Plasma cell vulvitis: A case report

Plasma cell vulvitis (PCV) is a rare inflammatory condition characterised by plasma cell infiltration in the vulva. A woman in her 80s was referred to a specialist gynaecology clinic with chronic, painful vulval ulcers that were non-responsive to topical betamethasone. Following a biopsy confirming PCV, combination therapy was initiated. This included non-pharmacological management, such as promoting aeration and using hypoallergenic clothing and washes, combined with the daily application of clobetasone cream 0.05% and clindamycin cream 0.1%. Additionally, topical estriol 1% was applied twice weekly. The patient experienced rapid symptom resolution, with the PCV lesion healing within six weeks of starting treatment. This case documents the rare occurrence of plasma cell vulvitis presenting as chronic vulval ulceration, and proposes a treatment regimen worth considering in instances where monotherapy has been ineffective.

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.

European Association of Urology Guidelines on Urethral Stricture Disease (Part 1): Management of Male Urethral Stricture Disease

OBJECTIVE

To present a summary of the 2021 version of the European Association of Urology (EAU) guidelines on management of male urethral stricture disease.

EVIDENCE ACQUISITION

The panel performed a literature review on these topics covering a time frame between 2008 and 2018, and used predefined inclusion and exclusion criteria for the literature to be selected. Key papers beyond this time period could be included as per panel consensus. A strength rating for each recommendation was added based on a review of the available literature and after panel discussion.

EVIDENCE SYNTHESIS

Management of male urethral strictures has extensively been described in literature. Nevertheless, few well-designed studies providing high level of evidence are available. In well-resourced countries, iatrogenic injury to the urethra is one of the most common causes of strictures. Asymptomatic strictures do not always need active treatment. Endoluminal treatments can be used for short, nonobliterative strictures at the bulbar and posterior urethra as first-line treatment. Repetitive endoluminal treatments are not curative. Urethroplasty encompasses a multitude of techniques, and adaptation of the technique to the local conditions of the stricture is crucial to obtain durable patency rates.

CONCLUSIONS

Management of male urethral strictures is complex, and a multitude of techniques are available. Selection of the appropriate technique is crucial, and these guidelines provide relevant recommendations.

PATIENT SUMMARY

Injury to the urethra by medical interventions is one of the most common reasons of male urethral stricture disease in well-resourced countries. Although different techniques are available to manage urethral strictures, not every technique is appropriate for every type of stricture. These guidelines, developed based on an extensive literature review, aim to guide physicians in the selection of the appropriate technique(s) to treat a specific type of urethral stricture.

Eosinophilic Vulvar Leukoderma

We report the case of a 54-year-old woman with asthma and atopic dermatitis who presented a white spot on the genitalia. Histologic examination showed numerous eosinophils in the epithelium and the dermis. Eosinophilic esophagitis is defined as an esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by an eosinophil-predominant inflammation. We discuss the possible relationship between the two diseases.

British Gynaecological Cancer Society (BGCS) vulval cancer guidelines: Recommendations for practice

The purpose of this guideline is to collate evidence and propose evidence-based guidelines for the diagnosis and management of adult patients with vulva carcinoma treated in the UK. Malignant melanoma may present via similar routes and will be discussed. The reader is referred to the Ano-uro-genital Mucosal Melanoma Full Guideline [1] for more detailed recommendations. The management of vulval sarcoma is outside of the scope of this guideline. For further information, including details of guideline development and GRADE of recommendations, please see BGCS website for details (https://www.bgcs.org.uk/professionals/guidelines-for-recent-publications/).

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.

Looking beyond oral mucosa: Initial results of everted saphenous vein graft urethroplasty (eSVGU) in long anterior urethral strictures

Objective

To prospectively evaluate the feasibility and initial results of an everted saphenous vein graft (eSVG) as a dorsolateral onlay, in patients with long anterior urethral strictures and/or chronic tobacco users.

Patients and methods

In all, 20 patients with long anterior urethral strictures (>7 cm) and/or chronic tobacco exposed oral mucosa were included in the study. The harvested SVG was hydro-distended, detubularised, and everted. Substitution urethroplasty using an eSVG was performed using a dorsolateral onlay technique. Symptoms were assessed using the International Prostate Symptom Score (IPSS) and uroflowmetry at 1, 3 and 6 months; and voiding and retrograde urethrograms, and urethroscopy were done at 3 months. Failure was defined as failure to void, need for interventions in form of direct-vision internal urethrotomy or endodilatation.

Results

Three patients were excluded because they underwent a staged urethroplasty. In all, 17 patients underwent eSVG substitution urethroplasty. The mean (SD, range) follow-up of our patients was 17.64 (5.23, 10–26) months. The mean (SD, range) length of the strictured segment was 14 (2.5, 10–18) cm and the length of the harvested SVG was 16.3 (2.7, 12–20) cm. The mean (SD) IPSS at 1, 3 and 6 months after catheter removal was 10 (2.8), 10 (3.4) and 10 (1.4) and the quality-of-life score was 1.76 (0.5), 2.05 (1.0) and 2.05 (1.0), respectively. Postoperatively, endodilatation was required in two patients. Complete failure occurred in one patient.

Conclusions

An eSVG, as a dorsolateral onlay graft, is a promising and prudent option for long anterior urethral strictures, especially in patients with poor oral hygiene and chronic tobacco use.

Vulvovaginitis- presentation of more common problems in pediatric and adolescent gynecology

Vulvovaginitis is one of the most common gynecological complaints presenting in the pediatric and adolescent female. The common causes of vulvovaginitis in the pediatric patient differ than that considered in adolescent females. When a child present with vulvar itching, burning and irritation the most common etiology is non-specific and hygiene measures are recommended. However these symptoms can mimic more serious etiologies including infection, labial adhesion, lichen sclerosis, pinworms and foreign body must be considered. Yeast infection is rare in the pediatric population but common in the adolescent. In the adolescent patient infections are more common. Yeast and bacterial vaginosis are commonly seen but due to the higher rate of sexual activity in this population sexually transmitted infections must also be considered.

Recurrence after management of meatal balanitis xerotica obliterans

INTRODUCTION

We review outcomes after management of meatal balanitis xerotica obliterans (BXO). The primary outcome was recurrent meatal BXO.

METHODS

A database comprising mostly hypospadias patients was queried for meatal BXO. The disease was confirmed histologically in all cases. Management included topical steroids and/or immunosuppressants, and/or surgical excision of BXO with two-stage oral mucosa graft circumferential replacement urethroplasty.

RESULTS

A total of 12 patients had meatal BXO (8 boys and 4 adults). Of these, 10 had hypospadias, two presenting without prior surgery and eight returning 5-30 years after one or multiple (n = 2) repairs. Another two boys did not have hypospadias: one developing BXO 10 years after newborn circumcision and the other having persistent meatal BXO following therapeutic circumcision. Topical and intraluminal steroids (1% betamethasone or clobetasol) and tacrolimus were used for ≥12 weeks each as primary therapy or for meatal recurrence in a total of six cases. Complete response with resolution of white discoloration and relief of stranguria only occurred in two of the three receiving clobetasol, with follow up ≤12 weeks. BXO excision and urethroplasty was done in 11 patients, 10 using oral mucosa grafts; one with a focal lesion and a negative frozen section had reoperative TIP. Of the 10 undergoing excision with two-stage replacement urethroplasty, six remain disease free at a mean follow-up of 23 months (8-48 months), and four had recurrent stranguria and visible meatal BXO at a median of 26 months (22-105 months). Three of the four with recurrences had additional treatment and one was lost to follow-up. All initially had topical steroids, and two also used tacrolimus, without clinical resolution. These three then underwent a second BXO excision and two-stage oral graft replacement urethroplasty. In two recurrences, BXO was found invading from the meatus proximally within oral mucosa (Figure). Of these three with secondary urethroplasties, two are free of disease at 6 and 18 months, and the third had another meatal recurrence 6 months after the second stage.

DISCUSSION

We found topical steroids and immunosuppressants to have limited efficacy, with two clinical complete responses achieved only with clobetasol in patients with short follow-up. Forty percent of patients recurred at 2-9 years after visually complete BXO excision and two-stage oral mucosa graft replacement urethroplasty, and in two cases disease invaded into oral mucosa, the first well-documented cases of this occurrence.

Effect of Lichen Sclerosis on Success of Urethroplasty

Lichen sclerosis (LS) is a chronic, relapsing disease with a variable presentation. In men, genitourinary LS may affect the penile foreskin, glans, meatus, and urethra. Treatment is multifaceted, ranging from pharmacotherapy to surgery. Urethral reconstruction due to stricture disease from LS is frequently plagued by a high recurrence rate. At the authors' institution, the high recurrence rate has shifted their practice toward potent steroids and minimally invasive surgical techniques. Management of recurrence includes dilation, meatotomy/meatoplasty, 1-stage and 2-stage repairs. Recalcitrant cases may necessitate abandonment of most of the urethra resulting in a perineal urethrostomy.