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 uncircumcised children, 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.1
Frequency
International
Meatal stenosis affects 9%-10% of males who are circumcised.
Mortality/Morbidity
- Meatal stenosis carries no risk of mortality.
- Morbidity is limited to the clinical symptoms and complications of surgical repair, including bleeding, infection, and recurrence.
Race
Meatal stenosis has no racial predilection. The condition can occur in circumcised males independent of ethnicity.
Sex
Meatal stenosis occurs only in males.
Age
Children who are not toilet-trained are more prone to develop meatal stenosis after circumcision because of exposure of the meatus to urine in diapers. Most 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 upon 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
- Meatal stenosis can be suspected based on 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 the diagnosis of the disorder.
- If the physician desires to calibrate the meatus, Litvak et al report that the meatus in children younger than 1 year will accept a lubricated 5F feeding tube. They also report that, in children aged 1-6 years, an 8F feeding tube should pass without difficulty.2
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
- 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.3
- In children with BXO, meatal stenosis seems to be quite common.
- 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
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].
Litvak AS, Morris JA, McRoberts JW. Normal size of the urethral meatus in boys. J Urol. Jun 1976;115(6):736-7. [Medline].
Gargollo PC, Kozakewich HP, Bauer SB, et al. Balanitis xerotica obliterans in boys. J Urol. Oct 2005;174(4 Pt 1):1409-12. [Medline].
Brown MR, Cartwright PC, Snow BW. Common office problems in pediatric urology and gynecology. Pediatr Clin North Am. Oct 1997;44(5):1091-115. [Medline].
Smith C, Smith DP. Office pediatric urologic procedures from a parental perspective. Urology. Feb 2000;55(2):272-6. [Medline].
Frank JD, Pocock RD, Stower MJ. Urethral strictures in childhood. Br J Urol. Dec 1988;62(6):590-2. [Medline].
Garat JM, Chechile G, Algaba F, Santaularia JM. Balanitis xerotica obliterans in children. J Urol. Aug 1986;136(2):436-7. [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].
Stenram A, Malmfors G, Okmian L. Circumcision for phimosis: a follow-up study. Scand J Urol Nephrol. 1986;20(2):89-92. [Medline].
Further Reading
Keywords
meatal stenosis, circumcision, circumcision complication, meatus, meatotomy
