Penile Carcinoma in Patients With Genital Lichen Sclerosus: A Multicenter Survey

EuroGuiderm guideline on lichen sclerosus-Treatment of lichen sclerosus

INTRODUCTION

Lichen sclerosus (LS) is an inflammatory skin disease affecting all ages. LS typically involves the anogenital site where it causes itching and soreness; it may lead to sexual and urinary dysfunction in females and males; however, it may be asymptomatic. First signs of LS are usually a whitening of the genital skin, sometimes preceded by redness and oedema; fissuring, scarring, shrinkage and fusion of structures may follow in its course. LS is associated with an increased risk of genital cancer. LS has a huge impact on the quality of life of affected patients, and it is important to raise more awareness of this not uncommon disease in order to diagnose and treat it early.

OBJECTIVES

The guideline intends to provide guidance on the diagnostic of LS (part 1), highlight important aspects in the care of LS patients, generate recommendations and treatment algorithms (part 2) on topical, interventional and surgical therapy, based on the latest evidence, provide guidance in the management of LS patients during pregnancy, provide guidance for the follow-up of patients with LS and inform about new developments and potential research aspects.

MATERIALS AND METHODS

The guideline was developed in accordance with the EuroGuiDerm Methods Manual v1.3 https://www.edf.one/de/home/Guidelines/EDF-EuroGuiDerm.html. The wording of the recommendations was standardized (as suggested by the GRADE Working Group). The guideline development group is comprised of 34 experts from 16 countries, including 5 patient representatives.

RESULTS

Ultrapotent or potent topical corticosteroids in females and males, adults and children remain gold standard of care for genital LS; co-treatment with emollients is recommended. If standard treatment fails in males, a surgical intervention is recommended, complete circumcision may cure LS in males. UV light treatment is recommended for extragenital LS; however, there is limited scientific evidence. Topical calcineurin inhibitors are second line treatment. Laser treatment, using various wave lengths, is under investigation, and it can currently not be recommended for the treatment of LS. Treatment with biologics is only reported in single cases.

CONCLUSIONS

LS has to be diagnosed and treated as early as possible in order to minimize sequelae like scarring and cancer development. Topical potent and ultrapotent corticosteroids are the gold standard of care; genital LS is often a lifelong disease and needs to be treated long-term.

[Lichen sclerosus in clinically relevant phimosis: incidence, risk factors, and association with squamous cell carcinoma of the penis]

BACKGROUND

Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory skin disease. It is frequently diagnosed following circumcision. Diabetes mellitus (DM) is a known risk factor in men. Malignant pathology is more common in patients with LSA. Data on LSA in men are very limited.

OBJECTIVE

This study investigated the incidence of LSA in men who had undergone circumcision. Risk factors and likelihood of malignancy were captured.

MATERIALS AND METHODS

Data of 215 patients were retrospectively analyzed. As potential risk factors, age, body mass index (BMI), DM, coronary heart disease (CHD) and arterial hypertension were identified. Data were analyzed and displayed graphically as spike histograms. Logistic regression was applied. Age and BMI were transformed using cubic spline function.

RESULTS

Mean age of patients was 37 years (± 22 years). Mean BMI was 26.4. In all, 24% of the patients had a BMI > 30. Of the patients, 11% had DM, 5.1% had CHD, and 19% had arterial hypertension. Pathology revealed LSA in 47% of patients. Malignant disease was apparent in 3.3% of patients (2.7% without concomitant LSA, 4% with concomitant LSA). Age (55 vs 20 years, odds ratio [OR]: 3.210 [1.421, 7.251]) was a significant risk factor for LSA. BMI (30 vs 22 kg/m2, OR 1.059 [0.614, 1.828]) and DM (OR: 0.42 [0.148, 1.192]) elevated the risk for LSA.

CONCLUSION

We saw high rates of LSA in patients had undergone circumcision. Higher age represents a significant risk factor. In 3.3%, final pathology revealed squamous cell carcinoma of the penis. Therefore, pathologic work-up of circumcision specimen is mandatory.

The Spectrum of HPV-independent Penile Intraepithelial Neoplasia: A Proposal for Subclassification

Compared with vulva, precursor lesions of human papillomavirus (HPV)-independent invasive squamous cell carcinoma (SCC) of the penis are insufficiently characterized. We analyzed the histologic and immunohistochemical characteristics of 70 peritumoral precursor lesions and correlated them with the histology and mutational profile of the adjacent HPV-negative invasive penile SCC. Atypical basal keratinocyte proliferation with variously elongated epithelial rete with premature squamatiziation, but regular superficial cornification, termed differentiated penile intraepithelial neoplasia (d-PeIN), were identified adjacent to 42/70 (60%) SCC (36/42 keratinizing ( P <0.001); 3 papillary, and 1 each verrucous, clear cell, sarcomatoid SCC). d-PeIN were associated with chronic inflammatory dermatoses (32/42; P <0.001), p53 overexpression (26/42; P <0.001), and hotspot mutations in TP53 (32/42; P <0.001), CDKN2A (26/42; P <0.001) or both (21/42; P =0.003) in the adjacent SCC. Cytoplasmic p16 ink4a overexpression in 5/42 d-PeIN correlated with CDKN2A missense mutations in the adjacent SCC. In all, 21/70 (30%) cornified verrucous or glycogenated verruciform precursors with minimal atypia and wild-type p53 (18/21; P <0.001) occurred adjacent to verrucous or papillary SCC (17/21; P <0.001) and keratinizing (4/21) SCC, which harbored mutations in HRAS and/or PIK3CA (12/21; P <0.004). Undifferentiated p16 ink4a -negative full-thickness precursors were identified in 7/70 (10%) SCC. Four histologically different HPV-independent penile precursor lesions can be assigned to 2 major genetic/biological pathways with characteristic highly differentiated precursors requiring different clinical management decisions. These include d-PeIN in chronic inflammatory dermatoses, with p53 overexpression and TP53/CDKN2A mutations, and the p53 wild-type verrucous and verruciform precursors unassociated with dermatoses, but with mutations in oncogenes PIK3CA and HRAS .

Comorbidities in Male Patients With Lichen Sclerosus: A Case-Control Study

OBJECTIVE

Lichen sclerosus (LS) is a chronic inflammatory skin disease. In male patients, it usually involves the glans penis and foreskin and can cause phimosis or meatal stenosis. The aim of this cross-sectional case-control study was to identify clinically important comorbidities in male patients with LS.

MATERIALS AND METHODS

By searching Turku University Hospital electronic health records, the authors identified 630 male patients diagnosed with LS between 2004 and 2020. To investigate possible comorbidities, the authors compared this patient group to a 10-fold larger control group.

RESULTS

The incidence of LS increased during the study period, from 5 to 27.5 per 100,000 men. Patients were most often diagnosed at 21 to 25 years of age. Patients with LS exhibited markedly increased risks of penile carcinoma (odds ratio [OR], 81.0; 95% CI = 10.82-3516.7; p < .001) and carcinoma in situ of the penis (OR = 60.5; 95% CI = 7.32-2738.9; p < .001). Patients also more commonly exhibited lichen planus (OR = 16.8; 95% CI = 8.97-32.39; p < .001), psoriasis (OR = 3.3; 95% CI = 1.80-5.70; p = .004), angina pectoris (OR = 1.8; 95% CI = 1.10-2.81; p = .013), obesity (OR = 2.6; 95% CI = 1.72-3.77; p < .001), type 2 diabetes (OR = 2.3; 95% CI = 1.74-3.09; p < .001), and hypertension (OR = 1.9; 95% CI = 1.53-2.37; p < .001). The most commonly performed urological procedures were operation for phimosis, uroflowmetry, and ultrasound measurement of residual urine.

CONCLUSIONS

Genital malignancies, other dermatological conditions, and diseases related to metabolic syndrome should be considered when treating patients with LS.

Lichen sclerosus: The 2023 update

Lichen sclerosus (LS) is an underdiagnosed inflammatory mucocutaneous condition affecting the anogenital areas. Postmenopausal women are predominantly affected and, to a lesser extent, men, prepubertal children, and adolescents. The etiology of LS is still unknown. Hormonal status, frequent trauma and autoimmune diseases are well-known associations for LS, yet infections do not seem to be clear risk factors. LS pathogenesis involves factors such as a genetic predisposition and an immune-mediated Th1-specific IFNγ-induced phenotype. Furthermore, there is a distinct expression of tissue remodeling associated genes as well as microRNAs. Oxidative stress with lipid and DNA peroxidation provides an enabling microenvironment to autoimmunity and carcinogenesis. Circulating IgG autoantibodies against the extracellular matrix protein 1 and hemidesmosome may contribute to the progression of LS or simply represent an epiphenomenon. The typical clinical picture includes chronic whitish atrophic patches along with itching and soreness in the vulvar, perianal and penile regions. In addition to genital scarring, and sexual and urinary dysfunction, LS may also lead to squamous cell carcinoma. Disseminated extragenital LS and oral LS are also reported. The diagnosis is usually clinical; however, a skin biopsy should be performed in case of an unclear clinical picture, treatment failure or suspicion of a neoplasm. The gold-standard therapy is the long-term application of ultrapotent or potent topical corticosteroids and, alternatively, topical calcineurin inhibitors such as pimecrolimus or tacrolimus. Collectively, LS is a common dermatological disease with a so far incompletely understood pathogenesis and only limited treatment options. To foster translational research in LS, we provide here an update on its clinical features, pathogenesis, diagnosis and (emerging) treatment options.

Penile Lichen Sclerosis: A Surgical Perspective of its Aetiology and Treatment

Penile lichen sclerosis is a longstanding inflammatory disease of the skin with a controversial aetiology. Penile lichen sclerosis (PLS) is a growing, inflammatory dermatitis of the anogenital region, which involves the meatus, prepuce, penile shaft, and glans penis. Although the accurate aetiology of PLS is contentious, multiple factors including genetics, autoimmunity, infections of human papillomavirus, hepatitis C, Epstein-Barr virus, risk factors (hormonal and trauma), etc., can be considered to be a part of the etiopathogenesis of PLS. The initial clinical presentations of penile lichen sclerosis are white plaques, atrophied skin, erythema, erosions, and sclerosis in the anogenital region. When the disease advances, the following can occur, including meatal constraints, telangiectasia, petechiae, soreness, papular lesions, tightness of the foreskin, difficulties in passing urine, itching, tenderness on erections, pain, cracking, bleeding, redness, rashes, tightness at frenulum, and dysuria. This disease has a dangerous course of action and if untreated it may be linked with severe urologic and sexual morbidities. PLS is usually treated with medical and surgical interventions like topical or intralesional steroids and circumcision. The role of circumcision is very critical in the course of action and prognosis of PLS, and its treatment is dependent on the stage of the disease. This review brings up the knowledge regarding epidemiology, etiopathology, clinical presentation, and management of PLS with an emphasis on the role of circumcision.

The treatment practices for anterior urethral strictures in China: A case-based survey

Objective

To investigate the treatment concept of Chinese urologists for anterior urethral strictures based on actual cases.

Methods

A self-designed case-based questionnaire was distributed to the members of Official WeChat account of Learning Union from March 19, 2020, to April 10, 2020. Questionnaires requested respondents' demographic information and responses to five cases of anterior urethral stricture: short obliterative bulbar urethral stricture caused by straddle injury (Case 1), idiopathic bulbar urethral stricture after failure of multiple endoscopic therapy (Case 2), iatrogenic long penile urethral stricture (Case 3), lichen sclerosis-related urethral stricture (Case 4), and anterior urethral stricture in indwelling catheter after multiple failure of endoscopic surgery (Case 5). Data was described by frequency and percentage.

Results

A total of 1,267 valid anonymous questionnaires were received. Urethroplasty was recommended more frequently than endoscopic surgery (Case 1: 47.8% vs. 32.8%,Case 2: 42.5% vs. 33.8%, Case 3: 36.1% vs. 26.7%). Referrals patients to other urologists engaged in urethral repair and reconstruction account for a high portion of the treatment (Case 1:18.4%, Case 2:23.1%, Case 3:36.5%, Case 4:27.7%,Case 5:9.3%). Excision and primary anastomosis urethroplasty (EPA) was preferred for treatment of Case 1 (42.5%). For Case 2, the most popular choice was EPA (30.6%). Although the patient has a history of failure in endoscopic surgery, 33.8% of urologists continue to choose endoscopic surgery. For Case 3, 20.0% of urologists would perform oral mucosal urethroplasty. Surprisingly, 5.9% chose EPA. For Case 4, 37.3% of urologists selected meatotomy, 30.4% suggested that glans and urethral biopsies should be performed. 21.0% chose to use steroid ointment after surgery. For Case 5, 26.3% of the respondents believed that urethrography should be performed after removing catheter more than one week, if the urine is obstructed during the period, performing cystostomy firstly.

Conclusions

In China, the concept of urethroplasty is more widely accepted than endoscopic surgery for the treatment of anterior urethral strictures. The concept of referral has been widely formed among Chinese urologists. Better understanding of the comprehensive treatment of lichen sclerosis related anterior urethral stricture and the principle of urethral rest should be strengthened.

[Which management for anterior urethral stricture in male? 2021 guidelines from the uro-genital reconstruction urologist group (GURU) under the aegis of CAMS-AFU (Committee of Andrology and Sexual Medicine of the French Association of Urology)]

OBJECTIVE

The purpose of this first french guideline is to provide a clinical framework for the diagnosis, treatment and follow-up of anterior urethral strictures. The statements are established by the subgroup working on uro-genital reconstruction surgery (GURU) from the CAMS-AFU (Andrology and Sexual Medicine Committee from the French Association of Urology).

MATERIAL AND METHODS

These guidelines are adapted from the Male Urethral Stricture : American Urological Association Guideline 2016, updated by an additional bibliography from January 2016 to December 2019. Twenty-seven main scenarios seen in clinical practice are identified: from diagnosis, to treatment and follow-up. In addition, this guidelines are powered by anatomical diagrams, treatment algorithms, summaries and follow-up tables.

RESULTS

Anterior urethral strictures are a common condition (0,1 à 1,4 %) in men. The diagnosis is based on a trifecta including an examination with patient reported questionnaires, urethroscopy and retrograde urethrography with voiding cystourethrography. Short meatal stenosis can be treated by dilation or meatotomy, otherwise a urethroplasty can be performed. First line treatment of penile strictures is urethroplasty. Short bulbar strictures (<2cm) may benefit from endourethral treatment (direct visual internal urethrotomy or dilation). In case of recurrence or when the stenosis measures more than 2 cm, a urethroplasty will be proposed. Repeated endourethral treatment management are no longer recommended except in case of palliative option. Urethroplasty is usually done with oral mucosa graft as the primary option, in one or two stages approach depending on the extent of the stenosis and the quality of the tissues. Excision and primary anastomosis or non-transecting techniques are discussed for bulbar urethra strictures. Follow-up by clinical monitoring with urethroscopy, or retrograde urethrography with voiding cystourethrography, is performed at least the first year and then on demand according to symptoms.

CONCLUSION

Anterior urethral strictures need an open surgical approach and should be treated by urethroplasty in most cases. This statement requires a major paradigm shift in practices. Training urologist through reconstructive surgery is the next challenge in order to meet the demand.

Cutaneous Horn of the Glans

Cutaneous horn is a protuberance constituted by compact keratinous material, with a hard consistence similar to a horn, which occurs more frequently in photoexposed areas. The authors describe a case of cutaneous horn on the glans considered a rare location. Verrucous carcinoma was the histopathological diagnosis of the base of the horn and lichen sclerosis, the precursor lesion.

Optimal treatment for penile verrucous carcinoma: a systematic literature review

BACKGROUND

Verrucous carcinoma, a rare low-grade well-differentiated squamous cell carcinoma, is known for its favorable biological behavior and lack of metastatic potential. However, aggressive resection is problematic in terms of compromised function and aesthetics. Hence, more conservative treatments are needed.

METHODS

To identify the up-to-date general biological behavior, diagnosis, and treatment trends, we searched PubMed using the keyword "penile verrucous carcinoma" without restrictions on publication date.

RESULTS

Current treatments for penile verrucous carcinoma include wide surgical excision, seldom preventive lymphadenectomy, and conservative chemotherapy without surgery or local excision with safe margins. Despite the advent of partial penectomy to minimally impact function and aesthetics, affected patients experience psychosexual problems. Local excision can be used to save the penile shaft and glans penis without preventive lymphadenectomy or adjuvant therapy and can achieve good clinical prognosis with rare recurrence.

CONCLUSIONS

To preserve the functional and cosmetic aspects, we recommend local excision, especially for tumors measuring < 3 cm and classified as stage T1 according to the 2016 tumor node metastasis clinical and pathological classification for penile cancer.

Pediatric Circumcision in the 21st Century National Health Service: A Snapshot of Practice in a United Kingdom Center

Introduction  Pediatric circumcision is a commonly performed operation, yet outcomes related to procedures performed for medical indications remain underreported.

Aim  The aim of this study was to report outcomes of therapeutic circumcision from our center.

Methods  Prospective registry of elective circumcisions was maintained and analyzed at a single institution in the United Kingdom. Data collected included information on complications (early and late), emergency presentations, and referrals back from primary care services.

Results  Between August 2015 and June 2019, 300 patients (mean age: 9 years; range: 3–16 years) underwent therapeutic circumcision. The average length of follow-up data available was 2.1 years (range: 6 months to 4 years). The overall complication rate was 4.7% ( n  = 16). There were no unplanned admissions and no cases returned to the operating room as emergency. Only 1% ( n  = 3) of patients presented with an early complication (minor bleeding, pain, urinary retention), and 3.7% ( n  = 11) suffered a late complication (meatal stenosis [2.7%]). All cases of meatal stenosis had lichen sclerosus confirmed on histology. Cosmetic satisfaction was 99%.

Conclusion  Therapeutic circumcision is an effective procedure in the pediatric population, which carries a low risk of early and late complications. Our study found that meatal stenosis only occurred in those patients with confirmed lichen sclerosus histology.

The risk of developing squamous cell carcinoma in patients with anogenital lichen sclerosis: A systematic review

INTRODUCTION

Lichen sclerosis (LS) is a chronic inflammatory skin disease, mostly affecting the anogenital region. Patients with LS have a higher risk of developing anogenital squamous cell carcinoma (SCC), although exact numbers are not known.

OBJECTIVE

To systematically review the absolute risk (AR) and incidence rate (IR) of developing SCC in patients with anogenital LS, as well as patient characteristics that influence the risk of developing LS associated SCC.

METHODS

A search was performed through the databases of Pubmed and Embase. Five reviewers independently screened the articles on title/abstract and full text published before 31st of July 2019. The selected articles were critically appraised using the Quality In Prognostic Studies tool.

RESULTS

Of 2238 titles and abstracts assessed, 15 studies were selected to be analysed. The AR of developing SCC in patients with LS varied between 0.21 and 3.88% for women and 0.00-0.91% for men across the included studies. The IR was 0.65-8.89/1000 person-years for women and 0.00-6.49/1000 person-years for men. This risk for women seemed to be increased by age, the presence of vulval intra-epithelial neoplasia (VIN), a long history of LS, late diagnosis of LS and partial compliance of treatment with topical corticosteroids. For men, no determinants were found.

CONCLUSION

We found fair evidence that the AR of developing SCC in patients with anogenital LS varied between 0.21 and 3.88% for women and 0.00-0.91% for men. Therefore, we recommend regular follow up and compliant treatment with topical corticosteroids, especially in older women.

Balanitis xerotica obliterans: an update for clinicians

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.

Lichen sclerosus: the role of oxidative stress in the pathogenesis of the disease and its possible transformation into carcinoma

Lichen sclerosus (LS) is an autoimmune chronic inflammatory disease usually involving the anogenital skin of both sexes; more rarely LS exclusively involves extragenital areas. As a chronic inflammatory disease, in most cases, LS evolves and progresses causing scleroatrophy of the skin or scars which may cause stenosis in the affected areas. A few LS patients are at risk of developing squamous cell carcinoma in their lifetime, but appropriate long-term treatment diminishes the possibility of a malignant evolution. Oxidative stress (OS) has been proven to play a role not only in the pathogenesis of LS, but also in the development and progression of the disease. OS, by causing DNA damage and lipid peroxidation, contributes directly to the possible malignant transformation of LS. Moreover, the increase in oxidative DNA damage is associated with mutations in tumor suppressor genes. Considering the role that OS plays in LS, therapeutic use of antioxidants appears to be rational and possible, in association with other treatments. Antioxidants would counteract the oxidative DNA damage, which is the most important factor for the progression of LS and its malignant transformation.

Genital Lichen Sclerosus Et Atrophicus: A Benign Skin Disorder With Malignant Aftermath

Genital lichen sclerosus et atrophicus (LSA) is an uncommon genital dermatosis. Its resemblance to vitiligo, especially during the earlier stages, leads to delay in its diagnosis. Apart from the common complications such as meatal stenosis, balanoposthitis, phimosis, and painful erections, squamous cell carcinoma is a rare but ominous complication of genital LSA. Herein, we present a case of long-standing penile LSA complicated by squamous cell carcinoma, stressing upon the requirement of early diagnosis and management of LSA.

Gender differences in genital lichen sclerosus: data from a multicenter Italian study on 729 consecutive cases

BACKGROUND

Studies specifically conducted to assess gender differences in genital lichen sclerosus (GLS) are not available. This multicenter study aimed to identify possible gender-related differences on GLS clinical features, history and course, through collecting data from a large mixed-sex sample of patients.

METHODS

This was a cross-sectional study on 729 subjects (53.8% females, 46.2% males) affected with GLS, consecutively observed within a network of 15 Italian dermatology units. The following information was specifically collected: clinical features and severity of symptoms related to GLS, extragenital involvement, previous therapies, diagnostic suspicion at referral, type of referring physicians, development of genital squamous-cell carcinoma (SCC).

RESULTS

Females complained of symptoms more frequent and severe than men; pallor and scarring-sclerosis-atrophy were the most frequent features without gender differences; itching-related signs were more frequent in females than in males as well as extragenital involvement; prior to receiving a definitive diagnosis, females received treatment more frequently than males; 40% of patients were referred with a misdiagnosis; the highest rate of correct suspected diagnosis at referral came from dermatologists than from other physicians; duration of the disease was found to predispose to SCC development.

CONCLUSIONS

Our findings highlighted several gender differences on clinical presentation and symptom profile of GLS. In spite of some characteristic features, misdiagnosis at referrals was frequent.

Squamous Cell Carcinoma Penis in a Case of Urethral Stricture Due to Lichen Sclerosus Balanitis Xerotica Obliterans: A Case Report and Review of Literature

Penile carcinoma is considered a delayed sequel of lichen sclerosus. It is important to recognize this not so uncommon complication in time as survival of patients with Squamous Cell Carcinoma (SCC) depends on early diagnosis and treatment. We describe a case of a 49-year-old male presenting with urethral stricture due to lichen sclerosus. He was treated for stricture disease and later on developed SCC penis after ten years of presentation.

Penile Inflammatory Skin Disorders and the Preventive Role of Circumcision

Penile inflammatory skin conditions such as balanitis and posthitis are common, especially in uncircumcised males, and feature prominently in medical consultations. We conducted a systematic review of the medical literature on PubMed, EMBASE, and Cohrane databases using keywords "balanitis," "posthitis," "balanoposthitis," "lichen sclerosus," "penile inflammation," and "inflammation penis," along with "circumcision," "circumcised," and "uncircumcised." Balanitis is the most common inflammatory disease of the penis. The accumulation of yeasts and other microorganisms under the foreskin contributes to inflammation of the surrounding penile tissue. The clinical presentation of inflammatory penile conditions includes itching, tenderness, and pain. Penile inflammation is responsible for significant morbidity, including acquired phimosis, balanoposthitis, and lichen sclerosus. Medical treatment can be challenging and a cost burden to the health system. Reducing prevalence is therefore important. While topical antifungal creams can be used, usually accompanied by advice on hygiene, the definitive treatment is circumcision. Data from meta-analyses showed that circumcised males have a 68% lower prevalence of balanitis than uncircumcised males and that balanitis is accompanied by a 3.8-fold increase in risk of penile cancer. Because of the high prevalence and morbidity of penile inflammation, especially in immunocompromised and diabetic patients, circumcision should be more widely adopted globally and is best performed early in infancy.

Male Urethral Stricture: American Urological Association Guideline

PURPOSE

The purpose of this Guideline is to provide a clinical framework for the diagnosis and treatment of male urethral stricture.

MATERIALS AND METHODS

A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates 1/1/1990 to 12/1/2015) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of urethral stricture. The review yielded an evidence base of 250 articles after application of inclusion/exclusion criteria. These publications were used to create the Guideline statements. Evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed based on benefits and risks/burdens to patients. Additional guidance is provided as Clinical Principles and Expert Opinion when insufficient evidence existed.

RESULTS

The Panel identified the most common scenarios seen in clinical practice related to the treatment of urethral strictures. Guideline statements were developed to aid the clinician in optimal evaluation, treatment, and follow-up of patients presenting with urethral strictures.

CONCLUSIONS

Successful treatment of male urethral stricture requires selection of the appropriate endoscopic or surgical procedure based on anatomic location, length of stricture, and prior interventions. Routine use of imaging to assess stricture characteristics will be required to apply evidence based recommendations, which must be applied with consideration of patient preferences and personal goals. As scientific knowledge relevant to urethral stricture evolves and improves, the strategies presented here will be amended to remain consistent with the highest standards of clinical care.

Current Practice Patterns Among Members of the American Urological Association for Male Genitourinary Lichen Sclerosus

OBJECTIVE

To determine the practice patterns of urologists who treat male genitourinary lichen sclerosus (MGU-LS) via a national web-based survey distributed to American Urological Association members.

METHODS

A 20-question survey was collected from a random sample of American Urological Association members. Respondents answered questions on their practice patterns for MGU-LS diagnosis, treatment of symptomatic urethral stricture disease, surveillance, and follow-up.

RESULTS

In total, 309 urologists completed the survey. The majority of respondents reported practicing more than 20+ years (37.5%) within an academic (31.7%) or group practice (31.1%) setting. The majority of respondents saw 3-5 men with MGU-LS per year (32.7%). The most common locations of MGU-LS involvement included the glans penis (66.2%), foreskin (26.3%), and/or the urethra (5.8%). Respondent first-line treatment for urethral stricture disease was direct visual internal urethrotomy (26.6%) and second-line treatment was referral to subspecialist (38.4%). After controlling for the number of patients evaluated with MGU-LS per year, those with reconstructive training were more likely to perform a primary urethroplasty for men with symptomatic urethral stricture disease (adjusted odds ratio 13.1, 95% confidence interval 5.1-33.8, P < .001). They were also more likely to counsel men on the associated penile cancer risks (adjusted odds ratio 4.6, 95% confidence interval 1.7-12.5, P < .01).

CONCLUSION

Reconstructive urologists evaluate the most number of patients with MGU-LS and are more likely to perform primary urethroplasty for urethral stricture disease. Men with MGU-LS should be referred to a reconstructive urologist to understand the full gamut of treatment options.

The contemporary management of urethral strictures in men resulting from lichen sclerosus

Lichen sclerosus (LS) is a chronic, inflammatory disease primarily involving the genital skin and urethra in males. Historically, the treatment of this common condition was a challenge due to its uncertain etiology, variable response to therapy, and predilection to recur. The etiology of LS is still debated and has been linked to autoimmune disease, infection, trauma, and genetics. Today, topical steroids are a mainstay of therapy for patients, even in the presence of advanced disease, and can induce regression of the disease. In advanced cases, surgery may be required and range from circumcision, meatoplasty, or, in the case of advanced stricture disease, urethroplasty or perineal urethrostomy. When urethroplasty is required, the use of genital skin as a graft or flap is to be avoided due to the predilection for recurrence. Surgical management should be approached only after failure of more conservative measures due to the high risk of recurrence of LS in the repaired site despite the use of buccal grafting. LS may be associated with the development of squamous cell carcinoma and for this reason, patients should undergo biopsy when LS is suspected and long-term surveillance is recommended.

Penile cancer: Perspective from a Canadian tertiary care centre

INTRODUCTION

Penile squamous cell carcinoma (SCC) is rare in North America; however, the morbidity can be devastating. This analysis represents the first reported penile cancer experience at a tertiary care centre in Canada.

METHODS

We carried out a retrospective review of all patients who received care at our centre for penile SCC from 2005 until the present time. Epidemiological and clinical data were collected for all patients. Survival analysis was performed using Kaplan-Meier methods with log-rank test and Cox regression for univariate and multivariate analysis, respectively.

RESULTS

We identified 42 patients who were treated at our centre for penile SCC. Of these, 29% underwent excisional biopsy, 38% had partial penectomy, and 33% had total penectomy. Five patients with high-risk tumours underwent modified inguinal lymph node dissection (ILND), while 7 patients had radical ILND for clinically palpable disease. Overall, the median cancer specific survival (CSS) was undefined, with a 60% survival at 102 months. However CSS was significantly correlated to pT stage, pN stage, and tumour grade. The median follow-up was 25 months (interquartile range: 11-48).

CONCLUSION

These findings confirm the poor CSS of patients with positive lymph nodes in penile SCC. Patients with pN0 after ILND had a durable CSS. Risk factors for penile SCC were confirmed as elevated body mass index, positive smoking history, and lack of circumcision. This first epidemiologic report on penile SCC from a Canadian tertiary care centre should be expanded to other national centres.

Evidence-based (S3) Guideline on (anogenital) Lichen sclerosus

Lichen sclerosus (LS) is an inflammatory skin disease that usually involves the anogenital area. All patients with symptoms or signs suspicious of lichen sclerosus should be seen at least once initially by a physician with a special interest in the disease in order to avoid delay in diagnosis, as early treatment may cure the disease in some and reduce or prevent scarring. The diagnosis is made clinically in most cases. Biopsies should only be performed under certain circumstances. The gold standard for treatment remains potent to very potent topical steroids; however, mild and moderate disease in boys and men may be cured by circumcision. Certain triggers should be avoided. http://www.euroderm.org/images/stories/guidelines/2014/S3-Guideline-on-Lichen-sclerosus.pdf http://www.awmf.org/fachgesellschaften/mitgliedsgesellschaften/visitenkarte/fg/deutsche-gesellschaft-fuer-gynaekologie-und-geburtshilfe-dggg.html.

Review of in situ and invasive penile squamous cell carcinoma and associated non-neoplastic dermatological conditions

Penile carcinoma is a rare genitourinary malignancy in North America and Europe with highest rates recorded in South America, Africa and Asia. Recent classifications have refined the terminology used in classifying intraepithelial/in situ lesions and additionally newer entities have been recognised in the invasive category. While increasing recognition of a bimodal pathway of penile carcinogenesis has facilitated understanding and classification of these tumours, handling and subtyping of penile malignancies presents a challenge to the reporting pathologist, in part due to their rarity. This article reviews the terminology and classification of in situ and invasive carcinomas and their relationship to human papilloma virus status. In addition, associated non-neoplastic dermatological conditions of relevance and appropriate ancillary investigations will be addressed.

[Penile dermatoses]

The diagnostics of penile skin alterations represent a urological and dermatological challenge. The spectrum of differential diagnoses ranges from benign skin alterations with no clinical significance, through infections, vesiculobullous diseases and neoplasms up to acute diseases necessitating emergency interventions. Evidence-based therapy concepts are not available for all these diseases and due to the rarity an interdisciplinary cooperation is expedient and promising.

Male genital lichen sclerosus

Male genital lichen sclerosus (MGLSc) is a chronic inflammatory skin disease responsible for male sexual dyspareunia and urological morbidity. An afeared complication is squamous cell carcinoma (SCC) of the penis. The precise etiopathogenesis of MGLSc remains controversial although genetic, autoimmune and infective (such as human papillomavirus (HPV) hepatitis C (HCV), Epstein-Barr virus (EBV) and Borrelia) factors have been implicated: Consideration of all the evidence suggests that chronic exposure of susceptible epithelium to urinary occlusion by the foreskin seems the most likely pathomechanism. The mainstay of treatment is topical ultrapotent corticosteroid therapy. Surgery is indicated for cases unresponsive to topical corticosteroid therapy, phimosis, meatal stenosis, urethral stricture, carcinoma in situ (CIS) and squamous cell carcinoma.

Partial penectomy and penile reconstruction. Initial surgical management of localized penile cancer

INTRODUCTION

Surgical management for penile carcinoma is mutilating and affects significantly quality of life. Hereby we present our experience on penile reconstruction (PR) immediately after oncologic resection.

MATERIALS AND METHODS

We included all patients from January 2007 until April 2012 who underwent PR after partial penectomy (PP). Patients included in the study were seen at four different hospitals. All procedures were done by the same surgeon. Information included were: oncological status at the moment of surgery, surgical technique used for reconstruction. Each case was also registered photographically. On follow-up visits data about outcome and patient's satisfaction were registered.

RESULTS

During the study period 15 patients underwent PR. Average age at the moment of surgery was 49 years. Average follow-up was 15 months. In 12 patients PR was made at the same time as PP. Of those, four cases underwent glans resurfacing, 2 glandectomy, 6 partial penectomy, and the remaining 3 have had PP in a different time in the past. Every case underwent a split thickness graft procedure. Only 2 patients had postoperative complications. One of them presented urethral stricture and the other graft ischemia. Three patients had positive nodes at the moment of PP and two during the follow-up. None of the cases have presented local recurrence and only one died. On follow-up the remaining patients refer a good quality of life and felt happy with aesthetic results.

CONCLUSIONS

Given the results presented hereby we propose that PR must be part of the same procedure as the PP.

Penile cancer: Clinical Practice Guidelines in Oncology

Squamous cell carcinoma of the penis represents approximately 0.5% of all cancers among men in the United States and other developed countries. Although rare, it is associated with significant disfigurement, and only half of the patients survive beyond 5 years. Proper evaluation of both the primary lesion and lymph nodes is critical, because nodal involvement is the most important factor of survival. The NCCN Clinical Practice Guidelines in Oncology for Penile Cancer provide recommendations on the diagnosis and management of this devastating disease based on evidence and expert consensus.

Differential gene hypermethylation in genital lichen sclerosus and cancer: a comparative study

AIMS

Lichen sclerosus (LS) is a chronic inflammatory disease of the genital skin of unknown aetiology. The role of LS in penile squamous cell carcinogenesis is not well characterized. HPV has been implicated in both, as have epigenetic changes. The presence of HPV and hypermethylation of the MGMT, p16, RASSF1, RASSF2, TSLC1 and TSP1 genes were studied in penile LS; MGMT, RASSF2 and TSLC1 hypermethylation in penile cancer and TSLC1 hypermethylation in vulvar LS and cancer extends previous results reported by our group.

METHODS AND RESULTS

Thirty-seven HPV genotypes and hypermethylation were evaluated by PCR/reverse-line-blot and methylation-specific PCR respectively, in 27 preputial LS, 24 penile SCC, 30 vulvar SCC, 21 vulvar LS and 22 normal skin cases. HPV66 was present in 3.7% of penile LS cases, and p16 and RASSF2 hypermethylation were more frequent in penile cancer than in penile LS. p16, RASSF1, RASSF2 and TSP1 hypermethylation were similar in penile and vulvar LS.

CONCLUSIONS

Gene hypermethylation is a common event in penile LS, and occurs approximately as frequently as in vulvar LS. Certain genes can be hypermethylated as an early or late event in LS or cancer, respectively. This suggests a possible sequential role for these alterations in the transition from benign to malignant lesions.

Prognostic factors and biomarkers of penile carcinoma

Penile squamous cell carcinoma (SCC) is a rare malignancy with highest incidence in underdeveloped and developing countries. Oncogenic human papilloma virus (HPV) DNA, mainly types 16 and 18, are found in ∼ 100% of patients with uterine cervix carcinoma. The incidence of this virus in SCC and its variations range from 30.5 to 80%. Despite controversies, contrary to the cervical carcinoma, in the carcinogenesis and disease progression of SCC, HPV-dependent and HPV-independent tumors need to be considered. Lymphadenectomies continue to be the gold standard treatment of lymph node metastases. Undesirable accuracy on staging system methods and high rates of lymphadenectomy complications are the principal objections to these surgical procedures; therefore, the main issue in patients with SCC is to know who should or should not undergo lymphadenectomy. The search for primary tumor anatomopathological and biomarker risk factors for lymph node metastases, such as has occurred in other tumors, may be an important tool to select lymphadenectomies candidates better. Histological subtypes, tumor grade, growth pattern, tumor thickness, lymphatic embolization by neoplasic cells and depth of infiltration have been reported as important prognostic factors for lymph node metastases. In our series, lymphatic vascular permeation, palpable lymph node after primary tumor control (cN stage), pattern of invasion, p53 and PCNA immunoreactivity are independent lymph node metastases risk factors in the multivariate model. It is strongly recommended that patients be concentrated in specialized centers or cancer hospitals and multi-centric prospective studies carried out on tumor markers in this rare disease, in order to stage better lymph node disease and avoid unnecessary surgeries with high morbidity rates.

Diagnosis and treatment of lichen sclerosus: an update

Lichen sclerosus (LS) is a chronic, inflammatory, mucocutaneous disorder of genital and extragenital skin. LS is a debilitating disease, causing itch, pain, dysuria and restriction of micturition, dyspareunia, and significant sexual dysfunction in women and men. Many findings obtained in recent years point more and more towards an autoimmune-induced disease in genetically predisposed patients and further away from an important impact of hormonal factors. Preceding infections may play a provocative part. The role for Borrelia is still controversial. Trauma and an occlusive moist environment may act as precipitating factors. Potent and ultrapotent topical corticosteroids still head the therapeutic armamentarium. Topical calcineurin inhibitors are discussed as alternatives in the treatment of LS in patients who have failed therapy with ultrapotent corticosteroids, or who have a contraindication for the use of corticosteroids. Topical and systemic retinoids may be useful in selected cases. Phototherapy for extragenital LS and photodynamic therapy for genital LS may be therapeutic options in rare cases refractory to the already mentioned treatment. Surgery is restricted to scarring processes leading to functional impairment. In men, circumcision is effective in the majority of cases, but recurrences are well described. Anogenital LS is associated with an increased risk for squamous cell carcinoma of the vulva or penis. This review updates the epidemiology, clinical presentation, histopathology, pathogenesis, and management of LS of the female and male genitals and extragenital LS in adults and children.

Genital lichen sclerosus/balanitis xerotica obliterans in men with penile carcinoma: a critical analysis

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The European Association of Urology guidelines identify lichen sclerosus (LS) as a strong risk factor for penile squamous cell carcinoma (pSCC). However, this statement is based on the findings of case-control studies (Level of Evidence 2a) and a direct causal relationship between LS/balanitis xerotica obliterans (BXO) and pSCC remains to be established. Firm guidelines with respect to the appropriate follow-up policy for LS/BXO are lacking, whereas the impact of synchronous LS/BXO on the prognosis of pSCC remains to be determined. The presence of histologically-confirmed synchronous LS/BXO in patients diagnosed with pSCC is relatively high, although it is not associated with an increased risk of adverse histopathological features. LS/BXO can develop in extragenital skin grafts used for reconstruction after organ-sparing surgery for pSCC.

OBJECTIVES

To determine the rate of lichen sclerosus/balanitis xerotica obliterans (LS/BXO) in patients with penile squamous cell carcinoma (pSCC) and establish whether the presence of LS/BXO is associated with adverse histopathological features of pSCC. To report the phenomenon of LS involving non-genital skin grafts in patients who underwent organ-sparing surgery and split-skin graft (SSG) reconstruction

PATIENTS AND METHODS

Between January 2002 and January 2010, 223 men underwent surgical treatment for pSCC. A group of 52 patients with histologically-confirmed synchronous LS was identified (group A; overall rate of LS/BXO = 23.3%) and compared with a group of patients without synchronous LS (group B; n = 171; 76.7%). A subgroup of patients who underwent surgical excision and SSG reconstruction was also identified The histology reports of graft biopsies obtained during follow-up were reviewed and the rate of LS involving the graft was also recorded.

RESULTS

Mean (range) age at diagnosis was 60.9 (34-81) years and 60.7 (28-89) years for groups A and B, respectively (P = 0.958). The mean (range) duration of follow-up was 38.3 (4-92) months for group A and 45.5 (4-107) months for group B (P = 0.162) No statistically significant differences were noted between groups A and B in terms of tumour grade (P = 0.091), stage (P = 0.697), presence of lymphovascular invasion (P = 0.333), histological subtype (P = 0.107), associated carcinoma in situ (P = 0.246) or nodal status at initial diagnosis (P = 0.555). In the subgroup of 188 patients who underwent SSG reconstruction, 41 (21.8%) patients had histologically-confirmed synchronous LS; in this subgroup, 26 (13.8%) patients underwent graft biopsy during follow-up. Genital LS involving the graft was identified in seven specimens, although none of these seven cases had associated recurrent pSCC.

CONCLUSIONS

The presence of histologically-confirmed synchronous LS in patients with pSCC is relatively high but is not associated with increased rates of adverse histopathological features, including carcinoma in situ. LS can develop in extragenital skin grafts, although its association with the long-term risk for recurrent pSCC is not apparent in the present study.

Lichen sclerosus and squamous cell carcinoma

Lichen sclerosus is a chronic inflammatory disease that can progress to malignancy. The literature indicates an association with anogenital squamous cell carcinoma and verrucous carcinoma. Two pathogenic pathways, differentiated vulvar and penile intraepithelial neoplasias, which have recently been described in relation to squamous cell carcinoma, are both highly associated with genital lichen sclerosus independently of human papilloma virus (HPV) infection. Furthermore, tumor-promoting molecular changes unrelated to HPV infection have been demonstrated and may explain the malignant potential of lichen sclerosus. The possible relationship between HPV and genital lichen sclerosus currently remains open to discussion, and the prognostic importance of the overlapping of these 2 diseases is still unclear. This review considers the relationship between lichen sclerosus and squamous cell and verrucous carcinomas, the possible oncogenic mechanisms involved, and their possible association with HPV infection.

Diagnosis and management of premalignant penile lesions

Diagnosing premalignant penile lesions from benign penile dermatoses presents a unique challenge. The rarity of these conditions and the low incidence of penile cancer mean that the majority of our knowledge is based on small, non-randomized, retrospective studies. The introduction of specialist penile cancer centres in the UK has resulted in the centralization of expertise and resources, and has furthered our understanding of the biological behaviour and management of this rare malignancy. We review the current trends in the approach to diagnosing and treating various premalignant penile conditions.

[Lichen sclerosus and squamous cell carcinoma]

Lichen sclerosus is a chronic inflammatory disease that can progress to malignancy. The literature indicates an association with anogenital squamous cell carcinoma and verrucous carcinoma. Two pathogenic pathways, differentiated vulvar and penile intraepithelial neoplasias, which have recently been described in relation to squamous cell carcinoma, are both highly associated with genital lichen sclerosus independently of human papilloma virus (HPV) infection. Furthermore, tumor-promoting molecular changes unrelated to HPV infection have been demonstrated and may explain the malignant potential of lichen sclerosus. The possible relationship between HPV and genital lichen sclerosus currently remains open to discussion, and the prognostic importance of the overlapping of these 2 diseases is still unclear. This review considers the relationship between lichen sclerosus and squamous cell and verrucous carcinomas, the possible oncogenic mechanisms involved, and their possible association with HPV infection.

Aesthetic neo-glans reconstruction after penis-sparing surgery for benign, premalignant or malignant penile lesions

Purpose

To describe the technique and results of penis-sparing surgery combined with a cosmetic neo-glans reconstruction for benign, pre-malignant or malignant penile lesions.

Patients and methods

Twenty-one patients (mean age 61 years) with penile lesions with a broad spectrum of histopathology underwent organ-sparing surgery with neo-glans reconstruction, using a free split-thickness skin graft harvested from the thigh. Three patients were treated by glans-skinning and glans-resurfacing, 10 by glansectomy and neo-glans reconstruction, four by partial penectomy and a neo-glans reconstruction, and four by neo-glans reconstruction after a traditional partial penectomy.

Results

The mean follow-up was 45 months; all patients were free of primary local disease. All patients were satisfied with the appearance of the penis after surgery, and recovered their sexual ability, although sensitivity was reduced as a consequence of glans/penile amputation.

Conclusion

In benign, premalignant or malignant penile lesions, penis-sparing surgery combined with a cosmetic neo-glans reconstruction can be used to assure a normally appearing and functional penis, while fully eradicating the primary local disease.