Genital Mucosa in Men Is a Frequent Target of Chronic Graft Versus Host Disease

Abstract 4183

Chronic GvHD (cGvHD) still remains a relevant problem after allogeneic stem cell transplantation (SCT), substantially contributing to morbidity and mortality of the procedure. Although manifestations of cGvHD in the genital organs of female patients are well recognized, only very few case reports regarding the involvement of male genital mucosa exist, resulting in the fact that in the organ system assessment forms generated by the NIH Chronic GVHD Consensus Group only female genital tract findings are included. In our observation male findings are present in daily practice if the patient is asked actively for genital problems. Therefore it seems to be a rather under-recognized manifestation of cGVHD. To estimate the prevalence of this problem we prospectively analyzed all male patients presenting in a five month period in our outpatient SCT-clinic for the presence of signs of cGvHD involvement of the genital mucosa or problems in the past. During 9/2010 – 1/2011 in total 250 male patients were seen for follow up after allogeneic SCT, eleven patients out of these (4,4 %) reported present or past signs of cGVHD of the genital mucosa. The clinical presentations varied widely and led from inflammatory processes with local irritation and pain to fibrosis and scarring of the prepuce and glans penis. Depending on their extent of involvement these findings resulted in a serious impact on quality of life and impaired sexual health in particular. In more detail, symptoms varied from: 1. mild inflammatory processes with erythematous changes of the glans (4/11– 36,6%); 2. extensive inflammatory processes with erythema and erosive changes (4/11– 36,6%); 3. phimoses (2/11–18,3%); 4. sclerodermoid processes with penile urethral strictures and urethral meatus stenosis (1/11–9%). In none of the patients any infectious pathogens responsible for the observed findings could be detected. Time between SCT and initial symptoms ranged from 6 months to 6 years after transplantation. Almost all patients with involvement of the genital mucosa showed signs of cGvHD in other mucosal sites, e.g. ocular/oral mucosa (10/11, 90,9%). Cutaneous cGVHD was present in 100%. Inflammatory processes responded mostly to antiinflammatory therapy with local steroid/topical tacrolimus. Since in the course of the disease 6/11 patients (54,5%) eventually developed phimoses, surgical intervention for this condition was required in 4 patients (66,6%). The patient with urethral strictures had a urethrotomy. For normal miction he still has to perform daily dilatations. In the few cases with mucosal biopsies histopatholology showed lichenoid changes (lymphohistiocytic infiltrates between epidermis and dermis with pigmentincontinence) fitting to inflammatory processes of cGvHD and fibrosis. In summary, the presented data implicate that patients after SCT need to be asked actively for genital problems since it is infrequently reported spontaneously. Special caution is required for patients with cutaneous or other mucosal (eyes/oral) cGvHD since they might have developed also unrecognized genital GVHD. Early and interdiscipilinary intervention is necessary to prevent phimoses and sclerodermoid stages as late manifestation.