Difference between revisions of "Meatal stenosis"
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| − | '''Meatal stenosis''' is a narrowing of the ''meatus'' (the opening of the urethra). Meatal stenosis is extremely rare in intact boys with a protective [[foreskin]]. About twenty percent of circumcised boys develop meatal stenosis. Meatal stenosis may be prevented by avoiding child [[circumcision]], which is a medically-unnecessary, non-therapeutic surgical [[amputation]] procedure. | + | '''Meatal stenosis''' is a narrowing of the ''meatus'' (the opening of the [[urethra]]). Meatal stenosis is extremely rare in [[intact]] boys with a protective [[foreskin]]. About twenty percent of [[circumcised]] boys develop meatal stenosis. Meatal stenosis may be prevented by avoiding child [[circumcision]], which is a medically-unnecessary, non-therapeutic surgical [[amputation]] procedure. |
== Background == | == Background == | ||
| Line 22: | Line 22: | ||
|date=2011-10 | |date=2011-10 | ||
|accessdate=2020-02-01 | |accessdate=2020-02-01 | ||
| − | }}</ref> Meatal stenosis is a relatively common acquired condition occurring in 10%-20% of males who are [[Circumcision| 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. | + | }}</ref> Meatal stenosis is a relatively common acquired condition occurring in 10%-20% of males who are [[Circumcision| 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 == | == Pathophysiology == | ||
| − | After [[circumcision]] and the loss of | + | After [[circumcision]] and the loss of [[Foreskin#Protective_functions| foreskin protection]], 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 (nappie). 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 [[intact]] 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, [[Robert S. Van Howe|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 | + | 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, [[Robert S. Van Howe|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 name="vanhowe2006">{{REFjournal |
|last=Van Howe | |last=Van Howe | ||
|init=RS | |init=RS | ||
| Line 53: | Line 53: | ||
==== International ==== | ==== International ==== | ||
| − | Meatal stenosis affects | + | Meatal stenosis affects 10%-20% of males who are [[circumcised]] in infancy. |
=== Mortality/Morbidity === | === Mortality/Morbidity === | ||
| Line 59: | Line 59: | ||
Meatal stenosis carries no risk of mortality. | Meatal stenosis carries no risk of mortality. | ||
| − | Morbidity is limited to the clinical symptoms and complications of surgical repair, including bleeding, infection, and recurrence. | + | Morbidity is limited to the clinical symptoms and complications of surgical repair, including [[bleeding]], [[infection]], and recurrence. |
=== Race === | === Race === | ||
| − | Meatal stenosis has no racial predilection. The condition can occur in circumcised males independent of ethnicity. | + | Meatal stenosis has no racial predilection. The condition can occur in [[circumcised]] males independent of ethnicity. |
| − | === | + | === Gender === |
Meatal stenosis occurs only in males. | Meatal stenosis occurs only in males. | ||
| Line 71: | Line 71: | ||
=== Age === | === 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. | + | Children who are not toilet-trained are more prone to develop meatal stenosis after [[circumcision]] because of exposure of the meatus to ammonia from the [[urine]] in diapers. Most children who are toilet-trained can verbalize their difficulties during micturition to their caregivers. |
== Clinical presentation == | == Clinical presentation == | ||
| Line 79: | Line 79: | ||
Patient history may include the following: | Patient history may include the following: | ||
| − | * Difficult-to-aim (upward deflected), high-velocity (long distance) stream of urine | + | * Difficult-to-aim (upward deflected), high-velocity (long distance) stream of [[urine]] |
* Pain upon initiation of micturition | * Pain upon initiation of micturition | ||
* Need to stand back from toilet or sit during urination | * Need to stand back from toilet or sit during urination | ||
| Line 115: | Line 115: | ||
=== Causes === | === 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. | + | 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,<ref name="brenneman1921">{{REFjournal |
| + | |last=Brennemann | ||
| + | |init=J | ||
| + | |author-link= | ||
| + | |last2= | ||
| + | |init2= | ||
| + | |author2-link= | ||
| + | |url=http://www.cirp.org/library/complications/brennemann1/ | ||
| + | |title=The ulcerated meatus in the circumcised child | ||
| + | |journal=Am J Dis Child | ||
| + | |date=1921 | ||
| + | |volume=21 | ||
| + | |issue= | ||
| + | |pages=38-47 | ||
| + | |accessdate=2024-02-04 | ||
| + | }}</ref> 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: | Other causes of meatal stenosis include the following: | ||
| Line 124: | Line 139: | ||
* Balanitis xerotica obliterans | * 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. | ** 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 [http://www.childrenshospital.org/ 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 | + | ** A 10-year retrospective series at [http://www.childrenshospital.org/ 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 | |last=Gargollo | ||
|init=PC | |init=PC | ||
| Line 166: | Line 181: | ||
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. | 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. (1997) 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 | + | Brown et al. (1997) 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 | |last=Brown | ||
|init=MR | |init=MR | ||
| Line 187: | Line 202: | ||
}}</ref> | }}</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. | + | * 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. |
* After being in place for one hour, the dressing is removed and the penis is prepared and draped into a sterile field. | * After being in place for one hour, the dressing is removed and the penis is prepared and draped into a sterile field. | ||
* Throughout this procedure, reassure the child and tell him what is being done. | * Throughout this procedure, reassure the child and tell him what is being done. | ||
| Line 231: | Line 246: | ||
=== Complications === | === Complications === | ||
| − | Complications include bleeding during or after meatotomy, infection, and recurrence. All of these complications are quite rare and respond readily to appropriate management. | + | Complications include [[bleeding]] during or after meatotomy, infection, and recurrence. All of these complications are quite rare and respond readily to appropriate management. |
Mild dysuria may persist for 1-2 days. Placing the child in a tub of warm water may provide relief. | Mild dysuria may persist for 1-2 days. Placing the child in a tub of warm water may provide relief. | ||
| Line 240: | Line 255: | ||
[[File:Kid_Friendly_Approach_to_Meatal_Stenosis.pdf]] | [[File:Kid_Friendly_Approach_to_Meatal_Stenosis.pdf]] | ||
| − | + | {{SEEALSO}} | |
| + | * [[Meatus]] | ||
{{REF}} | {{REF}} | ||
Latest revision as of 23:49, 1 March 2024
Meatal stenosis is a narrowing of the meatus (the opening of the urethra). Meatal stenosis is extremely rare in intact boys with a protective foreskin. About twenty percent of circumcised boys develop meatal stenosis. Meatal stenosis may be prevented by avoiding child circumcision, which is a medically-unnecessary, non-therapeutic surgical amputation procedure.
Contents
Background
Genital disorders are commonly encountered in the office of the primary care physician.[1] Meatal stenosis is a relatively common acquired condition occurring in 10%-20% 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 and the loss of foreskin protection, 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 (nappie). 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 intact 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.[2]
Epidemiology
Frequency
International
Meatal stenosis affects 10%-20% of males who are circumcised in infancy.
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.
Gender
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 ammonia from the urine in diapers. Most children who are toilet-trained can verbalize their difficulties during micturition to their caregivers.
Clinical presentation
History
Patient history may include the following:
- 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.[3]
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,[4] 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.[5]
- 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.
Differential diagnoses
Circumcision
Workup
Laboratory 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.
Treatment and management
Surgical care
Serial dilatation results in small tears of the meatus, which are followed by secondary healing. In the long term, this creates a tighter stricture at the tip of the penis; therefore, this procedure is discouraged.
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. (1997) 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.[6]
- 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.
- After being in place for one hour, the dressing is removed and the penis is prepared and draped into a sterile field.
- Throughout this procedure, reassure the child and tell him what is being done.
- Introduce one blade of a straight mosquito hemostat into the meatus and crush the ventrum of the meatus (approximately 3 mm) by closing the hemostat. This provides adequate hemostasis in most cases.
- 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 & 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).[7]
- 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.
Consultations
If the primary care physician is unwilling to perform a meatotomy, encourage consultation with a pediatric urologist.
Activity
After meatotomy, instruct caregivers to dress the child in loose underwear for 24 hours.
Restrict activities, such as contact sports, bicycle rides, and playground activities, for 3-4 days.
Follow-up
Further outpatient care
Following meatotomy, caregivers should 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 2 more weeks.
Complications
Complications include bleeding during or after meatotomy, infection, and recurrence. All of these complications are quite rare and respond readily to appropriate management.
Mild dysuria may persist for 1-2 days. Placing the child in a tub of warm water may provide relief.
Prognosis
Prognosis is excellent. Meatotomy cures the symptoms of most patients.
File:Kid Friendly Approach to Meatal Stenosis.pdf
See also
References
- ↑
Joudi M, Fathi M, Hiradfar M. Incidence of asymptomatic meatal stenosis in children following neonatal circumcision. J Pediatr Urol. October 2011; 7(5): 526-528. PMID. DOI. Retrieved 1 February 2020.
- ↑ Van Howe RS. Incidence of meatal stenosis following neonatal circumcision in a primary care setting. Clin Pediatr (Phila). January 2006; 45(1): 49-54. PMID. PMC. Retrieved 9 January 2020.
- ↑ Litvak AS, Morris JA, McRoberts JW. Normal size of the urethral meatus in boys. J Urol. June 1976; 115(6): 736-737. PMID. DOI. Retrieved 1 February 2020.
- ↑ Brennemann J. The ulcerated meatus in the circumcised child. Am J Dis Child. 1921; 21: 38-47. Retrieved 4 February 2024.
- ↑ Gargollo PC, Kozakewich HP, Bauer SB, et al. Balanitis xerotica obliterans in boys. J Urol. October 2005; 174(4 Pt 1): 1409-1412. PMID. DOI. Retrieved 1 January 2020.
- ↑ Brown MR, Cartwright PC, Snow BW. Common office problems in pediatric urology and gynecology. Pediatr Clin North Am. October 1997; 44(5): 1091-1115. PMID. DOI. Retrieved 1 February 2020.
- ↑ Smith C, Smith DP. Office pediatric urologic procedures from a parental perspective. Urology. February 2000; 55(2): 272-276. PMID. DOI. Retrieved 1 February 2020.
