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Urethral Meatal Stenosis in Males

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Urethral Meatal Stenosis in Males AMERICAN ACADEMY OF PEDIATRICS Urology Section Urethral Meatal Stenosis in Males The Section on Urology of the American dence is 3%2 These latter findings were not Academy of Pediatrics has charged this commit- confirmed by direct calibration. tee with the task of evaluating the status of the It was established by Litvak et al.,5 in their question of meatal stenosis in boys (excluding study of 200 boys coupled with Morton’s study6 of those with hypospadias). The objective informa- 1,000 circumcised boys, that the size of the tion on the subject is limited; however, our meatus corresponds generally with age. Three conclusions, based on review of available litera- distinct groups can be delineated. In boys 6 weeks ture and the committee’s deliberations, are as to 3 years of age, 85% had meatuses which were follows. calibrated to be more than 1OF, while 15% were less than 8F. Between 4 to 10 years, 73% Etiology measured 12F while only 7% were tight to 8F. Meatitis, an inflammation generally secondary Between the ages 11 and 12 years, 4% had a ti,ht to ammoniacal diaper irritation, has been cited as meatus at 1OF, while 75% were calibrated at 12F the underlying cause of secondary meatal steno- and the remainder were larger. sis.1 The lack of protection by the foreskin in the circumcised male is thought to correlate with an Suggested Significance increased incidence of meatitis. Meatal narrowing Meatal stenosis is difficult enough to define, has been noted to occur more commonly in the but an assessment of its significance is an even circumcised 1,2 The formation of a ventral greater challenge. There is a marked divergence lip of tissue is characteristic of secondary meatal of opinion in the literature concerning the effect narrowing and may cause deflection of the of the caliber of the urethral meatus on the urinary stream upward. Campbell, however, proximal urinary tract. suggested that congenital meatal stenosis is the Campbell believed that meatal stenosis was of underlying cause of meatitis,3 whereas Allen and “grave import” and that the early correction of Summers believe meatitis can be either the cause this condition would prevent thousands of or the effect of meatal stenosis.’ Other factors episodes of acute urinary infection in childhood.3 which have been stated to influence the develop- However, objective support for this statement is ment of secondary meatal stenosis include abra- currently lacking. Additionally it would appear sions and diet.2 that concrete evidence for significant risk to the upper urinary tract is also unavailable, although Incidence and Measurement Arnold noted an incidence of hydronephrosis in Calibration of the urethral meatus by Allen et 19% and Noe and Dale in 2%.8 Other secondary al.4 demQnstrated that 9% of newborn boys have a abnormalities include urethral stricture in 12% meatus tight to 4F which the authors consider to and “hypertrophy of the verumontanum” in be congenital meatal stenosis. In a later article the 21%. Finally Mowad and Michaels reported a same authors reported the results of visual inspec- causal relationship between meatal stenosis and tion in a group of 1,800 boys, ages 6 to 10 years. vesicoureteral reflux with resolution of reflux by Thirty-two percent were considered to have a simple meatotomy.9 “pinpoint meatus.” By subtracting the 9% inci- There are a number of reports in which enure- dence of congenital meatal stenosis previously sis is associated with meatal stenosis. Winsbury- reported, they concluded that the acquired inci- White found a 27% incidence of meatal stenosis in 778 PEDIATRICS Vol.Downloaded 61 No. from5 www.aappublications.org/news May 1978 by guest on September 27, 2021 enuretic boys,’#{176}Arnold and Ginsburg found a 75% The question of voiding symptoms manifested incidence in boys and girls,” while Mahony by urethral irritation, wetting, urinary urgency, reported meatal or juxtameatal strictures in 50%12 and frequency is subjective, and documenting a and subsequently believes that this incidence is causal relationship is tenuous at best. Although even greater (personal communication). In addi- many clinicians have seen marked resolution of tion, dysuria, urgency, frequency, and hematuria complaints of this type following meatotomy, the have all been suggested as symptoms secondary to same might be said for many of those left a narrow meatus. untreated. The question of vesicoureteral reflux being caused by meatal stenosis echoes the Diagnosis contention held ten years ago of its relationship to The differentiation between meatal narrowing bladder outlet obstruction. Sufficient data exist and urethral meatal stenosis is really the crux of regarding the spontaneous resolution of reflux to the problem. Stenosis implies disease while adequately explain these reports without invok- narrowing may be only an anatomic variant. As ing a cause-and-effect relationship. noted earlier, visual inspection does not correlate A concern voiced repeatedly by some urologists with actual calibration. regards the potential secondary effects of minimal In general, the articles dealing with calibration changes in urodynamics which may manifest of the urethral meatus do not include a statement themselves in later years as bladder neck contrac- indicating what meatal siz#{231}defines the presence tures or prostatitis. However, for the present, of stenosis. Allen et al. proposed that a size 4F actual evidence for such a relationship seems to meatus in a newborn child was stenotic and that be lacking. the size 6F was equivocal. From the evidence Recommendations derived from their extensive study, Litvak et al.5 advocated caution in labeling those boys with It is not the purpose of this report to come small meatuses for their age as having meatal down totally against meatotomy in any circum- stenosis. In an editorial comment appearing in the stance. That would be as foolhardy as stating that same article, Jeffs maintained that it was unreal- every child with visual narrowing of the urethral istic to claim that 15% of males 6 weeks to 3 years meatus requires meatotomy. This is a plea, of age with meatuses less than 8F require meato- however, for objectivity in making the diagnosis tomy. The author and the editor agreed that the of real stenosis. clinical status of the patient and not the Meatotomy as well as local therapy is justified appearance of the meatus was the deciding in those infants with a purulent meatitis. These factor. children may even be having obstructive symp- In an effort to realistically diagnose disease, toms, although actual urinary retention is some attempt at objectivity is necessary. Observa- unlikely. Additionally, in that group of boys who tion of voiding may be helpful, with spraying or have spraying or severe, uncontrollable deflection significant deflection of the urinary stream as of their urinary stream, correction is indicated. evidence of interference with voiding. Urody- Boys with documented infection with or namics with measurement of flow rate and even without apparent meatal narrowing require voiding velocity may be the only means of accu- complete evaluation with intravenous and void- rately identifying significant resistance (D.M. ing urography. If evidence of meatal narrowing is Gleason, personal communication, 1977). Finally, noted, correction in the course of evaluation is roentgenographic changes with actual dilatation indicated. of the urethra proximal to the meatus may be Subjective complaints, however, represent a indicative of secondary changes. more difficult problem. It would appear that narrowing of the urethral meatus as noted by Discussion inspection in itself does not justify meatotomy. Widely disparate opinions are held on the Voiding symptoms are difficult to interpret but subject of meatal stenosis, not only in terms of probably have no relationship to the caliber of the definition and diagnosis but on its clinical signifi- meatus. This also holds true for enuresis. cance as well. Most would agree at this time that When meatotomy is deemed necessary, it is the actual risk to the kidneys from obstruction difficult to justify the complexity and expense alone is minimal. Even the most stalwart expo- involved in carrying this out in the operating nents of the risks of obstruction agree that urinary room. Except in those rare instances of true infection is rarely associated with meatal narrow- stricture of the fossa navicularis, spreading of the ing.’2 meatus with a small hemostat after application of Downloaded from www.aappublications.org/newsAMERICAN by guest on September ACADEMY 27, 2021 OF PEDIATRICS 779 a local anesthetic is adequate to disrupt the thin REFERENCES ventral web present. Certainly this is no more 1. Berry CD, Cross R: Urethral meatal caliber. Am I Dis traumatic than a general anesthetic and much less Child 92:152, 1956. 2. Allen SJ, Summers JL: Mental stenosis in children. I Urol costly. 112:526, 1974. Finally, it becomes apparent that there is a 3. Campbell MF: Stenosis of the external urethral meatus. great deal of subjectivity involved in dealing with I Urol 56:740, 1943. the question at hand. We all agree that there is an 4. Allen SJ, Summers JL, Wilkerson JE: Meatal calibration art to medicine but let us not deny its science. of newborn boys. I Urol 107:498, 1972. 5. Litvak AS, Morris JA, McRoberts JW: Normal size of the There is a need for criteria regarding urody- urethral rneatus in male children. I Urol 115:736, namics which can be transmitted on a numerical 1976. level. Voiding flow and velocity studies may be 6. Morton HG: Meatus size in 1,000 circumcised children the key. Measurement of intravesical pressure from 2 weeks to 16 years of age. I Fla Med Assoc may also be necessary, at least initially, to settle 50:137, 1963. 7. Arnold SJ: Stenotic meatus in children: An analysis of the basic question of urethral meatal stenosis as a 160 cases.
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