Male genital lichen sclerosus misreported as candidal or other infective balanitides: A systematic review of the literature

Abstract

Background

Male genital lichen sclerosus (MGLSc) is a chronic inflammatory dermatosis presenting as balanoposthitis, with potential for irreversible scarring, sexual and urinary dysfunction, and malignant transformation. Inflammation and architectural disruption from MGLSc may predispose to secondary colonisation or infection with microbial organisms. This can confuse non-specialist clinicians, who may misattribute clinical signs and positive microbiological results to primary infection, thereby overlooking the underlying MGLSc as the root cause of disease.

Objective

To evaluate systematically published reports of infective balanitis and balanoposthitis for clinical features suggestive of MGLSc.

Methods

Following PRISMA 2020 guidelines, we searched MEDLINE and EMBASE for English-language articles reporting cases of non-sexually-transmitted infectious balanitis or balanoposthitis. Eligible studies were required to include adequate clinical photography. Clinical images were reviewed for signs of MGLSc.

Results

Out of 978 identified records, 15 studies met inclusion criteria, yielding 19 clinical images. All images exhibited clinical features consistent with MGLSc, despite being attributed to infections such as candida or bacterial pathogens. Histological confirmation, where performed, was frequently non-specific. Many cases reported incomplete resolution following antimicrobial therapy.

Conclusion

This review underscores a recurring problem in the literature viz. the misattribution of MGLSc to microbial infections. Attributing a named diagnosis to positive microbiological results without specialist input can lead to delays in accurate diagnosis and effective management, create fallacious diagnoses and erroneously perpetuate non-existent diagnoses. Improved awareness of the clinical features of MGLSc, and careful interpretation of microbiological data within the broader clinical context, will support more accurate patient care but also enhance the reliability of the literature.