Meatal Stenosis Treatment & Management

Nonoperative treatment has not been shown to be effective for this condition.

Serial urethral dilatation results in small tears of the meatus, which are followed by secondary healing and possible persistance or recurrence of scar tissue. In the long term, this may create a tighter stricture at the tip of the penis; therefore, this procedure is not recommended and is discouraged.

Meatotomy or meatoplasty is the definitive treatment for meatal stenosis. Meatotomy is a simple procedure in which the ventrum (bottom aspect) of the meatus is first crushed (for hemostasis) for 60 seconds with a straight clamp (the authors have found the striations of a small nontoothed bowel clamp to be ideal for this application, whereas others have found needle holders to be effective and prefer this method), then divided with fine-tipped scissors.

Brown et al reported excellent results following 130 office meatotomies, with only two recurrences of meatal stenosis and one patient with bleeding requiring stitches. ^[14] They also cited the cost-effectiveness of this treatment and noted good patient tolerance when a caring approach is used to reassure the child before and during the procedure. In this series, parents were encouraged to remain with the children during the operation; their presence seemed to have a calming effect.

In a retrospective study of 55 boys who underwent clinic meatotomy (CM) under topical lidocaine and prilocaine (EMLA) anesthesia, Fronczak et al found that although their success rate was lower than that reported in earlier studies and the incidence of pain higher, it was nonetheless possible to complete all of the CMs, and more than 90% of patients experienced resolution or improvement of their symptoms. ^[15] The cost of CM was approximately one tenth that of meatotomy performed under general anesthesia, with no evidence of inferiority evident in the literature.

If the caregivers and the patient are cooperative, meatotomy can be performed in the office of the physician with a topical eutectic mixture of local anesthetics (EMLA cream) applied liberally over the entire glans and secured in place for at least 30 minutes with an occlusive dressing. After being in place for 30 minutes, the dressing is removed, and the penis is prepared and draped into a sterile field.

Throughout the procedure, it is important to reassure the child and tell him what is being done.

One blade of a straight clamp is introduced into the meatus, and the ventrum of the meatus is crushed (~3 mm) by closing the clamp. This provides adequate hemostasis in most cases. The crushed area is divided with a straight fine-tipped scissors, and an antibiotic ointment is applied.

After the operation, it is critical that the caregivers separate the edges of the meatus and apply ointment twice a day for 2 weeks and then once a day for another 2 weeks to prevent one side of the meatotomy from adhering to the other side. Some medical professionals recommend dilation with a lubricated feeding tube or the tip of an ointment tube (antibiotic, steroid, or combination) for a period of up to 8 weeks. Some use topical application of steroid ointment or a combination of antibiotic and steroid ointment to decrease recurrence.

In a survey of office pediatric urologic procedures, which included meatotomy, lysis of labial adhesions, and newborn circumcision, Smith and Smith found that 95 of 99 parents stated that they were satisfied with their decision to have these procedures performed in the office, and 95% reported good outcomes (only one patient had recurrent meatal stenosis). ^[16]

Mild dysuria may occur after meatotomy, sometimes resulting in urinary retention. (See Complications.)

It is also important to note that spraying of the urine stream may occur for several days after surgical correction as a consequence of swelling. If stitches are used in a meatoplasty, urine spraying may persist until the stitches fully dissolve.

Depending on the age and temperament of the child, it may be preferable to perform meatotomy with the patient under sedation or general anesthesia in the operating room.

Some surgeons prefer meatoplasty, in which stitches are placed to help keep the meatus open, to meatotomy, citing research that suggests a lower recurrence rate after meatoplasty. ^[17]  Meatoplasty typically requires sedation or general anesthesia. Others have reported excellent results with meatotomy. Ultimately, the choice of approach (meatotomy, meatoplasty, or no surgery) is based on a thorough discussion among the provider, the family members, and the patient (if applicable).

After meatotomy, caregivers will typically be instructed to separate the edges of the meatus and apply antibiotic, steroid, or combination ointment twice a day for 2 weeks and then once a day for 2 more weeks. The physician may have other specific instructions, based on their usual care.

Complications include bleeding during or after meatotomy, infection (extremely rare) and recurrence. All of these complications are rare and typically respond readily to appropriate management.

Mild dysuria may be present for 1-2 days after meatotomy. If dysuria results in urinary retention, placing the child in a tub of warm water may stimulate micturition. Application of petroleum jelly or ointment to the meatus may decrease dysuria and the likelihood of retention. It can also be helpful to have the child void small amounts frequently rather than hold their urine for long periods of time.

In rare cases, a boy may develop a chronic inflammatory response that will be associated with some mild scabbing. This may require application of topical steroid or a redo procedure.

After meatotomy, caregivers should be instructed to dress the child in loose underwear for 24 hours. Activities, such as contact sports, bicycle rides, and playground activities, should be restricted for 3-4 days.

A systematic review and meta-analysis by Morris et al found that application of petroleum jelly to the glans after circumcision was associated with a reduction in the risk of meatal stenosis (relative risk, 0.024; 95% confidence interval, 0.0048-0.12). ^[4]

If the primary care physician is unwilling to perform a meatotomy, consultation with a pediatric urologist should be encouraged.

Typically, long-term follow-up by a specialist is not necessary; the vast majority of children do very well after surgical correction. Parents and patients should be aware of any changes in the urine stream that may indicate the rare recurrence of meatal stenosis.

If there are any questions or concerns, referral to a urologist should be made.