Meatal Stenosis

Updated: Dec 01, 2021
  • Author: Joel F Koenig, MD; Chief Editor: Marc Cendron, MD  more...
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Overview

Practice Essentials

Genital disorders are commonly encountered in the office of the primary care physician. [1]  Meatal stenosis, or distal urethral stricture, is relatively commonly seen as an acquired condition after circumcision. [1]

The incidence of this condition is difficult to define with precision. Some estimates have been as high as 9-18% of circumcised males or as high as 20% if the condition is defined as a meatus less than 5 French (1.67 mm) in diameter. [2, 3]  One meta-analysis, however, found a lower incidence of meatal stenosis after circumcision (0.66%) that was not statistically different from that in uncircumcised boys. [4]  Regardless of the exact incidence, meatal stenosis is a problem commonly encountered by primary care providers and specialists that negatively impacts patients and families.

Meatal stenosis is typically characterized by an upward-deflected, difficult-to-aim urinary stream and, more rarely, by dysuria and by urgent, frequent, and prolonged urination. Surgical meatotomy or meatoplasty is, in general, curative.

Rarely, meatal stenosis will be associated with hypospadias (before or after hypospadias repair) and may be noted with an abnormal urine stream or ballooning of the distal urethra.

Nonsurgical care has not been shown to be effective. Serial urethral dilatation is not recommended and is discouraged. Meatotomy or meatoplasty is the definitive treatment. (See Treatment.)

For patient education resources, see the Men's Health Center, as well as Foreskin Problems and Circumcision.

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Pathophysiology

After circumcision, a child who is not toilet-trained persistently exposes the meatus to urine, and this exposure results in inflammation (ammoniac dermatitis) and mechanical trauma as the meatus rubs against a urine-soaked diaper. Replacement of the delicate epithelial lining of the distal urethra by scar tissue may then result in fusion of the epithelial lining in the ventral meatus, leaving a narrow orifice at the tip of the glans. Because meatal stenosis is more commonly seen after circumcision, circumcision has been believed to be an important causative factor [5] ; however, the condition can also be seen in uncircumcised boys. [4]  

Research into other possible causative factors has identified some association with hypersensitivity reactions (atopic dermatitis, allergies, etc). [6] Meatal stenosis can also occur after hypospadias repair in approximately 3-10% of patients. depending on the severity of the hypospadias, [7]  and may require additional surgical repair

Balanitis xerotica obliterans (BXO; also referred to as lichen sclerosus) is a less common cause of meatal stenosis, but as many as 20% of boys undergoing circumcision for BXO may require subsequent operative treatment of meatal pathology. [8]

Another hypothetical cause 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 found meatal stenosis in 24 of 239 (7.29%) children older than 3 years; meatal stenosis was the most common complication of circumcision. [1]

Morris et al performed a systematic review and meta-analysis that assessed diagnosis of meatal stenosis after circumcision and the potential association of meatal stenosis with circumcision. [4]  They found that the risk of meatal stenosis after circumcision was low overall but that there was weak evidence suggesting a nonsignificantly higher prevalence in circumcised patients.

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Etiology

In a child who is circumcised, persistent exposure of the meatus to urine and mechanical trauma from rubbing against a wet diaper results in ammoniac 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:

  • Previous  hypospadias repair or congenital abnormality of the distal urethra associated with hypospadias
  • Trauma
  • Prolonged catheterization
  • BXO, an unusual condition that causes a whitish discoloration and dry appearance of the glans [9]

A 10-year retrospective series of boys with BXO at Boston Children's Hospital included 41 patients with a median age of 10.6 years, of whom 85% were aged 8-13 years. [10] 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; 27% (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.

Meatal stenosis occurs in as many as 20% of pediatric patients with BXO. Although BXO is difficult to treat, meatotomy typically produces a durable treatment of the meatal stenosis. Topical steroids or tacrolimus may also be used. [11]

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Epidemiology

Meatal stenosis has been estimated to affect as many as 9-20% of males who are circumcised. 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.

Given the wide variances in the reported rates of meatal stenosis, the precise effect race or ethnicity may play in the development of this condition is difficult to determine. However, when studies from different countries have been compared, no obvious racial predilection has been identified. [4]

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Prognosis

Meatal stenosis carries no known risk of mortality. The prognosis is excellent after surgery: Meatotomy or meatoplasty is typically curative of the misdirection of the urinary stream. Morbidity is limited to the clinical symptoms and complications of surgical repair, including bleeding, infection, and recurrence. If there are also voiding symptoms (eg, pain with urination or hesitancy), these may be related to underlying voiding dysfunction, and surgical correction of meatal stenosis may not alleviate them.

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Patient Education

By far the most common presenting symptom is misdirection of the urine stream, typically in an upward direction. This can make it more difficult for boys to aim the urine. For this reason, meatal stenosis is rarely dectected prior to toilet training. Rarely, severe cases may give rise to obstructive symptoms such as difficult or painful urination.

In cases of suspected meatal stenosis, the best evaluation is by a primary care or specialist provider who can observe the the patient urinating (eg, by observing voiding in clinic or reviewing a patient-provided video).

Once meatal stenosis is present, it is unlikely to resolve without intervention.

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