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Lichen sclerosus is a chronic inflammatory disease associated with substantial morbidity. Knowledge of the aetiology and progression of lichen sclerosus is therefore needed. In this cross-sectional study, 100 male patients diagnosed with lichen sclerosus were interviewed and examined. Since there is a possible link between lichen sclerosus and autoimmunity, blood tests were analysed for thyroid disease, antinuclear antibodies and antibodies to extracellular matrix protein 1, but autoimmunity was found to be infrequent. In 72 participants active genital lichen sclerosis was observed and complications were common; 27 patients had preputial constriction and 12 meatal engagement. In total, 13 patients needed a referral to the Department of Urology, including 1 patient with suspected penile cancer. In conclusion, despite available treatment with ultra-potent steroids and circumcision, lichen sclerosus in males is frequently complicated by phimosis and meatal stenosis. However, the disease can also go into remission, as seen in 27% of our patients.

The penile circular fasciocutaneous flap (FCF) is employed in the successful single stage reconstruction of long segment complex anterior urethral strictures especially when buccal mucosa is unavailable due to various reasons. A 65-year-old gentleman, chronic smoker and tobacco chewer, hypertensive on treatment, presented with obstructive lower urinary tract symptoms for 8 months. He had no prior urethral catheterization. On examination, he had circumcised penis, with stenosis of the external urethral meatus. Glans had no changes suggesting balanitis xerotica obliterans. Suprapubic cystostomy was done as he developed acute urinary retention during evaluation. Retrograde urethrogram (RGU) showed pan-anterior urethral stricture. He was planned for substitution urethroplasty. On oral cavity examination, he had moderate trismus with oral submucous fibrosis. As buccal mucosal graft was unavailable, he was planned for FCF. A ventral onlay tubularization FCF urethroplasty from meatus to bulbar urethra based on dartos dorsal pedicle was done. His postoperative recovery was uneventful. Pericatheter RGU did not show extravastion and he voided well with Qmax 14 ml/second. He is doing well at follow-up.

Parents often bring their children to the family doctor because of urological problems. Many general practitioners have received little training in this specialty. In this review, we aimed to provide a concise and informative review of common urological problems in children. This review will focus on the prepuce.

Summary 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. Download : Download high-res image (175KB) Download : Download full-size image Figure . Recurrent BXO invading the oral mucosa of the neourethra. The appearance after opening the neourethra. The white arrow points to meatal BXO; the black arrow indicates disease extending from the meatus proximally within the oral mucosa of the neourethra.

OBJECTIVE: As a consequence of the discussion on whether the health benefits of newborn male circumcision outweigh the risks and the discrepancies in reported figures of complications, we evaluated the incidence and morbidity of foreskin surgery due to medical indications in boys from the Capital Region of Denmark in 2014. METHODS: Medical records from all boys operated on the foreskin due to medical reasons in the Capital Region in 2014 were reviewed. Patients with hypospadias, ritual circumcision, and redo-surgery because of complications to nontherapeutic circumcision were excluded. RESULTS: A total of 181 patients were included. The cumulative risk of undergoing foreskin operation before 18 years of age was 1.7%. Forty patients had histologic verified balanitis xerotica obliterans (BXO) corresponding to a total risk of 0.37% of developing BXO. Mean age at surgery was 10.1 years (range 1–17). Phimosis was the most frequently reported indication (95.0%). The remaining 5.0% underwent surgery because of frenulum breve causing problems during erection. Before surgery, 27.1% had foreskin-related voiding problems and 17.1% had at least 1 episode of balanitis. Circumcision was initially performed in 44 cases. The remaining 137 patients had a foreskin-preserving operation performed. Nine boys had secondary circumcision after initially having foreskin-preserving operation. Fifty patients initially had preputial histology performed. BXO was verified in 37 patients. Of the 9 patients with redo-surgery due to recurrent phimosis, a further 3 had histologically verified BXO. CONCLUSIONS: Childhood foreskin-related problems in a region with no tradition of newborn male circumcision should not be neglected.

Background Lichen sclerosus (LS) is an uncommon idiopathic chronic inflammatory debilitating disease with predilection for the genital region. Our recent encounter with an LS case exhibiting perineural inflammation microscopically prompted us to assess the features of all patients diagnosed with LS at our institution. Materials and methods All cases of LS diagnosed between 1990 and 2014 were retrospectively reviewed. Diagnosis was confirmed with demonstration of microscopic features typical of LS. Results Sixty patients (42 women and 18 men) with 65 biopsy specimens of LS were identified, of which 41 were extragenital, 16 genital, and three had both. Histopathologically, significantly higher proportions of follicular plugging, atrophy, and vacuolar interface changes were observed in extragenital LS cases, while angiokeratoma-like, mycosis fungoides-like, and pseudoepitheliomatous changes were only seen in genital LS. Perineural inflammation was observed as a novel finding in 22 cases (33.8%) of LS. Conclusion Features of patients with LS in this study are generally comparable to those published in the literature, with some differences. In contrast to the literature, extragenital LS was more frequently encountered. Histopathologically, perineural inflammation was not an uncommon feature of LS and thus may serve as a clue in the differentiation of LS from its mimickers.

Summary Introduction Repair of severe primary and revision hypospadias is a demanding procedure. Debate continues as to whether a two-stage approach or single-stage technique is superior. The two-stage procedure with a free graft involves penile straightening followed by application of a graft for the neourethral plate at stage one; with tubularization at stage two after graft maturation. Objective To report the outcomes of a single surgeon's experience with the two-stage repair using a free graft for both severe primary and revision hypospadias with long-term follow-up. Materials and methods Between July 1998 and January 2010, 301 boys underwent a two-stage reconstruction. The surgical technique is described in the manuscript. Primary repairs (n = 208): indications for a two-stage approach with a free graft included meatal position, presence of corporal chordee, and poor glans development. Median follow-up from completion of the second stage was 75 months. Revision repairs (n = 93): indications included urethral fistula, excessive scarring/meatal stenosis, balanitis xerotica obliterans (BXO), and residual or untreated chordee. Median follow-up from completion of the second stage was 85 months. Results For the primary repairs (n = 208), the graft took well in all but one case. Second-stage complications included fistula (7), meatal stenosis (3), partial glans dehiscence (3), and all were re-operated (13). For the revision repairs (n = 93), the graft took well in all but four cases. Second-stage complications included fistula (5), meatal stenosis (3), breakdown (1) and reoperation (8). Discussion In a systematic review of 20 years of publications on the repair of primary severe hypospadias, the two-stage procedure with a free graft demonstrated an overall complication rate of 22%; this was a distinct overall benefit when compared with the single-stage procedures in terms of lower complication rates (Castagnetti and El-Ghoneimi, 2010). Our results for the severe primary repairs revealed significantly lower complication rates than those in the literature, with an overall re-operation rate of 6.3%, a fistula rate of 3.4%, and meatal stenosis and partial glans dehiscence at 1.4% each. Several papers have documented outcomes following the single-stage tubularized incised plate urethroplasty for re-operative hypospadias, giving overall complication rates ranging from 15.4 to 30%. Our data show a re-operative rate of 8.6%, a fistula rate of 5.3%, breakdown in 1.1%, and meatal stenosis in 3.2%. Conclusion The two-stage repair with a free graft for correction of both severe primary and failed primary hypospadias is a safe, viable, and durable procedure offering low morbidity and excellent cosmetic results. The authors advocate the two-stage repair with a free graft as the technique of choice for treatment of both of these challenging groups of the deformity. Summary Table . Graft type for primary and revision repairs. Graft type Primary repairs (n = 208) Revision repairs (n = 93) Inner prepuce 199 15 Posterior auricular Wolfe graft 4 60 Buccal mucosal graft 1 9 Composite graft 4 6 Shaft skin 0 3

Male genitourinary lichen sclerosus (MGU-LS) or balanitis xerotica obliterans (BXO) is a chronic inflammatory dermatological condition of unknown origin and pathogenesis.1 The true incidence and prevalence of MGU-LS are difficult to quantify, as a multitude of specialists are responsible for its diagnosis and treatment including urologists, dermatologists, and primary care physicians.2 MGU-LS causes destructive scaring and fibrosis of the glans, foreskin, and/or urethra.3 Prolonged inflammation secondary to MGU-LS may lead to a decline in male urinary and sexual function.2 Symptoms of MGU-LS include a worsening urinary stream, hesitancy, incomplete emptying, erectile dysfunction, urinary retention, and/or ejaculatory dysfunction.1,4,5 Due to the chronic, recalcitrant nature of MGU-LS, many men will require lifelong surveillance of disease progression and repeated surgical interventions.6 Furthermore, MGU-LS is associated with an increased risk of penile squamous cell carcinoma7 and other comorbid conditions such as hypertension, obesity, and diabetes.8 Physicians utilize a multitude of conservative measures to temporize and treat MGU-LS including topical steroid creams, photodynamic light, or topical calcineurin inhibitors (eg, tacrolimus).1 As the disease progresses, urologists may offer surgical interventions such as circumcision or urethroplasty to treat worsening phimosis or urethral stricture disease, respectively.9 Intervention and treatment recommendations for MGU-LS along its disease spectrum are subject to debate.6 Little is known about how urologists diagnose, treat, and survey MGU-LS and whether differences exist among providers who often treat MGU-LS compared to low-volume urologists. MGU-LS presents considerable challenges to the reconstructive urologist as these strictures are more likely to recur after urethroplasty than non-MGU-LS cases.9,10 Furthermore, MGU-LS is associated with a worse quality of life and sexual dysfunction compared to non-MGU-LS.1 To characterize the current practice patterns for the diagnosis, treatment, and surveillance of MGU-LS, we conducted a national survey of American Urological Association (AUA) members. Our primary aim is to address a knowledge gap in understanding how urologists treat and counsel patients with MGU-LS. To date, no prior survey has investigated how urologists treat this challenging disease. Determination of how urologists nationwide treat MGU-LS may help lead to promotion of standard practices of diagnosis, treatment, and surveillance.

Balanitis xerotica obliterans (BXO) is a chronic inflammatory skin disorder of unclear etiology. The etiology and the exact molecular mechanisms underlying the disease are still unknown. The human transglutaminase (TG) family consists of several proteins with catalytic activity essential for biological processes. In the present research we investigated the transcript levels of three TGs in patients operated on for congenital phimosis without or with histologically confirmed BXO; Thirty children with acquired phimosis were enrolled. The removed foreskins were sent both for histological diagnosis and for quantitative real-time PCR to evaluate the transcript levels of keratinocyte (TG1), tissue (TG2), and epidermal (TG3) transglutaminase; We observed a decrease in TG1 and TG3 transcripts by about 70% (p < 0.001) in foreskins from patients with BXO (n = 15) in comparison with patients without BXO (n = 15) and an increase in TG2 mRNA levels by 2.9 folds (p < 0.001); Reduced expression of both TG1 and TG3 was associated with the altered structure of the foreskin in BXO and can be a consequence of damage to keratinocytes. Increased expression of TG2 can be the result of chronic inflammation. TG2 overexpression can play a pivotal role in triggering and maintaining the inflammatory response in BXO patients.

Lichen sclerosus (LS) is a chronic, inflammatory condition which commonly involves the anogenital skin. This condition may affect the foreskin, glans, frenulum, meatus and urethra in males. It manifests itself with voiding symptoms. Obstructive uropathy is an extremely rare clinical presentation in childhood. This study reports the case of a 13-year-old boy presenting with obstructive uropathy due to LS and reviews the published data on the diagnosis, management and follow-up of this condition.

Purpose: Lichen Sclerosis (LS) is an often unrecognized and misdiagnosed chronic inflammatory skin condition of the anogenital area that affects quality of life, bringing severe discomfort and distress to affected men, women, and children. The purpose of this qualitative study is to explore the lived experiences of women with LS. Data sources: Content analysis was conducted of data obtained from three public online forums/blogs used by women with LS. A total of 527 postings/entries were analyzed for patterns and themes by four researchers. Conclusions: Five core themes emerged as a result of this study, revealing feelings of frustration and despair stemming from healthcare providers’ lack of knowledge in relation to Lichen Sclerosis, often leading to misdiagnosis, prolonged suffering, and an altered quality of life. Implications for practice: Knowledgeable healthcare providers and additional research into the cause, treatment, and cure of Lichen Sclerosis are needed. Advance-practice nurses stand to play an important role in the areas of education, research, policy making, and clinical practice to advocate for and empower women with LS. Lichen sclerosis (LS) is a chronic inflammatory skin condition of the anogenital area that affects quality of life, bringing discomfort, desolation, distress, and anxiety, to affected men, women, and children (Edwards & Goldson, 2003; Jones, Scurry, Neill, & MacLean, 2008; Powell & Wojnarowska, 1999; Val & Almeida, 2005). Known as balanitis xerotica obliterans in men, it can develop on the uncircumcised foreskin and head of the penis (Scheinfelf, Keough, & Lehman, 2010). LS occurs in women of all ages at a range between 6 and 10 times more frequently than in men (Yesudian, Sugunendran, Bates, & O’Mahony, 2005). In women, LS typically affects the anogenital area, although it also appears extragenitally in 15%‐20% of those affected (Edwards & Goldson, 2003; Neill, Lewis, Tatnall, & Cox, 2010; Pulgleise & Morey, 2007; Yesudian, Sugunendran, Bates, & O’Mahony, 2005). LS has been diagnosed in children as young as 6 months with an average diagnostic age of 5 years, often following accusations of child abuse because of the presentation of vulva soreness and anal fissures (Poindexter & Morrell, 2007; Wood & Bevan, 1999). There is a dearth of literature on LS despite the severe physical and psychological consequences the disease presents. The purpose of this qualitative study is to explore the lived experience of women with LS—a topic that remains scarce in the literature. The goal of this study is to fill this identified gap in the literature and to equip advanced practice nurses and other healthcare professionals with the knowledge they need to provide women with LS with timely, patient-centered, and competent evidence-based care. Review of the literature

Background We previously reported our short-term experience of foreskin preputioplasty as an alternative to circumcision for the treatment of foreskin balanitis xerotica obliterans (BXO). In this study, we aimed to compare this technique with circumcision over a longer period. Methods Between 2002 and 2007, boys requiring surgery for BXO were offered either foreskin preputioplasty or primary circumcision. The preputioplasty technique involved triradiate preputial incisions and injection of triamcinolone intralesionally. Retrospective case-note analysis was performed to identify patient demographics, symptoms, and outcomes. Results One hundred thirty-six boys underwent primary surgery for histologically confirmed BXO. One hundred four boys opted for foreskin preputioplasty, and 32, for circumcision. At a median follow-up of 14 months (interquartile range, 2.5-17.8), 84 (81%) of 104 in the preputioplasty group had a fully retractile and no macroscopic evidence of BXO. Of 104, 14 (13%) developed recurrent symptoms/BXO requiring circumcision or repeat foreskin preputioplasty. In the circumcision group, 23 (72%) of 32 had no macroscopic evidence of BXO. The incidence of meatal stenosis was significantly less in the foreskin preputioplasty group, 6 (6%) of 104 vs 6 (19%) of 32 ( P = .034). Conclusion Our results show a good outcome for most boys undergoing foreskin preputioplasty and intralesional triamcinolone for BXO. There is a small risk of recurrent BXO, but rates of meatal stenosis may be reduced.

What's known on the subject? and What does the study add? The clinical presentation and complications of lichen sclerosus are well known. What is less well known is the true incidence of the condition. The published figures are all based on attendance at general medical clinics or specialist clinics, but it is likely that the true incidence is much higher than this reported incidence as many men will not present to the doctor for treatment. The other uncertainty is the relationship of lichen sclerosus to the subsequent development of cancer of the penis. As pointed out in the paper, it is likely that between 4% and 8% of men with this condition will develop squamous cell cancer of the penis. However, it is unclear if lichen sclerosus itself causes the development of squamous cell cancer or if it is due to coexistent infection with human papillomavirus. This review provides a concise summary of the clinical and pathological features of the disease and describes its current medical and surgical treatment. It brings together a number of papers which have addressed the association of lichen sclerosus with squamous cell carcinoma of the penis and shows that the likely incidence of carcinoma is approximately 4–8% in men with this condition. SUMMARY Penile lichen sclerosus, also known as balanitis xerotica obliterans, is a chronic inflammatory condition of the penis which can occur at all ages. The inflammation leads to the formation of white plaques most commonly on the foreskin or penis, and can lead to inability to retract the foreskin or blockage to the flow of urine. Cancer may occur rarely. Penile lichen sclerosus is a progressive, sclerosing, inflammatory dermatosis of the glans penis and foreskin which is of uncertain aetiology. Recent studies have shown a link between lichen sclerosus and squamous cell carcinoma of the penis. In this review, we discuss the clinical presentation, pathology and current approach to treatment of this condition.

Lichen sclerosus (LS) is a chronic inflammatory disorder of the skin and mucosa, presenting to genitourinary physicians, pediatricians, and dermatologists. It affects both sexes with a lower incidence in men than in women. Autoimmune factors, infections, and genetic disposition are implicated in its pathogenesis. The classic clinical picture is of atrophic white plaques in the anogenital region. Pruritus, soreness, difficulty retracting the foreskin, and obstructive urinary symptoms are frequent complaints. Early histological confirmation by biopsy is recommended. The disorder is usually highly responsive to ultrapotent topical steroids. This may help arrest or delay the progressive nature of this disorder. Surgical treatment may be needed in cases of disease progression despite medical therapy. Circumcision is a successful treatment, if LS is limited to the glans and foreskin. In cases of meatal stenosis meatoplasty and in cases of urethral involvement one- or two-stage oral graft urethroplasty is necessary.

Purpose of review This article reviews the epidemiology, diagnostic modalities and treatment of localized and advanced penile cancer, with special emphasis on most recent findings from the literature. Recent findings Penile cancer is a rare disease and its treatment suffers from a paucity of evidence in the literature. Risk factors include phimosis with poor hygiene, human papilloma virus infections, chronic balanitis xerotica obliterans and smoking, among others. Surgical treatment for local disease remains the best option, but organ-preserving procedures provide good aesthetic and functional results with acceptable oncologic control. Regional disease, when present in the form of adenopathy, is best diagnosed with fine-needle aspiration, and treated with radical inguinal lymphadenectomy if resectable. Occult metastatic disease constitutes a challenge and is managed according to primary tumour risk factors. For nonresectable regional disease and metastases, neoadjuvant cisplatinum-based regimens are the best option, and provide a selection of patients who will be optimal candidates to consolidative surgical therapies. Summary Penile cancer at its various stages constitutes a therapeutic challenge. Management should be increasingly confined to high volumes centres of excellence, allowing for clinical trials, which will hopefully provide a better understanding of the disease and the best treatment approach.

OBJECTIVE • To describe the incidence of the development of male genital lichen sclerosus (LS) in non-genital skin grafts used in penile reconstruction after cancer surgery. PATIENTS AND METHODS • Between 1997 and 2009, 177 patients received surgical treatment for penile cancer in the Urology Department at Sunderland Royal Hospital, the regional penile cancer centre for the north-east of England. • Patients who had organ-sparing surgery and non-genital penile graft reconstructions were identified. • Histology reports for specimens obtained from those grafts were reviewed to identify the presence of male genital LS and the incidence of recurrence of squamous cell carcinoma (SCC). RESULTS • The mean (range) age of patients at diagnosis was 61.8 (32-89) years. Of the 177 patients, 139 had SCC, 32 had carcinoma in situ and six had verrucous carcinoma. • In total, 56 penile reconstructive procedures were performed using split-thickness skin grafts obtained from the inner thigh. • From those grafts, 18 specimens were obtained later for cosmetic, diagnostic or curative purposes. • Male genital LS was found in six of the 18 specimens, and one of them was associated with recurrent verrucous carcinoma. CONCLUSIONS • This is the first published series to describe the incidence of male genital LS in penile skin grafts taken from a remote site after penile cancer surgery. • These results represent new information that might help explain the aetiology of male genital LS.

Einleitung: Das mögliche Behandlungsspektrum nicht retrahierbarer Vorhäute (= Phimose) reicht von der topischen Kortisontherapie über vorhauterhaltende Erweiterungsplastiken bis zur radikalen Zirkumzision. Dabei weist die Mehrzahl der klinisch eindeutigen Phimosen eine normale Vorhauthistologie auf. Jedoch kann auch im Kindesalter ein Lichen sclerosus (LS) in bis zu 20 % der Zirkumzisionen nachgewiesen werden. Methoden: Zwischen 08/ 2005 und 08/2007 wurden in der Kinderurologischen Klinik Regensburg 222 konsekutive Vorhautbiopsien histologisch untersucht. 69,8 % hatten eine normale Vorhauthistologie, 11,3 % einen LS, 8,1 % einen initialen Lichen und je 3,6 % eine unspezifische Entzündung, eine narbige Fibrose oder eine atopische Dermatitis. Allen 25 Patienten mit klassischem LS wurde eine Nachbehandlung mit topischem Tacrolimus im Sinne einer Anwendungsbeobachtung als Off-label use angeboten. 20 Patienten applizierten postoperativ topisch Tacrolimus-0,1-%-Salbe für 3 Wochen und wurden median 13 Monate nachbeobachtet. 18 Patienten mit einem initialen Lichen wurden im gleichen Zeitraum ohne Therapie nachbeobachtet. Ergebnisse: Die topische Tacrolimus-Applikation wurde nebenwirkungsfrei vertragen, wobei 18 Patienten rezidivfrei blieben. Zwei Glans-Rezidive heilten erneut topisch mit Tacrolimus-0,1-%-Salbe aus. Keiner der Patienten mit einer lichenoiden Frühform erlitt ein Rezidiv oder einen Progress. Schlussfolgerungen: Der LS stellt eine schwer zu charakterisierende Erkrankung der Vorhaut, Glans und anterioren Urethra dar. Da es jedoch keine prädiktiven Faktoren für einen Progress oder ein mögliches Rezidiv des LS gibt, empfiehlt sich eine topische antientzündliche Nachbehandlung bei histologischer Diagnosestellung des LS unabhängig von der Lokalisation. Die anschließende Nachbeobachtung sollte engmaschig sein, um Rezidive frühzeitig erkennen und therapieren zu können.

Objectives: Balanitis xerotica obliterans (BXO) related strictures involving the external urethral meatus. We reviewed our result with the use of circular mucosal graft in the reconstruction of strictures. Methods: Between March 1997 and January 2012, 15 patients underwent circular buccal mucosal urethroplasy for BXO related anterior urethral strictures. Urethral catheter was removed within 2 weeks. Follow-up included patient symptoms assessment, cosmetic outcome and uroflowmetry. Results: Median follow-up was 20.5 months (range 4 to 96). Mean postoperative peak urinary flow rate obtained 1 month after catheter removal was 22.4 ml per second. All patients had a normal meatus and none had recurrent stricture, chordee or erectile dysfunction. A functional and cosmetic outcome was achieved in 100% of the patients. Conclusions: Circular mucosal graft technique for treatment of meatal strictures is an efficient method for the restoration of a functional and cosmetic penis.

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Most previous studies, with few exceptions, have focused on short-term outcomes of hypospadias repair in infancy or young adulthood. Little is known, however, about the long-term outcomes both after hypospadias repair in childhood and for uncorrected hypospadias into adulthood. We report how these patients present to a urologist and their concurrent symptoms and add a classification system of how these patients present for urethral stricture/fistula/hypospadias repair. OBJECTIVE • To characterize and categorize adults with hypospadias who presented to our clinic with urethral stricture and fistula to better clarify the presentation, history and intraoperative findings in this heterogeneous group and to better describe the natural history of this anomaly in adulthood. PATIENT AND METHODS • A retrospective chart review was performed on adults with hypospadias who underwent urethroplasty for urethral stricture, urethrocutaneous fistula, and/or hypospadias repair at Cleveland Clinic between 1993 and 2009. All procedures were performed by a single staff surgeon (K.W.A.). • The charts were reviewed for site of hypospadias, presenting complaint, overall symptoms, history of repair and type of surgery performed. RESULTS • Fifty-five adult patients were identified. Median age was 37 years (range: 18–72). About half of the patients had distal (glanular/subcoronal or pendulous) hypospadias (56.4%) and the others had more proximal (bulbar) hypospadias (43.6%). • Voiding symptoms (such as dysuria, weak stream, spraying, urgency, frequency) were the most common presenting complaint (50.9%) and overall symptom (81.8%). About half of patients underwent a two-stage urethroplasty (52.7%). • Based on their history of repair, patients were divided into three categories: I, patients who have undergone continuous multiple surgeries for repair with significant scarring and tissue loss; II, delayed complications after an initially successful childhood repair; and III, no previous repair. Most patients were category I (58.2%); however, seven patients (12.7%) were category III. Balanitis xerotica obliterans (BXO) was more common in this subgroup compared with other categories (42.9% vs 8.3%, respectively, P= 0.037). In two of the three patients in category III with BXO, the stricture length was longer than 7 cm. CONCLUSIONS • Adults with hypospadias represent a heterogeneous group. More than half of adults with complications related to hypospadias have had multiple operations (category I) representing one of the most difficult challenges to the reconstructive urologist. • Roughly 30% of patients undergo an initially successful repair in childhood with recurrent problems in adulthood (category II), suggesting that the outcomes of repair may not be as durable as estimated by studies with shorter-term follow-up. • Finally, BXO is over-represented in men with hypospadias who have not previously undergone repair, which contradicts the previous suggestion that the risk of BXO is related to the use of skin grafts/flaps from previous repairs and suggests that there may be an increased risk of severe stricture disease in patients who have never undergone corrective surgery for this anomaly.

The foreskin is an organ which holds surprising cultural importance. Male circumcision is the surgical removal of all or part of the foreskin of the penis and is undertaken for medical, religious, cultural or social reasons. There can be complications and surgeons must carefully consider the benefits and the potential risks before undertaking the operation.

OBJECTIVES Relatively little evidence is available in the published studies on the prevention of penile cancer and premalignant conditions of the penis. The present review examined the current evidence available in preventing penile cancer and pathologic subtypes of premalignant conditions and their treatment. The recommendations made in the present review formulate the basis of the recent 2009 International Consultation on Urologic Disease Consensus Publishing Group. METHODS The association of human papillomavirus subtypes and penile cancer is well-established, although the etiology, natural history, and treatment of premalignant lesions have mainly been reported in retrospective case series with short-term follow-up. The exact pathologic role of chronic inflammatory conditions, such as balanitis xerotica obliterans in the etiology of penile cancer remains largely unknown. RESULTS Some of the potential strategies for the prevention of penile cancer could include circumcision, reducing the risk of transmission of penile human papillomavirus infection with male vaccination, early treatment of phimosis, smoking cessation, and hygienic measures. Implementing some of these measures would require extensive cost/benefit analysis, with significant changes in the global health policy. CONCLUSIONS Owing to the current levels of evidence from published studies, firm guidelines cannot be formulated for the treatment of premalignant conditions, although preventative measures, such as reducing human papillomavirus transmission, could become strategic health targets.

Introduction: To evaluate the outcome of circumcised patients with balanitis xerotica obliterans (BXO) using uroflowmetry (UF). Methods: Between 2011 and 2013, 180 children underwent a circumcision for phimosis. The foreskin was examined on microscopy. Patients with an histological diagnosis of BXO were included in the study. Patients with BXO underwent UF two weeks after surgery and treatment with clobetasol propionate ointment. Patients were re-evaluated at 6, 12, 18 and 24 months postoperatively clinically and using UF. Results: 75 of 180 circumcised patients (41.6%) were included. At two weeks, Thirtytwo of 75 patients (42.7%) displayed a pathological UF. At six months, 15 patients (20%) had pathological UF and a new cycle of clobetasol was prescribed. At one year, 10 patients (13.3%) displayed patholgocial UF and underwent progressive urethral dilatation or meatoplasty. At 18 months, 71 patients (94.7%) displayed regular UF, 3 underwent a meatoplasty and one a staged urethroplasty for a severe urethral stenosis. At two years, UF was normal in 74 out of 75 (98.7%). Conclusions: We recommend to send for hystological examination all foreskins excised after circumcision. We believe that a clinical and uroflowmetric follow-up of pediatric patients with BXO is mandatory for a prompt identification of post-voiding dysfunction.

Balanitis xerotica obliterans (BXO) is a chronic inflammatory skin disorder, considered the male genital variant of lichen sclerosus. Anti-inflammatory drugs are commonly used in BXO. We evaluated the effects of an innovative formulation of ozonated olive oil with vitamin E acetate (OZOILE®) on the inflammatory status and tissue remodeling in male children with BXO. The mRNA transcripts of proteins involved either in inflammation or in dynamics of tissue regeneration were analyzed by quantitative real-time PCR, in foreskins affected by BXO removed from patients untreated or treated with OZOILE® cream for 7 days before circumcision. We found a significant reduction in mRNA levels of IL-1β, TNF-α, INF–γ, transglutaminase 2 and NOS2 in foreskins treated with OZOILE® in comparison to untreated ones (p < 0.001). No significant differences were observed in NF-κB activation in the specimens obtained from treated and untreated patients. Hence, OZOILE® treatment up-regulated hypoxia-inducible factor (HIF)-1alpha, vascular endothelial growth factor (VEGF) and E-cadherin gene expression (p < 0.001). The treatment with OZOILE® showed effective results in children affected by BXO by reducing the inflammatory process and stimulating mechanisms for tissue regeneration of the foreskin. A randomized clinical trial on a large number of children affected by BXO might be useful to verify the efficacy of topical treatment with OZOILE®.

Background Surgical options in male patients with genital lichen sclerosus (LS) involving the anterior urethra still represent a challenging issue. Objective To review the outcome of surgical treatment in patients with genital and urethral LS. Design, setting, and participants Multicenter, international, retrospective, observational descriptive study performed in two specialized centers. Two hundred fifteen male patients underwent surgery for histologically proven genital LS involving the foreskin and/or the anterior urethra. Intervention Circumcision (34 cases), meatotomy (15 cases), circumcision and meatotomy (8 cases), one-stage penile oral mucosal graft urethroplasty (8 cases), two-stage penile oral mucosal graft urethroplasty (15 cases), one-stage bulbar oral mucosal graft urethroplasty (88 cases), and definitive perineal urethrostomy (47 cases). Measurements Primary outcome was considered a failure when any postoperative instrumentation was needed, including dilation, or when recurrence was diagnosed. Results and limitations The average follow-up was 56 mo (range: 12–170 mo). Circumcision showed 100% success rate with no recurrence of the disease; meatotomy, 80% success rate; circumcision and meatotomy, 100% success rate; one-stage penile oral mucosal graft urethroplasty, 100% success rate; two-stage penile oral mucosal graft urethroplasty, 73% success rate; one-stage bulbar oral mucosal graft urethroplasty, 91% success rate; and definitive perineal urethrostomy, 72% success rate. Limitations include short follow-up for recording neoplastic degeneration and no instrument to investigate quality of life. Conclusions Patients with LS disease restricted to the foreskin and/or external urinary meatus showed a high surgery success rate. In patients with penile urethral strictures or panurethral strictures, the use of one-stage oral graft urethroplasty showed greater success than the staged procedures.

Objectives: To evaluate the long-term efficacy of topical application of a potent corticoid cream and skin stretching in the treatment of unretractable foreskin, pinpoint phimosis, balanopreputial adhesions and lichen sclerosus in prepubertal boys. Methods: 462 prepubertal boys (mean age 4.7 years) with unretractable foreskin applied a topical potent corticoid cream together with skin stretching twice daily for 6 weeks. Follow-up interview of all patients was performed to evaluate long-term results (median 22 months). Short- and long-term results were compared and evaluated. Results: 400/462 boys (86%) had a retractable prepuce after 6 weeks of treatment. 62/462 boys had no or only a partial response. After a median follow-up of 22 months, the treatment continued to be successful in 383/462 boys (83%). In 76/462 boys the foreskin was unretractable, of which 35 preferred surgical treatment. 12/462 boys presented with lichen sclerosus and the non-surgical treatment appeared efficient in 9/12 (67%). Conclusions: This study has shown that local application of a potent corticoid cream and skin stretching is a safe, simple and effective long-term treatment for all types of unretractable foreskin in prepubertal boys. The efficiency of the treatment was not related to the age of the patient or the type of unretractable foreskin.

We reviewed the literature regarding the clinical presentation, etiology, natural history, and medical and surgical management of lichen sclerosus in men.We performed a comprehensive search of the literature in PubMed, MEDLINE and other electronic databases between 1950 and 2006 using the key words lichen sclerosis, balanitis xerotica obliterans and urethral stricture. Our search resulted in 1,268 sources containing the words lichen sclerosus or balanitis xerotica obliterans. We reviewed 68 articles in the peer reviewed journals and 2 chapters on this subject.Lichen sclerosus is a chronic, lymphocyte mediated skin disease that was first described in 1887. It shows a predilection for the anogenital area in men and women. Much has been discovered regarding the epidemiology, natural history and histological features of this disease process during the last century, including the discovery of a strong association between lichen sclerosus and squamous cell carcinoma. The techniques of medical and surgical management of this disorder are still being elucidated. Biopsy of the initial lesion for definitive diagnosis and long-term followup of affected patients are well established, critical elements in the management of lichen sclerosus.Lichen sclerosus is a chronic, debilitating condition that may progress to cause significant voiding complications. Biopsy is recommended in all patients suspected of having lichen sclerosus to rule out squamous cell carcinoma. Further research is needed to improve the prevention, understanding and treatment of this challenging condition.

Die Balanitis xerotica obliterans (BXO) ist eine chronisch entzundliche progressive Hauterkrankung unklarer Atiologie und Inzidenz, deren Management im Kindesalter umstritten ist. Wenngleich meist nur die Vorhaut befallen ist, konnen bei meataler oder urethraler Lokalisation auch im Kindesalter komplexe Rekonstruktionen notwendig sein. Empfohlen wird die moglichst komplette chirurgische Entfernung der befallenen Hautpartien. Bei meatalem Befall, histologischem Zufallsbefund, Rezidiv oder unmoglicher Komplettentfernung sollte eine topische Therapie eingesetzt werden. In einer retrospektiven Analyse war in unserem Krankengut (n=13) die Rezidivrate nach topischer Therapie mit Tacrolimus (Protopic®), einem hochselektiven Immunmodulator, geringer als nach antientzundlicher Standardtherapie mit Betamethason. Tacrolimus-Salbe (Protopic®) stellt eine sichere und nebenwirkungsfreie Therapie dar. Da es keine pradiktiven Faktoren fur einen Progress oder ein Rezidiv der BXO gibt, ist aus unserer Erfahrung eine topische antientzundliche Nachbehandlung immer indiziert. Der anschliesende Follow-up sollte engmaschig sein, um Rezidive fruhzeitig erkennen und therapieren zu konnen.

Balanitis xerotica obliterans (BXO), first described by Stuhmer in 1928, is a chronic, progressive, atrophic, sclerosing process involving prepuce, glans and urethra. Its aetiology is unknown. After a short terminological excursus and a review of the aetiological hypothesis, we have focused on BXO in daily urological practice. We are here describing the clinical presentation and its differential diagnosis with premalignant and malignant lesions of the penis. We tried to define the relationship between BXO and squamous cell carcinoma of the penis. Particular attention was then cast on urethral stenosis. Finally, we focused on the treatment of BXO: corticosteroid local therapy as first line treatment or as adjuvant therapy after circumcision, surgical therapy including circumcision, laser therapy of the glans lesions, meatoplasty in the stenosis of the anterior urethra. We also stressed the need for histological examination of the preputial specimen for a correct follow-up and for medicolegal reasons.

Objective To review the technique and outcome of perineal urethrostomy or urethral perineostomy and to identify factors related to the procedure failure. Material and methods We studied 17 patients who underwent perineal urethrostomy between 2009-2013 in a single hospital. Success was defined as no need for additional surgical treatment or urethral dilatation. We reviewed the clinical data related to age, weight, previous urethral surgery, diabetes, hypertension, ischemic cardiopathy, lichen sclerosus and other causes and studied their association with the procedure failure (univariate analysis). We completed the analysis with a multivariate test based on binary regression. Results The average follow-up was 39.41 months. From all the causes, we found Lichen Sclerosus in 35%, idiopathic etiology in 29% and prior hypospadia repair in 18%. Postoperative failure occurred in 3 patients, with a final success of 82.4%. The binary regression model showed as independent risk factors ischemic cardiopathy (OR: 2.34), and the presence of Lichen Sclerosis (OR: 3.21). Conclusions The success rate with the perineal urethrostomy technique shows it to be a valid option above all when we preserve the urethral blood supply and plate. Lichen sclerosus and ischemic vascular problems are risk factors to re-stenosis.

Objective: The aim of this study was to assess the effectiveness of using topical steroid-based creams in the management of clinically diagnosed balanitis xerotica obliterans (BXO) in boys. Methods: The response in 56 boys to locally applied steroid-based creams was studied retrospectively. All had been referred by their general practitioners with symptoms of penile pathology and then subsequently had a clinical diagnosis of BXO made. The boys were initially assessed after 3 months of treatment and then at various intervals depending on their response. Results: The mean age at presentation of the boys was 8.9 (4 to 15) years. After the initial 3-month assessment, 10 (17.9%) boys had complete resolution. When the treatment period was prolonged by an average of 14 months, the total number of boys showing resolution increased to 17 (30.4%). All boys showing resolution had clinically mild BXO limited to the prepuce only. Those patients with established scar formation on the foreskin showed no significant improvement. Conclusions: Topical steroids seem to offer a reliable option only in the management of mild BXO limited to the prepuce in boys with minimal scar formation. Steroid-based creams can be offered to such patients provided they and their families are realistic as to the likelihood of success. This treatment is ineffective in the face of established scarring.

Balanitis xerotica obliterans (BXO) related strictures are complex and generally managed by 2-staged urethroplasty. We present our results with 1-stage dorsal onlay and 2-stage buccal mucosal urethroplasty for such strictures.Between January 2000 and April 2004, 39 patients underwent buccal mucosal urethroplasty for BXO related anterior urethral strictures. The 25 patients with a salvageable urethral plate (group 1) were treated with 1-stage dorsal onlay urethroplasty using a cosmetic incision. The 14 patients with a severely scarred urethral plate, focally dense segments or active infection (group 2) underwent 2-stage urethroplasty. Outcomes in terms of cosmetic appearance, stricture recurrence and complications in the 2 groups were assessed.At a mean followup of 32.5 months (range 3 to 52) 3 patients (12%) in group 1 had recurrent stricture, of which 2 and 1 were treated with optical urethrotomy and urethral dilation, respectively. All patients had a normal slit-like meatus and none had chordee or erectile dysfunction. Four group 2 patients (28.6%) required stomal revision and 2 had glans cleft narrowing after stage 1 urethroplasty. Following stage 2, 3 patients had recurrent stricture, of whom 2 were treated with optical urethrotomy and 1 underwent repeat urethroplasty.In BXO related strictures with a viable urethral plate 1-stage dorsal onlay buccal mucosal urethroplasty provides excellent intermediate term results. The cosmetic incision described provides a normal, wide caliber, slit-like glans. Two-stage procedures provide satisfactory outcomes but they are associated with a higher revision rate.

Lichen Sclerosus (LS), also known as Lichen Sclerosus et Atrophicus, or, in other literature as, Balanitis Xerotica Obliterans, is a chronic inflammatory skin disease which manifests in both males and females, affecting primarily the genitourinary area. The exact pathogenesis of LS is unknown and several hypotheses have been proposed, including autoimmune pathology, infective triggers, trauma (such as surgical interventions and sexual abuse) and genetic predisposition (rather than a direct genetic [...]

Objective: To investigate the incidence rate of circumcision for phimosis and other medically indicated reasons in Western Australian boys from 1 January 1981 to 31 December 1999. Design and setting: A population-based incidence study using hospital discharge data of all circumcisions performed in all WA hospitals during the study period. Main outcome measures: Changes in the incidence rate of circumcision for medically indicated reasons. Results: The rate of medically indicated circumcisions increased in boys aged less than 15 years during the study period. Phimosis was the most common medical indication for circumcision in all age groups. The rate of circumcision associated with phimosis was eight times that associated with balanoposthitis and 21 times that of balanitis xerotica obliterans. Boys aged less than five years had the highest rate of circumcision to treat phimosis, at 4.6 per 1000 person-years, representing about 300 circumcisions per year. Boys aged less than five years living in country areas were 1.5 times more likely to be circumcised for phimosis than boys living in metropolitan Perth. Conclusion: The rate of circumcision to treat phimosis in boys aged less than 15 years is seven times the expected incidence rate for phimosis. Many boys are circumcised before reaching five years of age, despite phimosis being rare in this age group.

Purpose: We review the long-term results of buccal mucosa grafts used as part of secondary hypospadias repair.Materials and Methods: We evaluated 47 patients for 10 years and analyzed long-term results of buccal mucosa grafts for hypospadias repair. Of the 47 patients 40 have been followed for more than 3 years.Results: The overall complication rate was 32% (13 of 47 cases). All complications occurred in the first 6 months following surgery, and the complication rate was significantly lower in the last 7 years of the series (19%) compared to the first 3 years (60%) (p = 0.01). All 3 patients in this series with a preoperative diagnosis of balanitis xerotica obliterans had a significant postoperative complication.Conclusions: Buccal mucosa appears to be a durable source of nongenital tissue for urethral replacement. Attention to detail in terms of graft harvest, graft preparation and graft fixation helps to avoid major postoperative complications. Onlay grafts appear to be preferable to tube grafts...

The ability to achieve a long-term, stable, stricture-free, hairless urethral lumen in patients with complex anterior stricture and compromised genital skin is one of the ongoing challenges of reconstructive urologic surgery. The conservative approach by endoscopic urethrotomy or dilatation with a self-catheterization schedule rarely affects a definitive cure except in the short filmy superficial strictures of the bulbous portion of the urethra. Genital fasciocutaneous island flaps are currently the golden standard for definitive, reliable resolution of anterior urethral strictures in patients who have not undergone a prior surgical procedure that may alter the penile or scrotal circulation, or those with skin loss from trauma, decubiti, radiation, or balanitis xerotica obliterans.

Background: Lichen sclerosus (LS) is a chronic inflammatory disorder that preferentially affects the anogenital region and rarely extra genital sites. It is more common in women and has a bimodal peak of incidence. The objective of the study was to document the clinical, demographic pattern and associated systemic diseases of lichen sclerosus (LS) among patients attending skin OPD, RIMS, Imphal.Methods: All patients presenting with signs and symptoms suggestive of lichen sclerosus (LS) were studied for a period of 24 months from March 2014 to February 2016. Clinical examination and relevant investigations including histopathology were performed.Results: A total of 54 patients were studied (17 males and 37 females). M:F ratio was 1:2.2. Majority belonged to 25-44 years age group (29.6%). Ano-genital LS comprised 81.4% of the cases. All patients presented with hypopigmented atrophic plaque (100%). The commonest site was prepuce (53.3%) in males and labia majora, labia minora and clitoris (62%) in females. There were 2 cases of balanitis xerotica obliterans (BXO). Ten patients (18.6%) had extragenital LSA and the sites involved were trunk, waist and extremities. Associated systemic diseases were detected in 6 patients. Conclusions: Lichen sclerosus is not an uncommon disease. Varied presentations ranging from asymptomatic white patch to severe inflammation and scarring were noted. Complications especially with genital involvement can be prevented by early diagnosis and adequate treatment. Screening for associated systemic disease may prove useful.

This study investigated whether boys with balanitis xerotica obliterans (BXO) have increased rates of obesity compared with boys with no concern for BXO (NCB). Boys ≤18 years old with circumcision pathology–confirmed BXO were compared with an age-matched group who had NCB during circumcision. Boys with BXO were found to have a mean body mass index of 70.64 percentile for age compared with 52.43 percentile in age-matched controls ( P = .0005). The rate of obesity was significantly higher in boys with BXO (42%) compared with 12.4% in boys with NCB (odds ratio = 5.12; 95% CI = 2.6 to 10.06). Given the increasing rates of childhood obesity and the long-term health consequences of both BXO and obesity, special attention should be paid to this population. Further research is needed to determine if BXO in obese children may represent an early indicator of a systemic disease process where intervention may be warranted.

Penis cancer appears as a small lesion that extends gradually to affect the whole of the glans and the shaft of the penis. Its peak incidence is in men aged 40 to 70 years. The most frequent malignant penis tumour is squamous cell carcinoma, which occurrence is probably favoured by smegma accumulation, HPV16 and 18 infection, smoke, and balanitis xerotica obliterans. Here we discuss the case of a 74-year-old man with sovrapubic pain and swelling. Physical examination reveals swollen glans with purulent secretions and oedema. The final diagnosis of squamous cell carcinoma is established by means of RMN and biopsy. Partial penectomy surgery follows. Histopathological examination shows poorly differentiated endophytic infiltrative growth. The tumour infiltrates corpus spongiosum, corpora cavernosa, and urethra. The proximal uretheral stump is free from infiltration (pT3).