Presented by: Kale Munien MBBS
Queensland Health Toowoomba Hospital

Introduction

Lichen sclerosis (LS) is recognized as a contributing factor in 10% of instances of idiopathic urethral stricture disease (IUSD), and this has significant implications for treatment approaches due to the underlying pathophysiology. Conventional excision urethroplasty may not yield optimal outcomes as inflammation frequently extends beyond the visible stricture. The primary objectives of this study are to address two research inquiries: the role of LS as an idiopathic cause of strictures and the presence of histological indications pointing to a predisposition of the surrounding tissue to develop strictures.

Materials

Patients diagnosed with IUSD underwent biopsies at the location of the stricture, as well as at one and two centimeters proximal and distal to it. Histological analysis encompassed macroscopic and microscopic observations, such as the identification of LS, hyperkeratosis, alterations in the epidermis, lichenoid infiltrates, ulceration, scarring, and inflammation. Methylene blue was employed to facilitate the identification of compromised urothelium. Subsequently, patients were prospectively monitored following the urethroplasty procedure.

Results

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A total of fifteen male patients were recruited between 2019 and 2022. No patient showed visible signs of LS, whereas microscopic evidence of LS was found in two patients solely at the two-centimeter proximal biopsy site. Scarring was observed in 93% of patients both proximal and distal to the stricture, while 20-40% exhibited signs of inflammation. Among the patients with microscopic LS and inflammatory changes, one experienced stricture recurrence following urethroplasty. Additionally, one patient diagnosed with inflammatory changes was found to have urethral carcinoma in situ and subsequently underwent penectomy.

Conclusion

The results indicate that LS could potentially be an underlying cause of IUSD. Furthermore, the pathophysiology of the condition may involve scarring and inflammation that extend beyond the strictured area, even distally from the stricture site. When encountering cases of inflammatory changes, it is crucial to conduct a thorough assessment for concurrent urethral pathologies. These findings have implications for the surgical management of IUSD and emphasize the need for additional research on the utility of routine biopsy and potential drug targets in USD.

Funding

No funding

Lead Authors

William Harrison, MBBS
Queensland Health

Co-Authors

Devang Desai, MBBS, FRACS
Queensland Health