Psychological and psychiatric morbidity in lichen sclerosus in a cohort recruited from a genitourinary medicine clinic

INTRODUCTION

Psychological and psychiatric effects are associated with sexually transmitted infections (STIs) and in particular in relation to anogenital human papillomavirus infection (HPV). ^1–4

Ostensibly lichen sclerosus (LS) can be a cosmetic disfiguring condition in both men and women. There can be, for example, total remodelling of the glans penis due to the infiltrative process.

Only one previous paper was identified, in the literature, relating psychological and psychiatric effects to LS. ⁵ This latter study was of women only in a vulval diseases clinic and the relevant LS subdivision was of 15 patients only.

This Southend study looks at a mixed sex cohort of 26 patients attending the sexually transmitted diseases clinic and psychological and psychiatric effects of LS are analysed and documented, with data accruing from a questionnaire.

METHODS

Cases of LS, between 2000 and 2008, attending serially at an associate university teaching hospital genitourinary (GU) medicine clinic, were retrospectively identified. They were diagnosed clinically by experienced clinicians. Forty-five cases were identified and 26 of those completed the questionnaire (57% response) mailed to them, or completed it while attending the clinic.

RESULTS

There were 26 patients evaluated (responders to the questionnaires); 61.5% were men and 34.6% women with one patient unclassified.

Nineteen percent were aged 19–39 years; with 8% aged 40–50 years and 73% aged 50 years or over. The age range was 19 years up to 62 years. Sixty-nine percent had had the disease for <5 years with 8% having the disease >20 years. Only 11.5% (3 patients) had had a confirmatory histological biopsy result.

Seventy-seven percent were not ever worried about infecting partner(s) while 19% were at one time or other worried about this potential occurrence. This was despite counselling whereby 15.5% were still believing that they could infect their partners whereas 7.5% did not receive counselling and also believed that they could infect their partners.

Thirty-eight and half percent were concerned about possible cosmetic defects from the LS; indeed 23% (6 patients) felt that the cosmetic appearance had affected their confidence and 27% felt that the cosmetic appearance affected libido; of the latter, seven patients in total stated that this libido reduction amounted to a median of 5.6 points on a scale range of 1:10.

One male patient had had a meatotomy and one male patient had had circumcision and urethroplasty. One female patient had had a partial vulvectomy but no surgical procedure had left permanent psychological scars in any of the patients.

Fifty-eight percent were concerned that the LS had produced, at any time, moderate to severe anxiety while 27% were concerned that it had, at one time or another, caused depression. Fifty-four percent (14 patients) believed that they had not been counselled enough about the unlikely outcome of malignant change. Nineteen percent had had insomnia with worry about the condition. Indeed, only 11.5% overall felt that the LS affects their lifestyle. Sixty-nine percent admitted to worrying about their LS while 23% were ‘stressed’ by it.

One single patient was on Acitretin therapy (retinoid immunosuppressant). Lastly, 11.5% were worried about starting a new relationship whereas 81% (21 patients) were not.

DISCUSSION

Wojnarowska's ⁵ 1997 study showed that their LS cases had effects symptomatically impinging on sex, leisure activities and sleep and that they scored highly on the global mood scale and on findings comparable to major illness compared with other vulval disease diagnostic groups. In addition, they found 56% of their LS had ‘chronic stress’, 33% were ‘probable psychiatric cases’ and 55% had severe effects on their sexual relationship.

In this study less (23%) were chronically stressed; also true ‘psychiatric’ cases were not unearthed during their care. Also there were only 11.5% worried about starting a new relationship that may reflect indirectly upon the overall harmony of their sexual relationships'; the latter being poor in Wojnarowska's study. ⁵ From the study, the following facts are apparent. When counselling the patients they must be reassured about the impossibility of potential infectivity of the condition, and the rarity of malignant change, coupled with the need for long-term surveillance regarding the latter.

LS should be added to HPV, herpes simplex anogenital infection and human immunodeficiency virus infection as a cause of GU medicine clinic psychological morbidity – relatively and comparatively speaking even though it is a rare condition with an unknown prevalence.