Presentation Authors: Ross Calopedos*, Katherine Richards, Prem Rashid, Port Macquarie, Australia, Sanjeev Bandi, Mackay, Australia, Amila Siriwardana, Michael Kwok, John Hempenstall, Devang Desai, Toowoomba, Australia
Introduction: This is the first in a series of unique studies looking to evaluate the prevalence of Lichen sclerosus (LS) and its sequelae, with the view to developing more effective management strategies. LS is an enigmatic condition that has resounding implications in management of 20% of individuals who will develop urethral strictures. Stricturing may not be contiguous with the foreskin and can occur distally, as isolated proximal and even pan-urethral disease. Moreover, LS-associated strictures have high recurrence rates, even after urethroplasty. There is also risk of malignant transformation (2.3-8.4%), however long-term surveillance of patients with LS is uncommon.
Methods: As random genital biopsies could not be undertaken, our study population was men presenting for circumcision. We undertook a retrospective multi-center study of 8 Australian regional centers. Data was collected from all circumcision patients between January 2006 - December 2016, including age, histopathology and urethral stricture or penile cancer treatment. Patients with unavailable medical records were excluded. Histopathological confirmation of LS was the primary outcome.
Results: Of 611 circumcision patients included, 48.8% did not have valid pathology sent. Of the remaining 313 patients, 63.6% (n=199) had confirmed LS. Median age at diagnosis was 65 years (IQR 40-77) compared with 22.5 years (IQR 18-41) for patients with normal pathology (p= < 0.0001). 78 (24.9%) patients had other histological diagnoses, including acute/chronic inflammation (19.5%), lichen planus (1.9%) and Zoon's balanitis (1.6%). 17.7% (n=34) of patients with LS had urethral strictures, with 26 (13.1%) requiring urethral dilation, 3 (1.5%) urethrotomy and 2 (1.0%) meatotomy. 2 (1.2%) lichen sclerosus patients had histologically confirmed penile cancer, of which one was treated by circumcision (0.5%), the other, radical penectomy (0.5%).
Conclusions: Our findings show that LS is a highly prevalent disease in circumcision patients. As only a minority of specimens were sent for pathology, this prevalence is likely under-reported. Subsequent or concomitant stricture disease was also high at almost 20%. Current practices in attaining tissue diagnosis and ongoing surveillance may be insufficient, subjecting patients to serious and possibly preventable complications. Further research should prospectively evaluate all circumcision specimens and include biopsy of men presenting with idiopathic urethral stricture disease to ascertain the incidence of silent LS.