leukoplakia, and scleroderma. Local symptoms can include pruritis, dysuria, phimosis, and lower urinary tract symptoms including weak stream and frequency. In all cases, a biopsy should be obtained to confirm the diagnosis and rule out squamous cell carcinoma (SCC) as many other medical conditions may mimic LS such as various fungal infections.
In cases of urethral involvement, the stricture typically starts at the meatus and progressively moves proximally within the urethra (Figure 1). In advanced cases, spongiofibrosis and mucosal involvement can be found as proximally as the posterior urethra. The proximal extent of disease is usually well demarcated and in our practice we have yet to see any cases with skip lesions noting that all patients with LS stricture start at the meatus. A recent review of 70 patients with isolated bulbar strictures noted LS in 44% of patients on pathologic re-review suggesting LS as a possible etiology for isolated bulbar strictures. While the possibility for an atypical skip presentation of LS with an isolated bulbar stricture seems to exist, it has not been our experience that this is the case. Bladder involvement has yet to be described.
(Enlarge Image)
Figure 1.
Retrograde urethrogram of LS stricture with obvious demarcation of proximal extent of disease. LS, lichen sclerosus.
Because of this, when the external genitalia is involved, one needs to always think of possible involvement of the internal organs—the urethra. Therefore, evaluation of the urethral is mandatory with a combination of American Urological Association (AUA) symptom scores, retrograde urethrography, cystourethroscopy and uroflow as clinically indicated in order to determine the severity and proximal extent of disease.
Clinical Features
LS in males can range in severity from mild to aggressive courses. It is most commonly found in the genital region with a 5:1 ratio of genital compared with extragenital involvement. When genital LS is present, it almost always involves the foreskin/glans and, in more serious cases, the urethra may be involved. Involved skin can appear gray or white in color with cracking or fissuring of the skin in later cases. In a retrospective review of 522 patients, Depasquale et al. found disease of the prepuce and glans only in 57% of patients and the meatus in 4%. A total of 20% had urethral involvement. When confined to the cutaneous surfaces, LS can often be treated conservatively with topical therapies or circumcision, however urethral involvement often portends a poor prognosis with need for more invasive therapies. LS can be confused with erythroplasia of Querat, lichen planus, leukoplakia, and scleroderma. Local symptoms can include pruritis, dysuria, phimosis, and lower urinary tract symptoms including weak stream and frequency. In all cases, a biopsy should be obtained to confirm the diagnosis and rule out squamous cell carcinoma (SCC) as many other medical conditions may mimic LS such as various fungal infections.
In cases of urethral involvement, the stricture typically starts at the meatus and progressively moves proximally within the urethra (Figure 1). In advanced cases, spongiofibrosis and mucosal involvement can be found as proximally as the posterior urethra. The proximal extent of disease is usually well demarcated and in our practice we have yet to see any cases with skip lesions noting that all patients with LS stricture start at the meatus. A recent review of 70 patients with isolated bulbar strictures noted LS in 44% of patients on pathologic re-review suggesting LS as a possible etiology for isolated bulbar strictures. While the possibility for an atypical skip presentation of LS with an isolated bulbar stricture seems to exist, it has not been our experience that this is the case. Bladder involvement has yet to be described.
(Enlarge Image)
Figure 1.
Retrograde urethrogram of LS stricture with obvious demarcation of proximal extent of disease. LS, lichen sclerosus.
Because of this, when the external genitalia is involved, one needs to always think of possible involvement of the internal organs—the urethra. Therefore, evaluation of the urethral is mandatory with a combination of American Urological Association (AUA) symptom scores, retrograde urethrography, cystourethroscopy and uroflow as clinically indicated in order to determine the severity and proximal extent of disease.