Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obervation Letter
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF
Letter to the Editor
2012:78:3;367-368
doi: 10.4103/0378-6323.95461

Occlusion, urine and genital lichen sclerosus

Christopher B Bunker
 Department of Dermatology, University College London Hospitals, London, United Kingdom

Correspondence Address:
Christopher B Bunker
Department of Dermatology, University College Hospital, 235 Euston Rd, London, NW1 2BU
United Kingdom
How to cite this article:
Bunker CB. Occlusion, urine and genital lichen sclerosus. Indian J Dermatol Venereol Leprol 2012;78:367-368
Copyright: (C)2012 Indian Journal of Dermatology, Venereology, and Leprology

Sir,

I congratulate my friends and colleagues, Drs. Gupta, Malhotra and Ajith on their perspicacious observations concerning the distribution of genital lichen sclerosus (GLSc), recently published in your journal. [1] I also applaud the clarity of their interpretation, with which I unequivocally agree, that occlusion of susceptible skin is central to the pathogenesis of this cryptic but important dermatosis. My own view is that it is occlusion specifically with urine that is key. May I have your permission, Sir, to paraphrase here from letters from myself that have appeared in the urology literature over the last couple of years about this theory? [2],[3]

In the male (M), GLSc affects principally the uncircumcised only rarely occurring in those who were circumcised at birth, where it is associated with trauma, instrumentation, genital jewellery (piercing) and gross anatomical abnormalities such as hypospadias and its surgical repair, [4] situations that can create urinary leakage. In girls, GLSc can be self-limiting, perhaps because tighter control of continence is acquired with aging (R. U. Sidwell-personal communication). In the adult female GLSc classically causes characteristic perianal disease [5] and has been associated with incontinence in women in a single report. [6] But GLSc never normally causes perianal disease in men because in striking contradistinction to women the male perineum is never normally chronically exposed to urinary irritation. However, MGLSc occurs and recurs in grafts. [4],[7]

Arguably, the arrangement of the distal urethra, navicular fossa and meatus has evolved to function as a low-pressure valve. The embryology is complicated and a wide, albeit often subtle, variation in naviculomeatal valve structure and function, and the relationships of both to striking variation in the structure and function of the prepuce, is revealed by meticulous clinical assessment. Many men presenting with GLSc will confess to dribbling after voiding and have abnormal naviculomeatal morphology on close examination. In these men, urine dribbling from the meatus after the prepuce has been replaced following voiding will spread widely between the juxtaposed mucosal surfaces. Occlusion and the phenomenon of koebnerization create the inflammation. [8] Our magnetic resonance spectroscopy work suggests that there is not one single indictable component of urine. [9]

Female GLSc seems to spare non-cornified stratified squamous epithelium. Women do not get urethral disease, [5] but this can be a devastating complication in men. Perhaps this is because, in the male, susceptibility to the irritant effects of urine may be due to variability in the epithelialization of the mucosa of the distal urethra and navicular fossa, as well as dysfunction of the naviculomeatal valve. The definition of mucosa is controversial but undoubtedly the proximal penile urethra possesses a true mucosa, while the circumcised glans certainly does not, the uncircumcised glans and inner prepuce might not, and the outer prepuce most likely does not. There are transition zones between true urothelium and true skin. Just as there is wide variability in the size and shape of the navicular fossa, there is probably variability in the site of the epithelial transition zones, the degree of keratinization of the glans, the length and, thus, surface area of the foreskin, and the disposition of adnexae. Perhaps urethral LSc eventuates because the transition to stratified keratinizing squamous epithelium occurs and/or urethral mucus glands are lost, too proximally, thus rendering the epithelium focally susceptible to the pernicious irritant effects of urine. Some recent histological findings may be pertinent to this argument. [10] Non-genital and especially true mucosal, e.g., buccal, skin grafts are held to be more successful than genital skin grafts in the repair of MGLSc. [11],[12]

The clinical observations of Gupta and his colleagues help us considerably in better understanding the pathogenesis of GLSc. Enlightenment in this regard is directly relevant to prevention or early diagnosis and medical and surgical treatment of the potentially catastrophic condition that is MGLSc. For example, surgical management of complicated GLSc must be designed so as not further to compromise naviculomeatal competence.

References
1.
Gupta S, Malhotra AK, Ajith C. Lichen sclerosus: Role of occlusion of the genital skin in the pathogenesis. Indian J Dermatol Venereol Leprol 2010;76:56-8.
[Google Scholar]
2.
Bunker CB, Edmonds E, Hawkins D, Francis N, Dinneen M. Re: Lichen sclerosus: Review of the literature and current recommendations for management: J. M. Pugliese, A. F. Morey and A. C. Peterson J Urol 2007;178:2268-2276. J Urol 2009;181:1802-3.
[Google Scholar]
3.
Bunker CB. Re: Sanjay Kulkarni, Guido Barbagli, Deepak Kirpekar, et al. Lichen sclerosus of the male genitalia and urethra: Surgical options and results in a multicenter international experience with 215 patients. Eur Urol 2009;55:945-6. Eur Urol 2010;58:e55-6.
[Google Scholar]
4.
Bunker CB, Neill SA. The genital, perianal and umbilical regions. In: Rook's Textbook of Dermatology. 7 th ed. Wiley-Blackwell; 2010. p. 71.20-23.
th ed. Wiley-Blackwell; 2010. p. 71.20-23.'>[Google Scholar]
5.
Bunker CB, Neill SA. The genital, perianal and umbilical regions. In: Rook's Textbook of Dermatology. 7 th ed. Wiley-Blackwell; 2010. p. 71.62-65.
th ed. Wiley-Blackwell; 2010. p. 71.62-65.'>[Google Scholar]
6.
Owen CM, Yell JA. Genital lichen sclerosus associated with incontinence. J Obstet Gynaecol 2002;22:209-10.
[Google Scholar]
7.
Abdelbaky AM, Aluru P, Keegan P, Greene DR. Development of male genital lichen sclerosus in penile reconstruction skin grafts after cancer surgery: An unreported complication. BJU Int 2011. [In press]
[Google Scholar]
8.
Weigand DA. Microscopic features of lichen sclerosus et atrophicus in acrochordons: A clue to the cause of lichen sclerosus et atrophicus? J Am Acad Dermatol 1993;28:751.
[Google Scholar]
9.
Edmonds EV, Bunker CB. Nuclear magnetic resonance spectroscopy of urine in male genital lichen sclerosus. Br J Dermatol 2010;163:1355-6.
[Google Scholar]
10.
Kulkarni S, Barbagli G, Kirpekar D, Mirri F, Lazzeri M. Lichen sclerosus of the male genitalia and urethra: Surgical options and results in a multicenter international experience with 215 patients. Eur Urol 2009;55:945-56.
[Google Scholar]
11.
Venn SN, Mundy AR. Urethroplasty for balanitis xerotica obliterans. Br J Urol 1998;81:735-7.
[Google Scholar]
12.
Bracka A. Re: Urethroplasty with abdominal skin grafts for long segment urethral strictures. J Urol 2010;183:1880-4. J Urol 2011;185:1985-6.
[Google Scholar]

Fulltext Views
203

PDF downloads
80
Show Sections