ABSTRACT
INTRODUCTION: It is estimated that approximately one out of 200 boys has the diagnosis of lichen sclerosus (LS), previously referred to as BXO (balanitis xerotica obliterans). Severe progressive disease is rare however, mismanagement of urethral tissues may contribute to progression of LS. STUDY DESIGN: The current literature regarding the management of severe lichen sclerosus was reviewed alongside our management of seven patients with ages ranging from six to ten years of age with severe lichen sclerosus who required surgical intervention. These patients were identified out of a busy pediatric practice that saw 5507 patients during the four-year span. Based on the pathophysiology of lichen sclerosus, urethral anatomy, and our management an algorithm was developed for medical and surgical management. RESULTS: All patients received initial medical treatment with topical steroids. Three patients underwent urethral mobilization and serial biopsy. One of these patients with severe disease required a second distal urethral mobilization. Three patients were treated with circumcision, and one is responding well to topical steroids after complex reconstruction. None developed postoperative urethral disease. DISCUSSION: Lichen sclerosus affects squamous epithelium but can extend to unaffected tissue if traumatized via the Koebner phenomenon. There are no randomized control trials for the management of the disease. Thus, appropriate early management with avoidance of urethral dilation or incision may prevent extension down the urethra that can lead to severe stricture disease. Several authors identified this as one of the worst forms of stricture diseases to manage. Based on the pathophysiology of the disease and our 4-year experience treating patients, we propose an algorithm for management of severe lichen sclerosus in boys. The diagnosis of lichen sclerosus in boys requires a high level of suspicion, and early biopsies should be obtained if suspected. If identified before circumcision or meatotomy, initial treatment should be medical. If the patient fails topical steroid therapy, circumcision and biopsy are the initial recommended surgical approach. Optimally, a biopsy with the first meatotomy establishes the diagnosis. If the disease persists, urethral mobilization may represent a curative treatment as it advances healthy urethra and allows complete removal of distal squamous epithelium instead of traumatic repeated dilations or incisions. CONCLUSION: This paper summarizes the available literature on the management of severe LS and provides a flow diagram based on the pathophysiology of the disease and our experience sever cases.
Subject(s)
Algorithms , Lichen Sclerosus et Atrophicus , Humans , Male , Child , Lichen Sclerosus et Atrophicus/therapy , Lichen Sclerosus et Atrophicus/diagnosis , Lichen Sclerosus et Atrophicus/physiopathology , Balanitis Xerotica Obliterans/therapy , Balanitis Xerotica Obliterans/diagnosis , Balanitis Xerotica Obliterans/physiopathology , Severity of Illness Index , Urethra/surgery , Urethra/physiopathology , Circumcision, Male , Glucocorticoids/therapeutic use , Urologic Surgical Procedures, Male/methodsABSTRACT
We present laboratory measurements showing the two-dimensional (2D) structure of energy conversion during magnetic reconnection with a guide field over the electron and ion diffusion regions, resolving the separate energy deposition on electrons and ions. We find that the electrons are energized by the parallel electric field at two locations, at the X line and around the separatrices. On the other hand, the ions are energized ballistically by the perpendicular electric field in the vicinity of the high-density separatrices. An energy balance calculation by evaluating the terms of the Poynting theorem shows that 40% of the magnetic energy is converted to particle energy, 2/3 of which is transferred to ions and 1/3 to electrons. Further analysis suggests that the energy deposited on particles manifests mostly in the form of thermal kinetic energy in the diffusion regions.