Lichen Sclerosus
Lichen sclerosus (also known as balanitis xerotica obliterans) is an acquired, non-cancerous disease of the penis and urethra. Though it is not contagious or sexually transmitted, its exact cause remains unknown, despite being chronic and often debilitating.
Men with lichen sclerosus (also known as balanitis xerotica obliterans) often develop physical abnormalities, including discoloration of the penile skin, particularly near the head or urethral opening, along with induration and narrowing of the urethra. Another common sign is smoothing of the indentation between the head and shaft of the penis. In some cases, the skin can fuse to the head, creating the appearance of an uncircumcised penis, where the skin cannot be retracted, a condition known as phimosis. Unlike typical phimosis, lichen sclerosus can cause this in circumcised men; in some cases, the penile shaft skin may permanently fuse to the head of the penis.
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Symptoms of lichen sclerosus can range from subtle to severe. Many patients with this condition develop urethral strictures, which may affect only the urethral opening or extend along part or all of the anterior urethra. The condition is often undiagnosed for years, even though it can usually be detected on physical examination once suspected.​
Diagnostic Evaluation
When patients with lichen sclerosus are referred or diagnosed, the initial approach is a thorough evaluation of the urethra. This starts with a bougie calibration, a simple and painless test to assess the size of the opening. Next, we perform a cystoscopy to check for narrowing beyond the tip of the penis. If narrowing is found, urethral imaging is done to determine the length, location, and severity of the stricture.
Treatment
After a complete diagnostic evaluation, treatment for lichen sclerosus is individualized based on symptoms and test findings. A urologist with expertise in male urethral and penile disorders formulates the plan. While topical steroids may improve skin changes, they do not cure associated strictures.
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In some cases, circumcision may be helpful for redundant diseased skin, but it can cause skin deficiencies in circumcised patients. For narrowing of the distal skin, we may perform a revision surgery that involves longitudinal incisions and transverse closures to add width without removing the skin.
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When lichen sclerosus is associated with urethral strictures, observation or dilation is not recommended. For very short strictures, a meatotomy or extended meatotomy is performed, while longer strictures are treated with urethroplasty (open urethral reconstruction).
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The most complex strictures are pan-urethral strictures, which affect the entire anterior urethra and can be over 22 cm long. Using penile skin to augment the urethra has been linked to high recurrence rates, so alternative tissues, like buccal mucosa (from the cheek) or thigh skin grafts, are often preferred for better long-term results.
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The approach has been to reconstruct the bulbar urethra using bilateral buccal mucosa grafts, followed by split-thickness skin grafts from the thigh for the remainder of the urethra. Although technical success at the 4-month mark is 100%, long-term outcomes are better with buccal mucosa than thigh skin grafts, which have shown higher failure rates.
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While surgical treatment can address the obstruction, it does not cure lichen sclerosus. Lifelong follow-up is essential for patients diagnosed with lichen sclerosus to monitor for recurrence.