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==Pathophysiology==
==Epidemiology==
===Frequency===
====International====
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==Background== Genital disorders are commonly encountered in the office of the primary care physician.<ref>{{REFjournal | last=Joudi M, Fathi M, Hiradfar M. | first= | coauthors= | title=Incidence of asymptomatic meatal stenosis in children following neonatal circumcision. | journal=J Pediatr Urol. Oct 2011; | volume=7( | issue=5): | pages=526-8.528 | url= | quote= | pubmedID= | pubmedCID= | DOI= | date=Oct 2011 | accessdate=}}</ref> 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.<ref>{{REFjournal | last=Van Howe RS | first=R. S. | coauthors= | title=Incidence of meatal stenosis following neonatal circumcision in a primary care setting. | journal=Clin Pediatr (Phila). Jan-Feb 2006; | volume=45( | issue=1): | pages=49-54. | url= | quote= | pubmedID= | pubmedCID= | DOI= | date=Jan-Feb 2006 | accessdate=}}</ref> == Epidemiology == === Frequency === ==== International ====
Meatal stenosis affects 9%-10% of males who are circumcised.
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.<ref>{{REFjournal | last=Litvak AS, Morris JA, McRoberts JW. | first= | coauthors= | title=Normal size of the urethral meatus in boys. | journal=J Urol. Jun 1976; | volume=115( | issue=6): | pages=736-7.737 | url= | quote= | pubmedID= | pubmedCID= | DOI= | date=Jun 1976 | accessdate=}}</ref>
=== Causes ===
* 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.<ref>{{REFjournal | last=Gargollo PC, Kozakewich HP, Bauer SB, et al. | first= | coauthors= | title=Balanitis xerotica obliterans in boys. | journal=J Urol. Oct 2005; | volume=174( | issue=4 Pt 1): | pages=1409-12.1412 | url= | quote= | pubmedID= | pubmedCID= | DOI= | date=Oct 2005 | accessdate=}}</ref>
** 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.
== Workup ==
=== Laboratory Studies studies ===
Meatal stenosis does not cause urinary tract infections, hydronephrosis, or any form of obstruction of the lower urinary tract. For this reason, no further urological investigation is warranted. If the diagnosis is in question, observing the child void, with particular attention to the force of the stream (increased), caliber of the stream (decreased), and duration of the voiding episode (usually prolonged), is helpful. If an elimination disorder is suspected, noninvasive urodynamics such as uroflow with electromyography (pad electrodes) and measurement of bladder capacity and postvoid residuals could be indicated. If associated infection is a possibility, urinalysis with culture should be obtained.
Meatotomy is the definitive treatment for meatal stenosis. Meatotomy is a simple procedure in which the ventrum of the meatus is crushed (for hemostasis) for 60 seconds with a straight mosquito hemostat and then divided with fine-tipped scissors.
Brown et al reported excellent results following 130 office meatotomies with only 2 recurrences of meatal stenosis and 1 patient with bleeding requiring stitches. 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, as their presence seemed to have a calming effect.<ref>{{REFjournal | last=Brown MR, Cartwright PC, Snow BW. | first= | coauthors= | title=Common office problems in pediatric urology and gynecology. | journal=Pediatr Clin North Am. Oct 1997; | volume=44( | issue=5): | pages=1091-115.1115 | url= | quote= | pubmedID= | pubmedCID= | DOI= | date=Oct 1997 | accessdate=}}</ref>
* If the caregivers and the patient are cooperative, this procedure can be performed in the office of the physician using a topical eutectic mixture of local anesthetics (EMLA cream) applied liberally over the entire glans and secured in place for at least one hour with an occlusive dressing.
* Divide the crushed area with a straight fine-tipped scissor and apply an antibiotic ointment.
* After the operation, it is critical that the caregivers separate the edges of the meatus and apply antibiotic ointment or petroleum jelly 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 ophthalmic ointment tube for a period of 4-8 weeks.
* In a survey of office pediatric urologic procedures, which included meatotomy, lysis of labial adhesions, and newborn circumcision, Smith and Smith (2000) 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 1 patient had recurrent meatal stenosis).<ref>{{REFjournal | last=Smith C, Smith DP. | first= | coauthors= | title=Office pediatric urologic procedures from a parental perspective. | journal=Urology. Feb 2000; | volume=55( | issue=2): | pages=272-6.276 | url= | quote= | pubmedID= | pubmedCID= | DOI= | date=Feb 2000 | accessdate=}}</ref>
* 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.