Male genital lichen sclerosus (MGLSc)
Men with MGLSc present with dyspareunia, urinary dysfunction
and rash. The differential diagnosis includes psoriasis,
eczema, lichen planus, Zoon’s balanitis and
carcinoma in situ. Diagnosis is clinical and biospy is rarely
needed. Goals in the management of MGLSC are restitution
of normal sexual and urinary function, abolition or signiﬁcant
reduction in the risk of penis cancer and preservation
of the foreskin. MGLSc could be a largely preventable
disease or, at the very least, could be completely cured if
diagnosed and treated early by medical and surgical means.
Fundamental to the achievement of these goals is the recognition
of the pernicious role played by chronic occluded
urinary irritation of susceptible keratinized epithelium in
the initiation and progression of MGLSc. These pathogenetic
insights affect medical and surgical management
strategies. Medical management constitutes ultrapotent
topical steroid treatment, soap substitution and
minimisation of urinary exposure and induces remission in
50–60%. Failure or relapse are strong indications for cir-
cumcision and this is curative in the majority. Topical
calcineurin inhibitors are contraindicated.
‘Idiopathic’ penile oedema and cellulitis
Chronic penile lymphedema is a rare situation with an
uncertain pathogenesis and important differential diagnosis.
It creates signiﬁcant physical and psychosexual morbidity
and presents considerable therapeutic challenges. The
literature is limited. A recent retrospective study of 30 cases
seen in a specialized clinic has been undertaken. Over a
third had Crohn’s disease (occult in 50%). Over a third had
serological evidence of streptococcal infection. Other
causes include sarcoid, anogenital/pelvic disease eg neoplasia
and its treatment, STD eg HSV, lichen sclerosus, ﬁlariasis,
foreign bodies and implants eg paraﬁnoma.
Rigoorous investigation is necessary. All patients responded
to protracted rotating systemic antibiotics (± short courses
of systemic steroids and specialised urological surgery –
circumcision and excision.