Editing Penis and Urethra Surgery (section)

== Lichen sclerosis (LS) ==

* '''<span style="color:#ff0000">A chronic inflammatory hypomelanotic, lymphocyte-mediated skin disorder that predominately affects the genitalia</span> and may involve the prepuce, glans penis, urethral meatus, and fossa navicularis'''
**'''<span style="color:#ff0000">Associated with urethral strictures in males</span>'''
***Possible mechanisms include:
**** Iatrogenic stricture resulting from repeated instrumentation
**** Pressure voiding associated with meatal stenosis causing secondary intravasation of urine into the glans Littre
***'''<span style="color:#ff0000">In females, urethral stricture is not a common feature of LS</span>'''
* Previously known as balanitis xerotica obliterans
* '''Epidemiology'''
** '''Affects primarily middle-aged men''', but it can occur in boys
*** '''Most common cause of meatal stenosis in the adult'''
**** '''Meatal stenosis in the male child appears to be a consequence of circumcision''', which allows for ammoniacal meatitis. Children seen with ammoniacal meatitis are usually started with meatal dilation using steroid cream. Within a week, the process seems to settle down.
*** '''Presents mainly in uncircumcised men'''
* '''Risk factors'''
** '''Cause has not been defined.'''
** '''Many mechanisms have been proposed:'''
*** '''Trauma'''
*** '''Auto-immune'''
*** '''Genetic'''
*** '''Infection'''
**** A study identified Borrelia burgdorferi infection in affected tissues in the early course of the disease§
**Patients are more likely to be active tobacco smokers, have a higher body mass index, hypertension, diabetes mellitus, coronary artery disease, and have longer urethral strictures compared to non-LS urethral strictures[https://pubmed.ncbi.nlm.nih.gov/27497791/ §]
* '''Diagnosis and Evaluation'''
** '''History and Physical Exam'''
*** '''History'''
**** '''Signs and Symptoms[https://pubmed.ncbi.nlm.nih.gov/27497791/ §]'''
*****'''Skin itching'''
*****'''Bleeding'''
*****Penile skin scarring, adhesions to the glans
*****Acquired buried penis
*****Pain
*****Dyspareunia
*****Painful erections
*** '''Physical exam'''
**** '''Appears as a whitish plaque'''
**** See Figure
***'''Other: biopsy'''
****'''Diagnosis is made through biopsy'''
* '''Capable of malignant transformation,''' progressing to squamous cell carcinoma in 2-8% of patients
**'''4–6% of patients with penile squamous cell carcinoma have associated LS'''
* '''Management'''
** '''Dermatologic management of genitalia''' 
***Treatment of genital skin LS reduces symptoms and progression to extensive stricture of the penile urethra[https://pubmed.ncbi.nlm.nih.gov/27497791/ §]
***'''2023 AUA Urethral Stricture Guidelines[https://pubmed.ncbi.nlm.nih.gov/27497791/ §]'''
****'''Topical moderate- to high-potency steroid creams, such as clobetasol or mometasone creams'''
****Calcineurin inhibitors such as tacrolimus have been shown to cause regression in external skin manifestations.
***'''CUA Penile Lesions 2019 Review: 0.05% clobetasol propionate (steroid) cream applied daily for 2–3 months'''
** '''Lichen sclerosis associated urethral stricture'''
***Strictures tend to be longer, compared to non-LS urethral strictures[https://pubmed.ncbi.nlm.nih.gov/27497791/ §]
***Strictures are more likely to be located in the penile urethra[https://pubmed.ncbi.nlm.nih.gov/27497791/ §]
***Urethroplasty is challenging in this population, often requires multiple oral mucosa grafts to reconstruct long-segment strictures, often with a lower success rate compared to non-LS urethral strictures[https://pubmed.ncbi.nlm.nih.gov/27497791/ §]
***'''Most surgeons now believe that LS is a disease of genital skin. For this reason, genital skin is not appropriate for reconstruction in patients with LS.'''
**** Although it is technically possible to use extragenital skin for reconstruction, '''oral mucosal grafting has emerged as a better tissue in patients with LS associated urethral strictures.'''
**'''Campbell’s:'''
*** '''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 (Temovate) may be adequate treatment. Long-term antibiotic therapy may also be helpful to improve inflammation because secondary infection of the inflamed tissue may occur.
*** '''Surgery is indicated in young patients with severe meatal stenosis.'''
**** Because patients with long-standing meatal stenosis often have severe proximal urethral stricture disease, retrograde urethrography should be performed before therapy is initiated.
**** '''If only the foreskin is involved, circumcision may be curative'''