Urine and occlusion in the pathogenesis of lichen sclerosus: insights from a case of post-urethrectomy remission

We report the case of a 58-year-old uncircumcised man with male genital lichen sclerosus (MGLSc) achieving complete remission following urethrectomy and ileal conduit formation for urothelial carcinoma. The patient presented with typical clinical features of MGLSc. Initial treatment with ultrapotent topical corticosteroids provided only moderate improvement. Circumcision was planned but delayed due to the diagnosis of bladder and ureteral carcinomas. Postsurgery, urine was diverted through an ileal stoma, and the urethral meatus was sealed. Remarkably, despite cessation of topical treatments, the patient's penile MGLSc showed complete resolution, with no residual active disease over a 4-year follow-up period. However, peristomal lichen sclerosus developed, emphasizing the role of occlusive urinary exposure in disease pathogenesis. This case supports the hypothesis that occlusive exposure to urine is a critical driver of MGLSc. The resolution of penile MGLSc following urethrectomy and the emergence of peristomal lichen sclerosus underscore the pathogenic importance of chronic urine contact. Key evidence includes the anatomical distribution of lesions, high prevalence of postmicturition dribbling, and resolution of MGLSc after circumcision or urethral isolation. This case highlights the interplay between urinary exposure, occlusion and epithelial susceptibility in MGLSc, and reinforces the necessity of addressing these factors in management. Further research into preventive strategies and targeted treatments for MGLSc and related conditions is warranted.