Patient History

A 47 year-old male with no other medical problems presented to a urology clinic in West Texas in 2015. At this time, he report slowness of his urinary stream and difficulty completely emptying his bladder. He reported that over the last several years he developed one urinary tract infection. He sought evaluation with another Urologist who performed a cystoscopy (look inside the urethra) which showed an area of scar tissue that was blocking his urine stream. He was offered a urethrotomy procedure whereby the surgeon used a scalpel attached to a cystoscope to stretch the scar open. Following this procedure, the scar tissue returned and he was counseled that nothing else could be done. From 2015 – 2017, the patient lived with a suprapubic tube draining his bladder to a leg bag. This tube required monthly office visits to be changed and he developed 3 more urinary tract infections from having this tube.

The patient sought care at Dell Seton Medical Center in the Spring of 2017. He underwent a retrograde urethrogram x-ray which demonstrated a diffuse, 4cm beaded appearance of scar tissue in his penile urethra (Panel A). Based on this image, he was immediately he was diagnosed with a skin condition called Lichen Sclerosis. This is a disease that occurs predominately in women, however in men, it causes scar formation in the urethra. He was counseled on his surgical options.

Treatment

The patient underwent a dorsal onlay buccal mucosal penile urethroplasty. (Panel B)This is a procedure that widens the caliber of the urethra by using a free skin graft from the inside of the mouth (a buccal graft). We open the urethral on the back side and then lay in our buccal skin graft. We then roll the “good urethra” over this and place a catheter to allow for healing. The catheter is removed after 4 weeks and a repeat x-ray is obtained. (Panel C) In this image, the urethra caliber is widened and there is no evidence of any leakage of contrast. Following this image, the patient’s suprapubic tube was removed and for the first time in over 2 years, the patient was catheter free.

Discussion

Lichen Sclerosis (LS) is a devastating skin condition that leads to scarification of the male urethra. It is also associated with a 10% increased risk of penile cancer. The diagnosis can be made based on physical exam which includes whitish plaques on the glans penis, a pin-point urethral meatus, and/or marked inflammation and induration along the urethra. LS can affect any segment of the male urethra but most commonly affects the glans and/or urethral meatus. Steroid creams may be tried for LS involving the glans or meatus, however scars localized to the penile or bulbar urethra often requires a definitive urethroplasty to fix. Performing a urethrotomy initially like this patient underwent is known to fail with a 95% re-stricture rate. Utilizing a graft from the mouth gives the best chance of success since the mouth is unaffected. Following surgery, men with LS should be routinely followed to ensure they remain stricture free.

Outcome and Follow up

Following removal of the patient’s suprapubic tube, he remains catheter free. He no longer needed any leg bags, he no longer needed to see his doctor every month for catheter changes, and he stopped getting recurrent urinary tract infections. At 3 months postoperatively, an office cystoscopy was performed which showed his graft was widely patent. He was emptying his bladder well with a low bladder residual on ultrasound. His urine stream was strong. His confidence was restored and his quality of life greatly improved.