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Lichen sclerosus (LS) is a chronic inflammatory disorder, presenting with pruritis and hypopigmentation of the vulvar and anogenital skin. LS presenting as a peri-clitoral mass has not been previously described. A 5-year-old patient with vulvar pruritis and ultrasound showing a homogenous mass was referred for suspected clitoromegaly with normal labs. Examination demonstrated a prepubertal patient with a mobile, soft, peri-clitoral mass and surrounding hypopigmentation consistent with LS. The cyst was excised surgically; pathology revealed an epidermal inclusion cyst. Postoperatively, she began using topical steroids for LS with symptom resolution. Thorough workup of clitoromegaly negative for hormonal causes requires further investigation to determine an alternative etiology of the mass. We suspect that inflammatory changes of LS and pruritus resulted in the peri-clitoral inclusion cyst. [ABSTRACT FROM AUTHOR]

• The purpose of this study is to identify the associated factors of two types of LVD and to compare the differences in related factors between the different pathological types of lichenoid vulvar disease. • The study conducted at the West China second Hospital of Sichuan University included a total of 1770 patients with biopsy-confirmed VLSC and VLS, along with 1209 patients with normal vulvovagina as control. • The incidence about lichenoid vulvar disease is influenced by various factors such as dietary habits, living environment, mental stress, concomitant diseases, hormone levels and so on. The purpose of this study is to identify the associated factors of two types of lichenoid vulvar disease (LVD) and to compare the differences in related factors between the different pathological types of lichenoid vulvar disease (LVD). The study conducted at the West China second Hospital of Sichuan University included a total of 1770 patients with biopsy-confirmed vulvar lichen simplex chronicus (VLSC)and vulvar lichen sclerosus(VLS), along with 1209 patients with normal vulvovagina as control. Further pathological subtype analysis was carried out on 163 cases of vulvar lichen simplex chronicus and 51 cases of vulvar lichen sclerosus. In addition, Univariate chi-square test and multivariate logistic regression were used to analyze the lichenoid vulvar disease group and vulvovaginal normal control group. Univariate analysis revealed that there were statistically significant differences (P < 0.05) in factors between the LVD group and the control group, except for living type, sleep habit, history of drinking, and allergic diseases. There was no significant difference in late sleep, spicy diet, and coffee intake in the factors of life and eating habits and the concomitant disease factors. Furthermore, univariate analysis showed that except for eating seafood, humid living environment, residence, caffeinated drinks, hypertension, and vaginitis, there were statistical differences in the related factors of LVSC. The incidence about lichenoid vulvar disease is influenced by various factors such as dietary habits, living environment, mental stress, concomitant diseases, hormone levels and so on, and there were no significant differences in these factors between VLS and VLSC except for income, work stress, systemic immune diseases, and menopause. [ABSTRACT FROM AUTHOR]

Lichen sclerosus (LS) is a chronic, autoimmune skin disease predominantly located in the anogenital region in women. In recent years, the role of the human microbiota in the pathogenesis of autoimmune diseases, including LS, has received interest. The study aimed to evaluate and compare the composition of the urinary, vaginal and gut microbiota in women with LS versus non-affected controls. Women diagnosed with LS (n = 16) and matched controls (n = 14) were enrolled in the study. From each participant, midstream urine, upper and lower vaginal swabs, as well as faecal samples, were collected. The microbiota composition was assessed using 16S ribosomal RNA (rRNA) gene sequencing of the V4 hypervariable region. We observed no LS-specific clustering in either of the four anatomic niches, using either hierarchical cluster analysis or weighted beta diversity metrics. However, for unweighted UniFrac, significant differences in the urinary and lower vaginal microbiota were observed when comparing women with LS to controls. These findings indicate that while the two groups have microbiota dominated by the same bacteria, variations do occur amongst less abundant bacteria. The LEfSe analysis revealed a higher relative abundance of the genus Streptococcus in the urinary and lower vaginal microbiota in women with LS compared to controls. Additionally, a higher relative abundance of phylum Euryarchaeota was observed in the gut microbiota in women with LS compared to controls. In this study, we demonstrated several differences amongst less abundant bacteria in the urinary, lower vaginal and faecal microbiota when comparing women with LS to controls. However, further research is required to assess whether these microbiota differences are causative or merely a result of the underlying LS disease. [ABSTRACT FROM AUTHOR]

Aim of our study was to evaluate the therapeutic effect of laser treatment in vulvar lichen sclerosus, mainly the reduction of existing symptoms as itching, burning and pain. We asked about the different outcome by using different application doses. We conducted a prospective randomized double-blind dose-controlled trial in our dysplasia unit specializing vulvar disorders. 67patients with active LS were included. LS was confirmed by biopsy or by the validated CSS (clinical scoring system of vulvar LS). Computer generated randomization resulted in two groups, each group received a different application dose.(LDG- low dose group, NDG- normal dose group) During the study period of 18 weeks all participants received three laser applications in three subsequent sessions of three weeks. Two follow-ups six and twelve weeks after the first application was performed. At every visit, the participants filled in the VAS (visual analogue scale) for recording the actual vulvar symptoms as itching burning or pain on a range from 0 to 10. Before treatment the mean VAS-Score was 4.3 (STD ± 2.4) in the NDG and 5.1(±2.6) in the LDG. After 18 weeks, the mean reduction was −2.4 (±2.3) for NDG and −2.7 (±2.8) for LDG. Four patients (two of each group) reported more pain after than before treatment. Both groups show significant lower VAS-Scores 18 weeks after the treatment than before therapy (p < 0.0001). The reduction of symptoms after 18 weeks between NDG and LDG was not significant (p = 0.6244). Laser treatment with the microablative CO2 laser leads to a significant improvement for symptoms of LS. A higher dosage of laser radiation shows no benefit concerning the symptoms. We have not observed any serious adverse events during this study. [ABSTRACT FROM AUTHOR]

To test the hypothesis that genital skin and male urethra affected by lichen sclerosus (LS) has increased collagen content and altered collagen structure. We used picrosirius red to stain and image collagen in human urethral, vulvar, and foreskin specimens with and without LS. Using Image J software, we quantified and compared (1) collagen content (using 2o metrics: collagen proportionate area [CPA] and collagen fiber count), (2) collagen fiber length and width, and (3) collagen structure using the texture analysis technique gray level co-localization matrix (GLCM) with respect to LS status and tissue type. We analyzed 23 LS specimens (vulva n=9, urethra n=7, foreskin n=7) and 29 non-LS specimens (vulva n=9, urethra n=7, foreskin n=13). Fiber count and CPA were significantly higher in all LS specimens compared to non-LS specimens (CPA: mean±SD 0.971±0.03 vs 0.948±0.02, P <.007; fiber count: mean±SD = 2906±127 vs 2509±78 fibers; P =.003). Collagen fiber width and length were similar with respect to LS status. GLCM analysis showed decreased inverse difference moment and increased entropy in LS tissues indicative of less homogeneous and more disorganized tissue structure (P <.001). LS tissues have greater collagen content compared to non-LS tissues. Quantitative assessment of collagen organization, using GLCM, revealed less homogeneity and more disorganization of collagen in LS compared to non-LS tissues. Taken together, our findings suggest that alterations in physical tissue properties seen in LS may be due to both increased collagen abundance and altered structure. [ABSTRACT FROM AUTHOR]

To determine the frequency of persistence of vulvar lichen sclerosus (LS) through the pubertal transition and assess if the symptomatology and exam findings differ by menarchal status at onset of symptoms A retrospective cohort study Academic tertiary care hospital Females aged 21 years or younger with a diagnosis of vulvar LS None Menarchal status at symptom onset, presenting symptoms, exam findings, persistence after menarche Of the 196 patients who met criteria, 141 were premenarchal and 55 postmenarchal. Of these 55, 36 had postmenarchal symptom onset, and the others had premenarchal symptom onset or LS diagnosis. Over the data review period, 26 patients were followed through the pubertal transition, and 10 (38.5%) had continued symptoms of LS. The premenarchal group (n = 141) was significantly more likely than the symptom-onset postmenarchal group (n = 36) to present with vulvar itching (70.2% vs 52.8%; P =.048), vulvar bleeding (26.2% vs 5.6%; P =.008), and bowel symptoms (16.3% vs 0%; P =.009). The premenarchal group was significantly more likely on exam to have subepithelial hemorrhages (24.8% vs 5.6%; P =.01). The postmenarchal group had more clitoral adhesions (25.0% vs 4.3%; P <.0001) and loss of labia minora (47.2% vs 2.1%; P <.0001). Thirteen postmenarchal patients presented with dyspareunia. This study suggests that premenarchal LS can persist after menarche in about 40% of adolescents and can initially develop in postmenarchal adolescents. Initial symptoms and exam findings differ on the basis of menarchal status. Continued surveillance is recommended. [ABSTRACT FROM AUTHOR]

Juvenile anogenital lichen sclerosus (JVLS) is a chronic inflammatory skin condition diagnosed visually by identifying skin changes including white patches, shiny and wrinkled skin, fissures and/or petechiae. Recent years have seen increasing recognition of the underrepresentation of skin of color in medical training and dermatology textbooks. Whether this gap in racially comprehensive dermatologic training resources is associated with disparities in the diagnosis of JVLS in people of color remains unknown. This study aims to evaluate potential racial differences in the diagnosis of JVLS when comparing Black children to children who are not Black. After IRB approval, we retrospectively collected data from children diagnosed with JVLS in a metropolitan area children's hospital joint dermatology-gynecology clinic between February 2020 and September 2022. Statistical analysis was performed using SPSS version 28.0 (IBM Corp, Armonk, NY). A total of 58 children diagnosed with JVLS were included in the study. This data represents findings at their first visit. Almost half (n=26, 45%) identified as Black (Table 1). The mean age at onset of symptoms (5.1 + 3.0 yrs), diagnosis (6.3 + 3.1 yrs), and latency between symptoms onset and diagnosis (1.3 + 2.3yrs) did not differ when comparing Black to not Black children (Table 2). While the prevalence of presenting symptoms such as itching did not differ between the two groups, more children who were not Black had been prescribed a topical antifungal prior to their initial visit (p=.02). There were significant differences in the frequency of documented skin changes with a higher prevalence of shiny, wrinkled skin of the clitoral hood (p=.03) as well as white patches on the labia majora (p=.04), perineum (p=.04) and perianal (p=.02) areas of Black children. In contrast, although fissures were most identified on the perineum and perianal areas, the difference between the two groups was not significant. And, although Black children had a higher reported percentage of disease involvement of the labia majora (p=.02) and perineum (p=.04), there was no difference in the reported degree of disease severity between the 2 groups. We report a difference between visual disease involvement and the perception of disease severity where Black children are classified as having less severe disease despite greater percentages of skin involvement. Future research is needed to identify and rectify potential diagnostic biases of vulvar dermatologic conditions in children with skin of color. [ABSTRACT FROM AUTHOR]

Annular lichenoid diseases encompass a diverse range of pathologies that present as circular, raised, or flat lesions that may vary in size and number. Examples include annular lichenoid dermatitis of youth, annular lichen planus, erythema dyschromicum perstans, erythema multiforme, fixed drug eruption, lichen sclerosus, neonatal lupus, porokeratosis, subacute cutaneous lupus erythematosus, and lichenoid syphilis. Clinical morphology and histopathology can differentiate these entities. [ABSTRACT FROM AUTHOR]

Vulval cancer is a rare gynaecological malignancy. In this study, we present a tertiary centre case analysis to examine the recurrence patterns and survival outcomes of vulval squamous cell carcinoma (SCC). This is a retrospective cohort study of women who received treatment at Oxford University Hospitals between February 2010 and July 2022 for primary vulval SCC. We included 98 cases. The median age at diagnosis was 68 years. Human Papillomavirus (HPV) infection and lichen sclerosis were observed in 21 and 50 cases, respectively. Surgical excision was the primary treatment. Recurrence within 2 years was more common with advanced stage (p = 0.047, RR = 2.26) and extracapsular lymph node spread (p = 0.013, RR = 2.88). Local recurrence was not associated with a specific cut-off value for tumour-free margin. Poor survival outcomes were observed with higher grade (p = 0.01), advanced FIGO stage (p < 0.001), HPV-independent cancer (p = 0.048), lymph node involvement (p < 0.001, HR = 7.14), extracapsular spread (p < 0.001, HR = 7.93), lymphovascular space invasion (p = 0.002, HR = 3.17), tumour diameter wider than 23 mm (p = 0.029, HR = 2.53) and depth of invasion more than 6 mm (p = 0.006, HR = 3.62). Perineural invasion is associated with shorter disease-free survival. Five-year cancer-specific survival rates for stages I, III, and IV were 90.2%, 40.8%, and 14.3%, respectively. - Recurrence within 2 years was associated with advanced stage and extracapsular spread of lymph node disease. - Local recurrence was not associated with a specific cut-off value for tumour-free margin. - Survival was poorer in locally advanced tumours, lymph node metastasis, extracapsular spread, lymphovascular space invasion, and HPV-independent cancers. • Vulval cancer is a rare malignancy. HPV and lichen sclerosis can lead to premalignant lesions. • Recurrence within two years is more common in advanced stage and extracapsular lymph node spread. • Local recurrence in stage I is not associated with a specific cut-off value for tumour-free margin. • Perineural invasion is associated with disease recurrence and shorter disease-free survival. • Five-year survival rates for stages I, III, and IV were 90.2 %, 40.8 %, and 14.3 %, respectively. • Poor prognostic factors included higher grade, stage, lymphatic spread, and larger dimensions. [ABSTRACT FROM AUTHOR]

Background: Lichen sclerosus (LS) is a chronic inflammatory skin disease that mostly affects the anogenital region of women and lowers patients' quality of life. Current standard treatment of LS is topical steroids.Objective: To evaluate the efficacy of topical progesterone 8% ointment and compare to standard therapy with topical clobetasol propionate 0.05% in premenopausal women presenting with previously untreated early onset LS.Study Design: Randomized, double-blind, 2-arm, single center superiority trial in premenopausal women with histologically confirmed vulvar LS who were randomized in a 1:1 ratio to receive clobetasol propionate 0.05% ointment or progesterone 8% ointment. The primary outcome was the clinical severity LS score after 12 weeks, which consists of six clinical features assessed by the physician. Secondary outcomes were the symptom severity LS score, which consists of three symptoms rated by the patient, the Short Form SF-12 physical and mental health scores, and adverse events. Response to medication was assessed by biopsy at the end of the treatment to evaluate inflammatory parameters.Results: Overall, 105 women were screened, 102 underwent vulvar biopsy and 37 received a histologically confirmed diagnosis of LS and were randomized: 17 to progesterone and 20 to clobetasol propionate. At 12 weeks, the mean clinical LS scores improved from 4.6 (SD 2.0) to 4.5 (SD 1.7) in the progesterone arm, and from 4.6 (SD 2.8) to 2.9 (SD 2.2) in the clobetasol propionate arm (difference in favor of clobetasol 1.61; 95% CI 0.44 to 2.77, p = 0.009), and the mean symptom severity LS scores improved from 4.5 (SD 3.8) to 3.1 (SD 3.0) in the progesterone arm, and from 4.7 (SD 2.8) to 1.9 (SD 1.8) in the clobetasol propionate arm (difference in favor of clobetasol 1.32; 95% CI -0.25 to 2.89, p = 0.095). LS was in complete remission in 6 out of 10 patients (60%) with available biopsy in the progesterone arm, and in 13 out of 16 patients (81.3%) in the clobetasol propionate arm (odds ratio in favor of clobetasol 0.35; 95% CI 0.06 to 2.06, p = 0.234). No drug-related serious adverse event occurred during the trial.Conclusions: Topical progesterone 8% ointment is inferior to standard therapy with topical clobetasol propionate 0.05% in previously untreated premenopausal women with vulvar LS after 12 weeks treatment. [ABSTRACT FROM AUTHOR]

This Clinical Opinion replaces the NASPAG Clinical Recommendation: Pediatric Lichen Sclerosus published in 2014. The objective of this document is to provide guidance in the diagnosis and management of vulvar lichen sclerosus (LS) in the pediatric and adolescent patient in order to treat patient symptoms and reduce long-term sequelae. LS is a chronic inflammatory condition affecting the anogenital region that may present in the prepubertal or adolescent patient. Clinical presentations include significant pruritus, loss of pigmentation and vulvar adhesions with loss of normal vulvar architecture. Management includes topical agents for induction and maintenance therapy, as well as long-term follow-up for identification and treatment of recurrence and sequelae. This document is intended for use by both primary and specialty pediatric and adolescent gynecology (PAG) providers, including specialists in pediatrics, gynecology, adolescent medicine, and dermatology. [ABSTRACT FROM AUTHOR]

• Despite major efforts in the management of PeCa aimed at improving staging and consequently providing more solid indications for OSS, there hasn't been a notable shift towards more conservative treatments. • Surgeries for advanced-stage tumors are still marked by high rates of complications potentially affect the sexual and psychosocial health of patients. • Mutations in SWI-SNF complex and inactivated JAK-STAT signaling enriched at relapse. • These issues may foster a tendency toward avoidance behaviors, contributing to a delayed clinical presentation of the disease as well as its treatment. Penile cancer (PeCa) is a rare disease. HPV infection, smoking, phimosis, and lichen sclerosus represent well-known associated risk factors. Primary aim of our study is to evaluate the incidence and risk factors of PeCa and to outline the adopted diagnostic and therapeutic approaches. Secondary aim is to investigate risk factors associated with aggressive disease and to identify the complications arising from its surgical treatment. We conducted a retrospective analysis using the PearlDiver™ Mariner database, from January 1, 2011, to December 31, 2021, identifying all patients diagnosed with PeCa and PeIN, evaluating comorbidities, risk factors, and social and economic conditions. We evaluated the imaging modalities employed for staging as well as the treatment strategies. Finally, we evaluated the most frequent complications associated with inguinal lymphadenectomy (ILND). During the study period, 17,494 patients were diagnosed with PeCa and 5,965 with penile intraepithelial neoplasia (PeIN). US was the most frequently utilized imaging modality, followed by PET and PET/CT. Use of CT and MRI was around 5%. Surgical treatment was the predominant strategy, utilized in 31.3% of PeCa and 22.9% of PeIN. Wide Local Excision/Glansectomy emerged as the most common surgical procedures. MLR analysis identified smoking as a risk factor for metastatic PeCa (OR; 95% CI = 1.49; 1.379–1.609), HPV infections were associated with a 35% decrease in risk (OR; 95% CI = 0.65; 0.562–0.744) (all P < 0.001). Lichen sclerosus and phimosis were associated with a doubled risk of demolitive surgery. Approximately 40% of patients experienced complications associated with ILND. Despite advances in PeCa management, there's no significant move toward more conservative treatments. Surgical treatments are still marked by high rates of complications, potentially affect the sexual and psychosocial health of patients. These issues may foster a tendency toward avoidance behaviors, contributing to a delayed clinical presentation and treatment. [ABSTRACT FROM AUTHOR]

Differentiating pediatric vulvar lichen sclerosis versus vitiligo is a clinical challenge. For both conditions, patients often have a delayed or initial misdiagnosis. Both conditions classically present with hypopigmentation, while LS is more likely to present with symptoms such as pruritus, bleeding, and pain. We aim to add to the existing literature by comparing signs and symptoms in a cohort of patients with either conditions. A retrospective case control study was performed at a single tertiary children's hospital from January 2016 to September 2022. Diagnosis was made by visual inspection by both a pediatric gynecologist and a pediatric dermatologist. Biopsy is not routinely performed for diagnosis. Data collected included demographic information, presenting signs and symptoms, and treatment regimens. Additionally, this interdisciplinary clinic utilizes a standardized collection form for all notes including a detailed dermatologic assessment. This allows us to both monitor patient's disease progression as well as standardize care. For statistical analysis we utilized a test of independence (Pearson's Chi Squared versus Fisher's Exact) Within our study time frame, there was n=80 patients diagnosed with LS and n=18 with vitiligo. Vitiligo and LS had a similar age at presentation (5 and 6 respectively). Ethnicity was similar between the 2 groups, while vitiligo had a higher percentage (55% versus 35%) of African American patients (p< 0.001). Pruritus was a common symptom in both conditions (70% LS and 33.3% vitiligo). Symptoms of vulvar pain (15%), pain with defecation (15%), and bleeding (8.75%) were seen in LS patients, while none of the vitiligo patients had those symptoms. Figure of 8 and clitoral involvement were seen in both conditions as well. Both conditions involved the perianal region and perineum. Vitiligo and LS are challenging to differentiate; however, these data support pain (either vulvar or pain with defecation) and bleeding as more commonly seen in LS compared to vitiligo; however, most patients with LS did not present with these symptoms. These findings also support the importance of interdisciplinary clinics given the overlap of these conditions with varying treatment and long-term implications. Future direction will include evaluating outcomes on management options as well as identifying similarities in patients with LS flares. [ABSTRACT FROM AUTHOR]

Radio(chemo)therapy plays an important role in the treatment of vulvar cancer, either as postoperative treatment or as definitive treatment in patients who present with inoperable disease. Only limited data are available regarding outcome after modern state of the art radio(chemo)therapy and more information regarding prognostic factors are warranted. The aim of this study was to evaluate disease outcomes after radio(chemo)therapy in patients with vulvar cancer with special emphasis on the impact of lichen sclerosis on local control. All consecutive patients (n = 109) from the western half of Denmark who were treated with definitive (n = 52) or postoperative (n = 57) radio(chemo)therapy between January 2013 and January 2020 were included. Local control, cause-specific survival and overall survival, as well as morbidity, were analysed using Kaplan–Meier statistics. Prognostic factors for local control were analysed in univariate and multivariate analysis. At a median follow-up of 35 (4–95) months, 46 (42.0%) patients were diagnosed with recurrence. Eighty per cent of the recurrences were located to the vulva region, leading to a 5-year local control of 58.9% (confidence interval 47.9–69.9). Cause-specific survival was 62.9% (confidence interval 53.1–72.7), whereas overall survival was 58.0% (confidence interval 47.6–68.5). Grade 3–4 morbidity was diagnosed in 10 (9%) patients. Lichen sclerosis (hazard ratio 3.89; confidence interval 1.93–7.79) was an independent risk factors for local recurrence. Patients without lichen sclerosis had a 5-year local control rate of 83.6% (confidence interval 67.2–99.0) and 62.6% (confidence interval 43.2–82.0) after postoperative and definitive radio(chemo)therapy, respectively. In patients with lichen sclerosis, the local control rate was 44.0% (confidence interval 19.3–69.0) and 17.6% (confidence interval 0–30.0) after postoperative and definitive radio(chemo)therapy, respectively. Radio(chemo)therapy plays an important role in the treatment of vulvar cancer. However, despite dose escalation, a substantial proportion of patients experienced local relapse. Pre-existing lichen sclerosis seems to have a significant impact on the risk of recurrence. This should influence surveillance programmes for these patients. • Patients received state of the art radio(chemo)therapy with MRI and PET-CT for contouring and dose planning. • Prescribed dose was 64 Gy to the gross tumour volumes and 50–51.2 Gy to elective volumes. • Recurrences after radio(chemo)therapy were mainly locally with involvement of the vulvar region. • Pre-existing lichen sclerosis was the most important risk factor for local recurrence. • Close surveillance programmes should be available for early detection of local recurrence for salvage surgery. [ABSTRACT FROM AUTHOR]

To assess long-term outcomes of lichen sclerosus (LS) in the female pediatric population, specifically in relation to patient age, treatment type and duration, and remission. Retrospective chart review was conducted to identify female pediatric patients (0-18 years of age) who were diagnosed with LS between January 1, 2015 and January 1, 2020 at the University of North Carolina Dermatology and/or Obstetrics and Gynecology Departments. Patients were contacted via telephone for follow-up interviews consisting of a series of questions regarding patient age, symptom onset, time of diagnosis, treatment, and current symptoms. Of the 128 patients identified, 61 patients consented and participated in follow-up interviews. At the time of study follow-up, 55/61 (90%) of participants reported their symptoms were improved. Patients reported using a variety of treatments, with medium- to high-potency topical steroids being the most common. At the time of follow-up, 53/61 (87%) of patients reported being asymptomatic, 37/53 (70%) of whom were not using any form of maintenance therapy. Those who achieved symptom resolution did so at an average of 8.4 years of age. There was no significant difference in age in asymptomatic patients receiving maintenance therapy and those receiving no maintenance therapy. There was a positive correlation for the duration of LS treatment and time in remission (P <.001). Increased patient age at time of follow-up also correlated positively with time in remission (P <.001). In our cohort, the need for continued maintenance therapy was not correlated with age or, by proxy, pubertal status. Thus, LS remission might be determined more by early and successful pharmacological interventions. [ABSTRACT FROM AUTHOR]

Objective: To assess the outcomes and safety of conservative management of lichen sclerosus urethral stricture disease (LS-USD).Methods: This multi-institutional study included patients with LS-USD managed with endoscopic procedures or clean intermittent catheterization (CIC) regimens between 2005 and 2019. Those with an obliterative stricture, a history of prior urethral reconstruction, or <3 months follow-up was excluded. Primary outcome measures were urinary tract infection (UTI), acute urinary retention (AUR), serum creatinine, and uroflowmetry values. Secondary outcome measures included patient-reported outcome measure questionnaires on urinary and sexual function. Failure was defined as progression to reconstructive surgery or permanent indwelling catheterization.Results: 112 men were analyzed with a median follow-up of 30.0 months (IQR 12.0-55.5). Median age was 52.5 years (IQR 42.6-61.0) and median body mass index was 34.5 kg/m2 (IQR 29.9-40.7). Median stricture length was 12.0 cm (IQR 2.8-20.0). 89% of patients underwent urethral balloon dilation, with a median of 2 (IQR 1-3) per patient. CIC was performed in 46% of patients, with 31% of this subgroup using intraurethral steroids. 84% of patients avoided invasive surgery or permanent indwelling catheterization, with an improvement in urethral stricture patient-reported outcome measure scores (P = .0013). Those who failed were more likely to have a history of UTI (P = .04), urosepsis (P = .03), AUR (P <.001), and more likely to perform CIC (P = .01).Conclusions: Over medium-term follow-up, most patients with LS-USD were safely managed with conservative techniques. Caution is warranted in those who develop UTIs, urosepsis, and AUR and the potential long-term consequences of repetitive conservative interventions must be considered. [ABSTRACT FROM AUTHOR]

Objective: Vulvar Lichen sclerosus (LS) is a chronic inflammatory disease in which architectural changes and symptoms like itching, soreness, pain and dyspareunia can affect quality of life and sexual activity. Perineoplasty has been shown to be effective as a supportive surgical treatment in women with refractory dyspareunia in addition to the standard topical immunosuppressive treatment. The aim of this study was to evaluate retrospectively general complaints, patient satisfaction concerning sexual activity, reduction of dyspareunia/apareunia, orgasm ability and recurrence of LS after perineoplasty.Study Design: This study is a retrospective monocentric observational study, in which patients with vulvar LS who had undergone perineoplasty were invited to fill out a standardized questionnaire during the follow-up time. The main outcome measure is the overall patient satisfaction after surgical therapy of vulvar LS.Results: Forty-one of the 70 invited patients with a median age at surgery of 58 years (18-74 years) and a median 60 years (19-76 years) at the last follow-up were evaluated. The median follow-up time was 2.3 years (1-5 years). There was a significant (p < 0.001) reduction in general complaints after surgery. Twenty-two patients were very satisfied, 15 were satisfied and 3 were not satisfied with the outcome of the surgery. Only 2 patients would not recommend the surgery. Although, there was a significant (p = 0.02) reduction in dyspareunia after surgery, 10 patients still felt pain during sexual intercourse.Conclusion: This is one of the largest studies reporting on long-term results of perineoplasty. It showed that perineoplasty is a safe surgical treatment option with a high satisfaction rate in patients with dyspareunia due to LS and a desire to regain sexual activity. Perineoplasty can improve sexual activity and achieve overall satisfaction in selected patients even though the recurrence rate of LS in sexually active patients remains high. [ABSTRACT FROM AUTHOR]

• To our knowledge, the study is the first one describing VLSA treated with combination of high-frequency electrocautery therapy and ALA-PDT. • Our results suggest that this combined therapy for the treatment of VLSA can effectively clear skin lesions with a high clearance rate. • According to our observation, the recurrence rate of skin lesions in patients under this combined therapy is relatively low. ALA-PDT effectively treats Vulvar lichen sclerosus et atrophicus (VLSA), but it requires multiple repetitions for satisfactory results. To enhance efficacy, we employed a combination of high-frequency electrocautery therapy and ALA-PDT in treating seven VLSA patients. Lesions and leukoplakia in the seven women with VLSA were removed using a high-frequency generator. PDT was administered after wound healing, and it was repeated six times. Follow-up assessments were carried out at 1, 3, and 6 months to evaluate the severity of pruritus and investigate lesion repigmentation. Following the combined therapy, the disappearance of pruritus was observed in all patients, and normal color and thickness were restored to their skin. Two patients reported mild pruritus with a score of 2 one month after treatment, which persisted until the 6-month follow-up, while the remaining patients remained free from pruritus. No recurrence of skin lesions was observed in any of the patients. The combined therapy for the treatment of VLSA is found to be convenient, effective, and easily promotable. [ABSTRACT FROM AUTHOR]

Objective: To assess the accuracy of clinical diagnoses and the true incidence of lichen sclerosus (LS) in patients with phimosis.Materials and Methods: The 92 adult male patients who were qualified for circumcision due to phimosis, were included in the study. The patients were diagnosed clinically by a urologist and dermatologist before the surgical procedure. After the circumcision, the resected foreskins were examined by 2 independent uropathologists.Results: Preoperative clinical diagnosis of LS was established in 54 patients (58.7%); healthy-looking skin in 26 (28.3%) and other penile diseases in 12 (13.1%) patients. After histopathological examination, the diagnosis of LS was established in 62 patients (67.4%), but only in 44 patients with previous LS clinical diagnosis. LS was histopathologically confirmed in 18 other patients with clinically diagnosed healthy skin (n = 17) or lichen planus (n = 1). Healthy skin was histopathologically confirmed in 10 cases in patients diagnosed clinically before as LS. Other 15 histopathological diagnoses were Zoon balanitis (n = 3), nonspecific balanitis (n = 5), lichen planus (n = 1), psoriasis (n = 1), invasive penile cancer (n = 3), Bowen's disease (n = 1), penile intraepithelial neoplasia 2 usual type (n = 1).Conclusion: LS has been revealed as the most common histopathological diagnosis in patients undergoing circumcision in our study. Histopathological examination seems to be necessary to exclude this disease. [ABSTRACT FROM AUTHOR]

• This study assessed cytokines/chemokines derived from vulvar lichen sclerosus (VLS) keratinocytes and fibroblasts. • CHI3L1, GDF-15, IGFBP-2 and DKK-1 were the most dysregulated cytokines/chemokines in VLS compared with healthy skin cells. • The dysregulated cytokines/chemokines in VLS keratinocytes and/or fibroblasts are implied in both inflammation and collagen/fibroblast metabolism. • These findings suggest a close crosstalk between inflammation and altered collagen biology in VLS pathophysiology. [ABSTRACT FROM AUTHOR]

Objectives: To report surgical and oncological outcomes of total glans resurfacing in a consecutive series of superficial penile cancers.Design, Settings and Partecipants: 26 patients were enrolled in the present trial. A retrospective analysis was conducted. Inclusion criteria were age < 80, "de novo" malignancy, clinically suspected superficial disease and disease confirmation by a penile biopsy. Clinically palpable corporeal or urethral involvement, high histological grade, clinically palpable nodes on physical examination and unwillingness to comply with follow-up were considered as exclusion criteria.Outcome Measurements and Statistical Analysis: Descriptive features and surgical outcomes were extrapolated from the clinical records. The categorical variables were described using frequency and percentage, and the continuous variables were described using median and interquartile range (IQR) value. Kaplan-Meier analysis was used to estimate survival over time.Results and Limitations: Median follow-up was 38 (IQR 13-86) months. Median age was 65 (IQR 55-68). An history of lichen sclerosus was reported by 50% of patients. No intraoperative complications were reported. Median hospital stay was 5 (IQR 2-6) days. Final histology confirmed superficial disease in 42.4% and T1 in 53.8%. T2 was detected in a single case. Postoperative complications were minimal (3.8%). No regional nodal recurrence was reported. At Kaplan-Meier analysis, overall survival rate was 100% at 1 year, 1-year recurrence free survival was 96.1% and 2-year recurrence free survival was 88.5%.Conclusion: Total glans resurfacing may represent an excellent option for organ preserving surgery in patients with a superficial penile cancer. Surgical and oncological outcomes proved to be satisfactory. [ABSTRACT FROM AUTHOR]

• Lichen sclerosus possibly conceals a humoral immune response to a glycoprotein ECM1. • SiRNA ECM1 gene knockdown in human dermal fibroblasts contributed to upregulate and downregulate the genes for protein binding. • Collagen-4 and laminin-332, as well as collagen-7 that is unresponsive to ECM1 knockdown, showed altered expression in LS lesional skin. • ECM1 gene silencing in fibroblasts alters gene expression for structural, fibrogenic, and carcinogenic properties, which may have features reminiscent of LS skin. Lichen sclerosus (LS) is an acquired inflammatory mucocutaneous disease affecting the anogenital area, characterized histologically by hyalinosis and thickened vessel walls in the dermis. The presence of serum autoantibodies against extracellular matrix protein 1 (ECM1) in LS patients may suggest its involvement in disease pathogenesis. To examine if reduced ECM1 production by dermal fibroblasts contributes to the pathogenic features of LS. Gene expression in ECM1 knockdown human dermal fibroblasts was analyzed by cDNA microarray. Functional enrichment for genes involved in cellular functions was conducted. Protein expression was analyzed by ELISA and confocal laser scanning microscopy using LS skin. Microarray analysis identified 3035 differentially expressed genes in ECM1 knockdown cells, wherein 1471 were upregulated genes related exclusively to cell adhesion, proliferation, apoptosis, intracellular signaling, and extracellular matrix organization. Further narrowing with criteria specific for localization and function of ECM1 identified 48 upregulated genes identified to have structural, fibrogenic, and carcinogenic properties. Of these, laminin-332 and collagen-IV displayed altered immunolabeling within the basement membrane zone (BMZ) and dermal vessels in LS skin, similar to that of collagen-VII, which exhibited unchanged transcription levels in ECM1-knockdown fibroblasts. Collagen-VII bound to recombinant ECM1 in a solid-phase immunoassay and colocalized with ECM1 in the skin BMZ. Further, ECM1-knockdown fibroblasts exhibited a marked delay in cell migration and gel contraction. In the absence of ECM1 expression in fibroblasts there is selective dysregulation and disassembly of structural and extracellular matrix molecules, which may result in microstructural abnormalities reminiscent of LS. [ABSTRACT FROM AUTHOR]

Lichen sclerosus (LS) may cause the glans and prepuce to become fused, making a standard circumcision impossible. Most authorities recommend excision of the fused area with glans resurfacing, although partial circumcision is often performed. To evaluate an alternative technique that preserves the fused area and allows a complete circumcision without grafting. Over 3 yr (January 2016—March 2018), 28 men (age 28–93 yr; mean 62 yr) underwent the restoration of lost obscured coronal sulcus (ROLOCS) procedure with over 1 yr of follow-up. Complications were reviewed retrospectively with an additional survey. The shaft skin is incised at the corona. Dartos is divided, which allows antegrade dissection just outside the fused glans membrane. The foreskin is removed and shaft skin sutured to dartos below the corona. Postoperative pain, aesthetic satisfaction, sexual enjoyment, glans sensation, and urinary symptoms were measured. There were no major complications. In all cases, the coronal sulcus was restored and the glans skin became soft without skin grafting. All were satisfied with the aesthetics. Of the patients, <70% experienced mild to low-moderate pain; 55% and 25% had, respectively, improved or reduced glans sensation; and 40% reported improved enjoyment of sex. Histology showed LS in all cases with squamous cell carcinoma in four, including three out of five patients who had previously undergone partial circumcision. Although this is the largest series reported yet, the numbers were too small for a meaningful statistical analysis. The ROLOCS operation offers an aesthetically superior alternative to partial circumcision and is easier to perform with less morbidity than skin grafting. The restoration of lost obscured coronal sulcus (ROLOCS) procedure provides an alternative to partial circumcision or circumcision with skin grafting when the foreskin is welded to the head of the penis (glans) due to lichen sclerosus. It produces a good cosmetic result, but the glans can be sore until it heals. In patients with lichen sclerosus, where the foreskin and glans are fused, it is not necessary to resurface the glans when performing a circumcision, provided that the fused layer is preserved. [ABSTRACT FROM AUTHOR]

Background: Vulvar lichen sclerosus is a progressive dermatitis with significant itching, pain, and sexual dysfunction.Objective: To investigate topical steroid use and clinical improvement across multiple specialties.Methods: Retrospective cohort study at dermatology, gynecology, and vulvovaginal specialty clinics from 2012 to 2017. Descriptive statistics and panel logistic regression were performed.Results: A total of 333 women attended 1525 visits (median 6/patient; range, 1-24 visits). Patients used steroids exactly as prescribed at 66% of visits, less than prescribed at 26%, and not at all at 8%. Versus no use, exact use improved symptoms (odds ratio [OR], 4.6; 95% confidence interval [CI], 2.2-9.6) and physical examination findings (OR, 6.9; 95% CI, 2.7-17.6) more than infrequent steroid use (symptoms: OR, 2.5; 95% CI, 1.2-5.4; physical examination findings: OR, 4.2; 95% CI, 1.6-11.0). Sexual activity status was noted in 93% of vulvovaginal, 29% of gynecology, and 0% of dermatology visits. At intake, 42% of women were sexually inactive because of pain; of these, 37% became sexually active after steroid treatment. Steroid adherence was not associated with change in sexual activity.Conclusions: Women with vulvar lichen sclerosus improve more when topical steroids are used exactly as prescribed, although some improvement occurs with imperfect use. Sexual activity documentation is inconsistent, limiting quality of life follow-up. [ABSTRACT FROM AUTHOR]

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/). [ABSTRACT FROM AUTHOR]

The objective of this systematic review and meta-analysis was to evaluate the efficacy and the effectiveness, as well as the safety and tolerability, of urethral bulking agents (UBAs) in women with mixed or stress urinary incontinence. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were used to identify relevant articles. In total, 3510 records were found. A total of 42 full texts were evaluated but only 21 (48.8 %) were selected for the qualitative and quantitative analysis. The pooled improvement rate in studies with a follow-up of ≤1 and >1 year was 46.0 % (95 % CI: 37.0 %-57.0 %; I2: 88.9 %) and 57.0 % (95 % CI: 39.0 %-74.0 %; I2: 89.6 %), respectively. The outcome 'cure/dryness' ranged from 9.1 % to 56.7 %. The pooled cure rate was 26.0 % (95 % CI: 21.0 %-32.0 %; I2: 89.9 %) and 21.0 % (95 % CI: 16.0 %-27.0 %; I2: 34.2 %) in females with a follow-up of ≤1 and >1 year, respectively. The treatment success rate ranged from 32.7 % to 93.3 % in 12 studies; it was objectively assessed with different tools (e.g., the Stamey scale in 5 studies). The pooled objective treatment success rate was 7.0 % (95 % CI: 59.0.0 %-75.0 %; I2: 82.4 %) and 46.0 % (95 % CI: 37.0 %-55.0 %; I2: 55.3 %) in women with a follow-up of ≤12 and >12 months, respectively. The percentage of adverse events was 0.4 % (vaginal infection, irritation, lichen sclerosus, worsening urinary incontinence). However, the use of UBAs as the first-line therapy should be demonstrated in more comparative studies (randomized studies MUSs vs. UBAs). UBAs should be considered a first-line surgical therapy only for women with SUI and mixed UI with high anaesthesia risk, elderly patients, or patients reluctant to undergo surgery. Thus, UBAs should not be offered as first-line therapy for those women desiring a "one-time" durable solution for primary or recurrent SUI. [ABSTRACT FROM AUTHOR]

Context: Phimosis is considered virtually universal in newborn males and likely to resolve within a few years. Persistent phimosis can result in pain, sexual dysfunctions, increased risk of penile inflammatory conditions and penile cancer. There are two forms - primary phimosis and secondary phimosis - the latter often representing a consequence of lichen sclerosis, diabetes and obesity.Objectives: To conduct a systematic review to determine the prevalence of phimosis at different ages.Data Sources: PubMed, Google Scholar, the Cochrane Library, and bibliographies of original studies were searched using the keyword phimosis.Study Selection: Studies containing original data on phimosis at any age.Data Extraction: Two reviewers independently verified study design, extracted data and rated studies for quality.Results: Forty-three eligible studies were included: 27 from PubMed, 4 from Google Scholar, and 12 from bibliography searches. Phimosis was reported in most newborns, then gradually decreased in prevalence. Most studies did not differentiate primary from secondary phimosis, so values reported were net phimosis prevalence. There were 13 studies with data for males age ≥18 years. In all, 962 of 17,136 men had been diagnosed with phimosis (range 0.5%-13%). A random effects model found risk of phimosis in men was 3.4% (95% CI 1.8-6.6).Conclusion: Phimosis takes many years to resolve. Apart from spontaneous resolution, clinical interventions also contribute to the gradual reduction in prevalence among uncircumcised boys. The wide range of phimosis prevalence reported in adulthood may reflect variability in the extent of foreskin-preserving treatment of phimosis in different study cohorts. [ABSTRACT FROM AUTHOR]

Objective: To elucidate current understanding on the pathophysiological mechanism of genital lichen sclerosus (LS), urologic manifestations, and treatment options.Materials and Methods: The Medline/PubMed and Embase databases were systematically reviewed for publications pertaining to LS. After applying inclusion and exclusion criteria, references were assessed for relevance to the pathophysiology, presentation, and treatment of LS by title and abstract review by 2 independent reviewers, yielding 186 articles for assessment.Results: The contemporary understanding of the epidemiology and histology of LS is reviewed herein. Additionally, we explore in detail the 3 hypotheses regarding the pathophysiological mechanism contributing to disease presentation: infectious etiology, primary immune dysregulation, and the isotraumatopic response. We summarize the available biological evidence supporting each hypothesis. This discussion provides context for understanding LS morbidity and may spur new avenues of research. For the clinician, we review the clinical presentation of disease, including the risk of progression to squamous cell carcinoma. The current medical and surgical treatment options are also detailed.Conclusion: LS remains a potentially insidious disease which may lead to debilitating urinary and sexual dysfunction. Cross disciplinary research should aim for earlier detection, as well as more effective and durable treatment. The exact cause of LS remains unknown. [ABSTRACT FROM AUTHOR]

• In 3414 women with vulvar lichen sclerosus we found 299 subsequent cancers. • We found an increased risk of vulvar, vaginal and oropharyngeal cancer. • Patients with vulvar lichen sclerosus need regular gynecological follow-up. • Checks of oropharyngeal cavity are also recommended. Vulvar lichen sclerosus is a chronic inflammatory disease involving vulvar skin. The risk of developing invasive vulvar cancer for women with LS is reported in the literature, but the risk of extra-vulvar tumors has been under-investigated. This multicentric study aims to estimate the risk of developing cancers in a cohort of women with a diagnosis of vulvar lichen sclerosus. A cohort of women diagnosed with and treated for vulvar lichen sclerosus in three Italian gynecological and dermatological clinics (Turin, Florence, and Ferrara) was retrospectively reviewed. Patient data were linked to cancer registries of the respective regions. The risk of subsequent cancer was estimated by dividing the number of observed and expected cases by the standardized incidence ratio. Among 3414 women with a diagnosis of vulvar lichen sclerosus corresponding to 38,210 person-years of follow-up (mean 11.2 years) we identified 229 cancers (excluding skin cancers and tumors present at the time of diagnosis). We found an increased risk of vulvar cancer (standardized incidence ratio = 17.4; 95 % CL 13.4–22.7), vaginal cancer (standardized incidence ratio = 2.7; 95 % CL 0.32–9.771), and oropharyngeal cancer (standardized incidence ratio = 2.5; 95 % CL 1.1–5.0), and a reduced risk of other gynecological tumors (cervical, endometrial, ovarian) and breast cancer. Patients with vulvar lichen sclerosus should undergo annual gynecological check-up with careful evaluation of the vulva and vagina. The increased risk of oropharyngeal cancer also suggests the need to investigate oropharyngeal cavity symptoms and lesions in patients with vulvar lichen sclerosus. [ABSTRACT FROM AUTHOR]

Vulvar lichen sclerosus (VLS) is a chronic skin disease that affects the skin of the vulva with itching, irritation, and pain. It may present in a prepubertal or adolescent patient. The etiology of VLS remains unclear. Autoimmune, genetic, hormonal, or infectious conditions may be involved in the pathogenesis of VLS [1]. Recent studies suggested unbalanced skin microbiota in the region of VLS [2-4]. We thus hypothesized that alterations of skin microbiotas may contribute to the development of VLS. To evaluate the compositional characteristics and the differences in the vulvar skin microbiota, we performed a pilot case-control study by comparing the prepubertal girls with VLS to girls with Labial adhesions and healthy controls. We recruited a total of 45 patients in the outpatient Pediatric and Adolescent Gynecology clinic of the Children's Hospital Zhejiang University from October 2021 to June 2022. Vulvar dermal swab samples from prepubertal girls with VLS (n=19), girls with Nevus of vulva and without specific vulvovaginitis (n=11), and girls with Labial adhesions (n=15) were obtained. DNA was extracted from all the vulvar skin swab samples. The V4 fragments of 16S rRNA were amplified for high-throughput sequencing and analyzed by QIIME2 [5]. The composition differences of the vulvar skin microbiota between the VLS and the other two groups were analyzed by α diversity, β diversity, and LEfSe analysis (http://huttenhower.sph.harvard.edu/galaxy/). Our results showed that the average age of onset of VLS is 6.52 (Table 1). There were no differences in the α diversity (Kruskal-Wallis test; P=0.06 for Faith_pd diversity index, Figure 1a; P=0.58 for Pielou diversity index, Figure 1b) among three groups. In terms of β diversity, principal coordinate analysis (PCoA) showed the statistical differences of composition of taxa among these three groups (PERMANOVA test; Jaccard, p=0.001, Figure 1c; unweighted UniFrac, p=0.001, Figure 1d). Our results revealed girls with VLS had a statistically higher relative abundance of Parvimonas spp., Helcococcus spp., and Peptococcus spp. compared to the controls, and a higher relative abundance of Parvimonas spp., Methylobacterium spp., Helcococcus spp., Peptococcus spp., Moryella spp., Lactobacillus spp. compared to girls with Labial adhesions. Parvimonas spp., Helcococcus spp., and Peptococcus spp. are specifically higher in girls with VLS. Cutaneous dysbiosis in patients with VLS may provide a chance to explain the pathogenesis of VLS and new concepts for its treatment. ▪ ▪ ▪ [ABSTRACT FROM AUTHOR]

The most common presenting symptoms of vulvar lichen sclerosus (LS) in the pediatric age group are pruritis and vulvovaginal irritation. Here we describe an atypical first presentation of LS, characterized by a periclitoral keratin pearl. A 6 year 2 month old patient was referred to a tertiary pediatric and adolescent gynecology (PAG) clinic for a periclitoral cyst which had been present for at least several months. The patient's mother had noted occasional extrusion of white material, with no change in cyst size. The patient described pain with wiping or cleaning the vulvar area. On examination, the labial architecture was normal and there were no skin lesions. To the left of the clitoral hood, a raised area was noted (Figure 1) and a small amount of white material extruded. After application of 1% lidocaine gel and with retraction of the clitoral hood, a 0.75 × 0.5cm keratin pearl was removed (Figure 2). Daily sitz baths were recommended. At follow up four months later, the patient was doing well with no itching or pain, and no bladder or bowel symptoms. On examination, thick white material was again noted extruding from the same area. A small midline clitoral hood adhesion, posterior to the glans, was visualized which created the space for the pseudocyst. Pallor of the medial labia majora with mild thinning and wrinkling of the skin was also seen, consistent with early LS. The patient was prescribed topical clobetasol for treatment of LS with clitoral adhesions. Keratin pearls form from the buildup of secretions and debris in a pseudocystic space, such as that formed by clitoral adhesions. Symptoms include pain with friction and a foreign body sensation[1]. Surgical treatment of clitoral adhesions causing keratin pearls has previously been described[2]. In the pediatric population, topical estrogen has been successfully used to non-operatively treat clitoral adhesions and prevent keratin pearl recurrence[1]. In adult women presenting with clitoral adhesions with or without keratin pearls, 6-17% have a history of lichen sclerosus[3,4]. As described in this case report, the PAG provider should consider LS in the differential diagnosis of clitoral adhesions causing keratin pearls. Serial examinations provide the opportunity to identify early skin changes consistent with LS, and to implement topical steroids for treatment of LS and prevention of keratin pearl formation. 1. Bragiel et al. JPAG (2022) https://doi.org/10.1016/j.jpag.2022.10.002. 2. King and Goldstein. Sexual Medicine (2017) https://doi.org/10.1016/j.jsxm.2017.04.052. 3. Krapf J et al. Sexual Medicine (2022) https://doi.org/10.1016/j.jsxm.2022.05.032. 4. Aerts L et al. Sexual Medicine (2018) https://doi.org/10.1016/j.esxm.2018.01.003. Supporting Figures or Tables ▪ ▪ [ABSTRACT FROM AUTHOR]

Objective: To report success and patient reported urinary and sexual outcomes of patients who underwent anastomotic urethroplasty and dorsal buccal onlay urethroplasty.Materials and Methods: Patients who underwent primary transecting anastomotic or dorsal buccal onlay urethroplasty for bulbar strictures at our institution between 1998 and 2015 were analyzed. Patients who had a prior urethroplasty, involvement of a different portion of the urethra, or a diagnosis of lichen sclerosis (LS) or hypospadias were excluded. Outcomes were assessed by cystoscopy at 4 months, validated questionnaires assessing urinary, erectile, and ejaculatory function at the time of their most recent assessment.Results: A total of 40 and 139 patients were included in the dorsal buccal and anastomotic groups, respectively. Wide patency at 4-month cystoscopy was 97.5% and 100% (P= .06) and the long-term success was 95% and 99.3% (P= .06) with a mean follow-up of 51.4 and 63.3 months. Patient reported outcomes were similar with 2 exceptions: postvoid dribbling was reported more often in the onlay group (28.1% vs 8.3%, P< .0001), and tethering with erections in the anastomotic group (23.4% vs 3.1%, P= .008). Ninety-eight percent of patients in the anastomotic group and 91% in the dorsal buccal onlay group would choose their surgery again (P= .07).Conclusion: Both anastomotic urethroplasty and dorsal onlay graft are associated with high success with comparable satisfaction. Patient reported outcome measures were similar regardless of approach, despite inherent differences in stricture length. Our data indicates that anastomotic urethroplasty should not be avoided due to concerns of sexual side effects. [ABSTRACT FROM AUTHOR]

Objectives: To explore the use of neo-vaginal advancement flaps in the treatment of distal urethral strictures with description of the techniques and preliminary results in transwomen.Methods: Five patients were treated. A 7-flap was used in 2 patients and an inverted U-flap in 3 patients. In 1 patient with an inverted U-flap, the urethra was further enlarged using buccal mucosa because of Lichen Sclerosus. Three out of 5 patients already underwent previous interventions.Results: Median patient age was 67 years (range: 41-74) and median stricture length was 2.0 cm (range: 1.5-2.0). Median operation time was 41 minutes (range: 38-70). One low-grade complication (bladder spasms) was reported. No patient suffered a recurrence after a median follow-up of 37 months (range: 6-97). All patients were satisfied with the result.Conclusion: Neo-vaginal advancement flaps can be safely used in transwomen with distal urethral strictures. The success rate and patient's satisfaction are encouraging. [ABSTRACT FROM AUTHOR]

Objective: To evaluate procedural trends and outcomes for reconstruction of complex strictures at our tertiary center over the last decade.Methods: We retrospectively reviewed complex urethral reconstruction comparing 3 techniques: (1) buccal mucosal graft (BMG), (2) penile skin flap, or (3) perineal urethrostomy (PU) at our center (2007-2017) with ≥6 months follow-up. Strictures amenable to anastomotic repair were excluded. Success was defined as no need for further operative management.Results: Among 1129 strictures cases, 403 complex strictures were identified for analysis (median length 4.5 cm). Median age was 53.2 years (standard deviation ± 14.9). Reconstruction was most commonly performed using BMG (61.3%), followed by penile skin flap (21.6%) and PU (19.1%). PU use has increased steadily over the past decade, rising from 4.3% of case volume in 2008 to 38.7% in 2017 (P = .01). Over time, the proportion of reconstruction using BMG has remained stable, while penile skin flaps are now less commonly utilized. Over a median follow-up of 50.7 months, 16.9% (68/403) patients failed at a median of 13.9 months. Success rates were higher following PU (94.8%) compared to BMG and skin flaps (78.5% and 78.2%, respectively) (P = .003) despite PU patients being older (median age 62.6 years), having longer strictures (median 5.0 cm) and more commonly having lichen sclerosus (LS) (22.1%).Conclusion: Over a decade of a urethral reconstructive practice, PU has increasingly become preferred for older patients with long strictures and adverse etiology. BMG urethroplasty rates remain stable, while penile skin flap use is decreasing. Success rates of PU for these complex strictures are markedly higher than those of grafts and flaps. [ABSTRACT FROM AUTHOR]

Abstract Lichen sclerosus is an unusual, chronically relapsing mucocutaneous disease that usually afflicts the anogenital region. Oral lesions of lichen sclerosus are rare, with only 36 histologically verified cases reported to date. The classic histopathologic findings of oral lichen sclerosus include: an area of subepithelial hyalinization, loss of elastic fibres, and band-like mononuclear inflammatory infiltrate. Despite its rarity, oral lichen sclerosus should be included in the differential diagnosis of porcelain- or ivory-white macules. Here we present three new cases of oral lichen sclerosus. A review of these cases and the previously reported cases revealed that oral lichen sclerosus is slightly more common in women and can affect individuals of any age. Oral lesions of lichen sclerosus usually do not require treatment, except when there are significant symptoms or aesthetic complaint. Almost 50% of the patients with oral lichen sclerosus present with extraoral manifestations. Thus, referral to a dermatologist and a gynaecologist is advised. Although no cases of malignant transformation of oral lichen sclerosus have been reported, regular, long-term follow-up of patients with oral lichen sclerosus is indicated. [ABSTRACT FROM AUTHOR]

Abstract Introduction The recommended pathological resection margin (8 mm) for vulvar squamous cell carcinoma (SCC) is broader than for SCC located elsewhere, and does not depend on tumor grade or lesion size. Our aim is to evaluate the resection margin in vulvar SCC in relation to local recurrence, and to determine the impact of other prognostic factors. Materials and methods Data of all surgically treated patients at the Gynecological Oncology Center South with vulvar SCC, FIGO IB-IIIC, between 2005 and 2015 were analysed retrospectively. The relation between the pathological resection margin and other clinicopathological factors with the risk of local recurrence was analysed. Results In this cohort of 167 patients, the tumor was radically removed in 87% of the patients. Yet, in 57% the pathological resection margin was <8 mm. Including re-excisions, the median closest margin was 7.0 mm. There was no significant difference in the risk of local recurrence for a resection margin <8 mm or ≥8 mm (25.0% (n = 20) and 22.2% (n = 16)), nor in the median resection margin of patients with or without local recurrence (6.5 mm and 7.0 mm). Lichen sclerosus was the only significant risk factor for local recurrence. Conclusion A pathological resection margin <8 mm was not related to an increased risk of local recurrence. The most important predictor of local recurrence was the presence of lichen sclerosus. A resection margin <8 mm in vulvar SCC can therefore be accepted, especially in tumors located close to clitoris, urethra or anus. [ABSTRACT FROM AUTHOR]

Vulvar lichen sclerosis (VLS) is a chronic inflammatory skin disorder. Evidence is accumulating that microRNAs (miRNAs) exert crucial roles in initiation and development of a wide range of human diseases. MiR-155-5p has been frequently reported to be implicated in the tumorigenesis and progression of multiple types of cancers, however, its biological role in VLS remains unclear. This study aimed to explore the role of miR-155-5p in VLS and clarify the potential molecular mechanisms involved. In the present study, miR-155-5p was observed to be significantly upregulated in VLS tissues. Functional studies showed that miR-155-5p facilitated cell proliferation, accelerated cell cycle progression and inhibited forkhead box O (FOXO) signaling pathway in fibroblast cells. Mechanical studies demonstrated that miR-155-5p exerted its promoting effects on fibroblast cell proliferation via targeting both forkhead box O3 (FOXO3) and cyclin-dependent kinase inhibitor 1B (CDKN1B). Besides, Pearson's correlation analysis revealed that miR-155-5p expression was negatively correlated with the mRNA expression of FOXO3 and CDKN1B in VLS tissues. Taken together, our results indicate that miR-155-5p promotes fibroblast cell proliferation and inhibits FOXO signaling pathway by negative modulation of both FOXO3 and CDKN1B in VLS, and that miR-155-5p may be used to be a potential therapeutic target for VLS. [ABSTRACT FROM AUTHOR]

Objective: To assess the long-term results of our experience with this technique which we have developed as an alternative to Fenton's procedure.Study Design: A retrospective questionnaire study of all patients undergoing the procedure in our department from Jan. 2006 to Dec. 2013. The main outcome measure was the change in sexual satisfaction scores, using a visual analogue scale, before and after the procedure.Results: There was a statistically significant improvement in sexual satisfaction scores in the majority of patients. This was particularly marked in patients who had previously undergone an unsuccessful Fenton's operation.Conclusions: Double opposing Z plasty with VY advancement of the perineum (The Plymouth Procedure)should be offered to all patients in whom Fenton's operation has been unsuccessful,and considered as an alternative to Fenton's as a primary procedure. [ABSTRACT FROM AUTHOR]

Background Vulvar lichen sclerosus et atrophicus (VLSA) is a chronic inflammatory skin disease of unknown etiology that mainly affects postmenopausal and perimenopausal women. The primary clinical symptoms of VLSA are itching, burning pain, and dyspareunia that can results in decreased quality of life. Existing therapies including topical corticosteroid ointment, topical calcineurin inhibitors, estrogens, are not very effective for treatment of VLSA. Objective To evaluate the effectiveness and safety of 5-aminolevulinic acid mediated photodynamic therapy (ALA-PDT) in the treatment of VLSA. Materials and methods Ten patients with VLSA who had failed conventional treatment received ALA-PDT. 10% 5-ALA in an oil-in-water emulsion was applied to the lesions and occluded with plastic film for 3 h, when the lesions were irradiated with 100 mW/cm 2 , 635 ± 15 nm red light for 20 min. Treatments were repeated three times at 2-week intervals. Objective and subjective symptoms and signs of the vulvar lesions based on horizontal visual analogue scales were recorded at each treatment and 1, 3, and 6 months after the last session. The quality of life was assessed using dermatology life quality index (DLQI) questionnaire. Results All patients completed three ALA-PDT treatments and the follow-up visits. Clinical symptoms of itching disappeared completely in nine patients, one patient had itching decreased from severe to mild. All subjects showed objective improvement in lesions. The DLQI of all cases improved after treatment. The main side-effects of ALA-PDT were pain, erythema, and swelling. Side-effects were transient and tolerable. All patients reported being “satisfied” or “very satisfied” with their outcomes. Conclusions ALA-PDT is an effective and safe approach for the treatment of VLSA [ABSTRACT FROM AUTHOR]

Pediatric anogenital lichen sclerosus (LS) can be difficult to differentiate from other vulvar dermatoses. While biopsy is performed in adults, in children diagnosis is primarily visual with unknown accuracy. We sought to assess the accuracy of visual diagnosis of pediatric anogenital LS. An IRB approved survey was disseminated via REDCap to listserv members of NASPAG in 2022. The survey included 13 de-identified images of the anogenital area obtained after consent with 4 possible diagnostic choices: vitiligo, LS, non-specific vulvovaginitis, and other. Clinical history was not provided. Participants' responses were compared to the clinical diagnosis of an experienced pediatric gynecologist and pediatric dermatologist who evaluated each patient during a multidisciplinary vulvar dermatology clinic. Statistical analysis was performed using SPSS. Categorical variables were compared among groups using the χ2 test or Fishers' exact test. Statistical significance was defined as a P value less than.05. The 34 respondents who completed the survey included 28 pediatric gynecologists, 3 Ob/Gyn, 1 adolescent medicine specialist, 1 pediatric gynecology nurse practitioner and 1 pediatric gynecology fellow (Table 1). More than half (71%, n=24) reported being in practice greater than 10 years and at academic centers (79%, n=27). Only 12% (n=4) reported having a designated vulvar dermatology clinic at their institution. More than half of the respondents (56%, n=19) reported seeing 6 or more pediatric patients with LS or vitiligo per 3 months. The majority (94%, n=32) reported white non-Hispanics as representing a substantial portion of their patient population. Black or African American children comprised a substantial proportion of only 18% (n=6) of respondents. None of the 34 respondents correctly visually diagnosed all 13 cases (Table 2). Only 4 of 10 LS cases were correctly identified by >50% of respondents. Of the 6 LS cases not correctly identified by the majority, vitiligo was most frequently chosen as the diagnosis. Both vitiligo cases were identified correctly by a majority of respondents. Accuracy of diagnosis of LS was not statistically significantly associated with years of practice (p=.26), practice setting (p=.36), designated vulvar dermatology clinic (p=.74) or number of patients (p=.09). Accurate diagnosis of pediatric anogenital LS may not be based on visual examination alone. Further studies are needed to evaluate the effect of knowledge of symptoms and differences in training (as with dermatologists) on diagnostic accuracy. Supporting Figures or Tables https://www.abstractscorecard.com/uploads/Tasks/upload/19245/RGXGDRUQ-1381262-1-ANY.docx https://www.abstractscorecard.com/uploads/Tasks/upload/19245/RGXGDRUQ-1381262-2-ANY.docx [ABSTRACT FROM AUTHOR]

Verruciform xanthoma (VX) is a rare, benign, mucocutaneous lesion that can be difficult to diagnose. Vulvar VX remains poorly understood but is often associated with other vulvar conditions. Only 3 cases have ever been reported in adolescents. The objective of this case report is to discuss the clinical findings of a rare case of vulvar VX in an adolescent. A 16-year-old female presented to the pediatric gynecologist for a second opinion of a vulvar lesion. Her medical history was notable for a history of vulvar lichen sclerosus (LS) treated with topical Clobetasol and Tacrolimus from ages 8-14 with resolution of her symptoms and skin findings. The lesion initially occurred 6 months prior as a 20 × 30 mm area of raised, thickened skin on her right vulva (Figure 1). A biopsy was recommended, but the lesion resolved spontaneously before this could be performed. The lesion recurred 2-3 weeks prior to the gynecology appointment, with a similar but less prominent appearance. On exam, a 10 × 5 mm whitish plaque was noted on her superior right labium minus, with a denuded portion superiorly (Figure 2). An office vulvar punch biopsy was performed of the lateral, midportion of the lesion. Pathology results demonstrated "verrucous hyperplasia accompanied by foam cells in the papillary dermis" consistent with a diagnosis of VX. This case highlights several important points in the care and evaluation of an unknown vulvar lesion in an adolescent. While vulvar VX is rare, with a mean age of presentation around 40, it should still be considered in the diagnosis of an unusual vulvar lesion. Suspicious lesions on the vulva that do not respond to or recur with other treatments should be biopsied, even in adolescents. Additionally, when VX is suspected or diagnosed, clinicians should be prompted to look for associated vulvar conditions. Although in this case, the diagnosis of LS was already known and the symptoms and skin findings had resolved by the time of presentation of VX, it is possible that the epithelial changes caused by her LS were long-lasting and predisposed her to vulvar VX. Finally, any VX lesion should be completely excised, as recurrence is extremely common without full removal. In summary, verruciform xanthoma should be on the differential diagnosis for any unusual vulvar lesions, even in an adolescent, and complete excision of confirmed lesions should be undertaken, followed by a close examination for associated vulvar conditions. Supporting Figures or Tables https://www.abstractscorecard.com/uploads/Tasks/upload/19245/RGXGDRUQ-1378477-1-ANY.pdf https://www.abstractscorecard.com/uploads/Tasks/upload/19245/RGXGDRUQ-1378477-2-ANY.pdf [ABSTRACT FROM AUTHOR]