Introduction
Background
Genital disorders are commonly encountered in the office of the primary care physician. Meatal stenosis is a relatively common acquired condition occurring in 9-10% of males who are circumcised. This disorder is characterized by an upward deflected, difficult-to-aim urinary stream and, occasionally, dysuria and urgent, frequent, and prolonged urination. Surgical meatotomy is curative.
Pathophysiology
After circumcision, a child who is not toilet trained persistently exposes the meatus to urine, resulting in inflammation (ammoniacal dermatitis) and mechanical trauma as the meatus rubs against a wet diaper. This causes the loss of the delicate epithelial lining of the distal urethra. This loss may result in adherence of the epithelial lining at the ventral side, leaving a pinpoint orifice at the tip of the glans. Because this condition is exceedingly rare in children who are not circumcised, circumcision is believed to be the most important causative factor of meatal stenosis.
Another hypothetical cause of this condition is ischemia due to damage to the frenular artery during circumcision, resulting in poor blood supply to the meatus and subsequent stenosis. In a prospective study of circumcised boys, Van Howe (2006) found meatal stenosis in 24 of 239 (7.29%) children older than 3 years, making meatal stenosis the most common complication of circumcision.
Frequency
International
Incidence is 9-10% of males who are circumcised.
Mortality/Morbidity
- Meatal stenosis carries no mortality.
- Morbidity is limited to the clinical symptoms and complications of surgical repair including bleeding, infection, and recurrence.
Race
No racial predilection exists. The condition can occur in circumcised males independent of ethnicity.
Sex
Meatal stenosis only occurs in males.
Age
Children who are not toilet trained are more prone to have meatal stenosis after circumcision because of exposure of the meatus to urine in diapers. Usually children who are toilet trained can verbalize their difficulties during micturition to their caregivers.
Clinical
History
- Difficult-to-aim (upward deflected), high-velocity (long distance) stream of urine
- Pain at initiation of micturition
- Need to stand back from toilet or sit during urination
- Burning at meatus
- Blood spots in underwear
- Urgent, frequent, and prolonged emptying of the bladder
Physical
- Diagnosis of meatal stenosis can be suspected by the presence of a small meatus during examination, particularly if, with lateral traction, the ventral edges of the meatus appear fused.
- Observation of the child while voiding helps immensely in confirming diagnosis of the disorder.
- If the physician desires to calibrate the meatus, Litvak et al report that the meatus of children younger than 1 year will accept a lubricated 5 French feeding tube. They also report that for children aged 1-6 years, an 8 French feeding tube should pass without difficulty.
Causes
- In a child who is circumcised, persistent exposure of the meatus to urine and mechanical trauma from rubbing against a wet diaper results in ammoniacal dermatitis, loss of meatal epithelium, and fusion of its ventral edges. This results in a pinpoint orifice at the tip of the glans.
- Other causes of meatal stenosis include the following:
- Unsuccessful hypospadias repair
- Trauma
- Prolonged catheterization
- Balanitis xerotica obliterans (BXO), which is an unusual condition that causes a whitish discoloration and dry appearance of the glans, can also cause meatal stenosis. A 10-year retrospective series at Boston Children's Hospital included 41 patients with a median age of 10.6 years. Eighty five percent of the patients were aged 8-13 years. The disease process was found to involve the prepuce, the glans, and, sometimes, the urethra. The most common referral diagnoses included phimosis (52%), balanitis (13%), and buried penis (10%). In 46% of the patients, circumcision was curative. Twenty seven percent (11 patients) had meatal involvement that was treated by meatotomy and meatoplasty, and 22% required extensive plastic procedures of the penis including buccal mucosal grafts (Gargollo, 2005).
- In children with BXO, meatal stenosis seems to be quite frequent.
- Although BXO is difficult to treat, meatotomy yields good results in patients with BXO.
More on Meatal Stenosis |
 Overview: Meatal Stenosis |
| Differential Diagnoses & Workup: Meatal Stenosis |
| Treatment & Medication: Meatal Stenosis |
| Follow-up: Meatal Stenosis |
| References |
| Next Page » |
References
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Gargollo PC, Kozakewich HP, Bauer SB, et al. Balanitis xerotica obliterans in boys. J Urol. Oct 2005;174(4 Pt 1):1409-12. [Medline].
Litvak AS, Morris JA, McRoberts JW. Normal size of the urethral meatus in boys. J Urol. Jun 1976;115(6):736-7. [Medline].
Persad R, Sharma S, McTavish J, et al. Clinical presentation and pathophysiology of meatal stenosis following circumcision. Br J Urol. Jan 1995;75(1):91-3. [Medline].
Sijstermans K, Hack WW, Bos SD, van der Horst HJ. [Urethral meatal stenosis in boys easily overlooked]. Ned Tijdschr Geneeskd. Dec 10 2005;149(50):2765-9. [Medline].
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Stenram A, Malmfors G, Okmian L. Circumcision for phimosis: a follow-up study. Scand J Urol Nephrol. 1986;20(2):89-92. [Medline].
Van Howe RS. Incidence of meatal stenosis following neonatal circumcision in a primary care setting. Clin Pediatr (Phila). Jan-Feb 2006;45(1):49-54. [Medline].
Further Reading
Keywords
meatal stenosis, genital disorder, acquired genital disorder, circumcision, circumcision complication, meatus, meatotomy
