Complications
Scarring and subsequent loss of normal anatomic structure may be seen in untreated disease and develops in the setting of chronic inflammation, often with silent progression.[58]
Early recognition and management of LS can prevent this complication. Maintenance therapy is important, even for well-controlled disease, to prevent architectural changes.[84]
Once scarring develops, it cannot be reversed; however, depending on severity and functional impairment, lysis of adhesions can be used to treat strictures.
Urinary retention and incontinence can be seen in the setting of chronic scarring that affects the urethra or leads to narrowing of the introitus.[114][115] Prevention of urinary retention and incontinence relies on early diagnosis and treatment with continued maintenance therapy.
Systemic agents such as mirabegron can be considered for incontinence. In some cases surgical intervention may be an option, such as if scarring has occurred in locations such as the vulva or urethra. Surgery is the definitive treatment for men with urethral stricture/meatal stenosis.
Men with untreated penile LS may develop sclerosis and narrowing of the foreskin, leading to phimosis or adhesions of the foreskin to the glans, which may cause sexual dysfunction/dyspareunia and urethral disease.[50] Meatal stenosis (abnormal narrowing of the urethral opening) may also occur, which can be a chronic and recurrent issue in men with the condition.
SCC and its precancerous precursors dVIN and PeIN may develop in long-standing untreated anogenital disease.[4][5]
One systematic review of 15 studies found the absolute risk of developing SCC in the presence of anogenital lichen sclerosus in women to be up to 3.88%, compared with 0.002% in the general female population, and up to 0.91% in men with LS, demonstrating an over 800-fold increase compared with men without the condition.[107]
Some studies have demonstrated the presence of anogenital LS adjacent to SCC in over half of all cases of SCC in women and 40% of cases in men.[55][108][109]
Early diagnosis and treatment of LS (and consistent use of maintenance therapies as required) is important to prevent progression to malignancy.
SCC and dVIN may present with skin texture or color change; nonhealing hyperkeratotic areas, erosions, or firm papules/nodules should be considered suspicious for dVIN. If lesions suspected to be due to LS persist despite therapy or progress, biopsy is indicated to rule out malignancy.[35][56][61] It is recommended that patients with anogenital LS are monitored with clinical examination at 6- to 12-month intervals to assess for signs of malignant transformation.[84]
If dVIN or SCC develops, treatment is usually surgical excision depending on the stage and extent of the condition (e.g., vulvectomy in women, circumcision or wide local excision in men).[110][111][112]
Dysuria can occur in untreated anogenital disease due to urine coming into contact with inflamed and fissured/eroded skin (this is a short-term complication that usually resolves with initiation of treatment and resolution of inflammation).
In children, dysuria may lead to a fear of voiding and subsequent overflow incontinence.[7]
In men, dysuria can develop in the long-term as a result of chronic scarring around the urethra, due to phimosis, or adhesions of the glans.
Prevention of dysuria relies on early diagnosis and treatment with continued maintenance therapy and treatment of scarring (if this is a contributing factor) with urethral dilatation or lysis of adhesions.
Dyspareunia (painful intercourse) and sexual dysfunction in women can occur at any time during the course of LS.[40][47] In one systematic review and meta-analysis, 59% of 486 women with LS reported sexual dysfunction.[47]
Dyspareunia may develop due to active skin inflammatory changes (causing atrophy, erosions, fissures), or resulting nerve and muscular changes in the setting of a chronic overlying inflammatory condition.[40][47] Dyspareunia may also develop due to functional limitations associated with scarring.[46]
Prevention of dyspareunia and sexual dysfunction relies on early diagnosis and treatment with continued maintenance therapy. If women continue to experience pain and sensitivity after their clinical signs have improved, consider vulvodynia (vulval pain with no obvious underlying cause) and refer to a pain specialist or vulval specialist. Treatment to target nerve or pelvic muscle involvement with topical or systemic agents and pelvic floor physical therapy should also be considered.[113] If dyspareunia is related to scarring, consider referral for treatment with lysis of adhesions.
Men with untreated penile LS may develop sclerosis and narrowing of the foreskin, leading to phimosis or adhesions of the foreskin to the glans. This can in turn can lead to painful erections and associated sexual dysfunction.[50]
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