Stenosis of the External Urethral Meatus

Note:

Meredith F. Campbell, M.D., is the author of the famed Campbell's Urology, a standard textbook that has been published for decades in many periodically updated editions.

In this paper, Dr. Campbell clearly identifies the lack of a foreskin (caused by circumcision) as a etiological factor in the development of meatal stenosis. Most cases of meatal stenosis, therefore, are iatrogenic complications of circumcision.

This text was originally published with three illustrations, which were X-ray images. They are not suitable for reproduction here.

The reader is cautioned that this text was published in 1943 and may not contain current medical practice or recommendations.

Stenosis of the external urethral meatus is the neglected stepchild among serious urinary tract obstructions. A study of the world's medical literature of the past 25 years discloses an average of one contribution a year on the subject, predominantly in German, and nearly always concerned with a single case report.² Its consideration in urologic and pediatric literature has been scant. Most patients in whom the lesion is recognized are children., in practically all of whom may be considered congenital and it may also be congenital in adults. In older patients its recognition is most likely to coincide with attempted urethral instrumentation or the acquisition of gonorrhea. While the symptomatic discomfiture due to urinary difficulty immediately concerns the patient or his parents, urinary backpressure damage of the proximal urinary tract, and particularly the kidney, is the important vital consideration. Urographic study in a relatively small series of these cases may be expected to reveal examples of advanced upper tract obstruction uropathy and wholly disproportionate to the commonly accepted benignity of the meatal lesion. Despite the usual utter simplicity of diagnosis of meatal stenosis by inspection and its treatment by meatotomy, thousands are today suffering serious progressive urinary tract obstruction because of the failure of their medical advisors to recognize this condition. This report is based on a clinical study of 152 personal cases in which I have satisfactory office or hospital records. Adults have not been included nor have a large number of children whose records have been inadequate. The age of the patients in this series range from 7 weeks to 16 years; a fourth were under 24 months of age; half were between 24 months and 10 years. Twenty-six were females. The common complication of stenosis of the external meatus—the ulcerated meatus—is also considered. Unfortunately for our records, urographic studies were made in only a limited number (63, cytoscopy 87) of these patients, yet sufficient to demonstrate beyond question the potential gravity of the tight urethral meatus.

ETIOLOGY

Etiologically stricture of the external meatus may be classified as: 1) congenital (98 percent); 2) acquired (2 per cent) a) traumatic (indwelling catheter, instrumentation, etc.); b) Infection (gonorrhea, non-gonorrheal infection, vaginitis, etc.).

Congenital. This variety is analogous to, and frequently accompanies, congential stricture in the urethra proper (3 cases), at the bladder neck (1 case), in the ureteral (2 cases), intestinal and biliary tracts. An abnormal tight local embryonal closure of the urethral gutter occurs and in the absence of infection there is little or no sclerosis. Whether of embryonal correlation, when a long prepuce exists, a tight phimosis commonly accompanies a normally situated stenosed meatus. Parenthetically, at circumcision, if there is any question as to the adequacy of the meatal caliber, I routinely perform liberal meatotomy. In my experience, urethral stenosis commonly occurs in hypospadias (12 cases in this series) and is the urgent consideration; it also occurred in one case of epispadias and in 3 cases of congenital torsion of the penis.

Acquired. Urethral stenosis presenting a picture of sclerotic stricture may result from trauma or infection or the combination of these processes. This lesion is observed chiefly in adults, and particularly since the advent of transurethral prostatic resection and the more widespread employment of the indwelling catheter. Here localized meatal ulceration, due to the trauma, foreign body reaction and the constant moisture of the discharge whih the catheter engenders, heals by sclerosis and produces stricture. Doubtless, the incidence of meatal stenosis caused by instrumental trauma (sounds, cystoscopes, etc.) is relatively small. In the male, urethritis may conceivably be an etiologic factor in some instances but as a rule the tight meatus passes unrecognized until the acquisition of gonorrhea or some instrumentation directs attention to the condition. In three of our cases there had been "recurrent non-specific urethritis" and we believe to be due to the tight meatus. In 3 boys, acute gonorrhea caused the pin-point orifice to be discovered; the youngest was 3 1/2 years old. In the female a persistent or severe vaginitis may explain instances of meatal stenosis and here the urethral lesion is definitely a sclerotic one. Yet we have observed the condition congenitally in several young girls in some of whom the excessive backpressure injury cystographically and cytoscopically presented the picture of bladder damage so commonly seen in advanced prostatic obstruction.

PATHOLOGY

Pathologically, the backpressure changes are usually greatest in the bladder, and, secondly, in the upper urinary tract; the complicating infection which may always be anticipated—for example, so-called "chronic pyelitis" in the young accelerates the destructive process. Urinary infection was recorded in a fourth of our patients, in 16 of whom the urologic examination was performed because of "chronic pyelitis."

In some instances the dilatation is localized to the lower tract and particularly the urethra as was observed in a seven year old boy³ admitted to the hospital because of hematuria. The bleeding was found to originate in a congenitally stenosed ulcerated meatus. The entire urethra and particularly the prostatic segment were markedly dilated; the bladder wall showed only slight damage and the uterovesical valve mechanism was still intact. Yet the extreme bulbous dilatation of the prostatic urethra was most unusual. In a newborn colored child an extermely large an apparently swollen prepuce was noted. A week later the obstetrical intern performed circumcision but at once found himself in a large ventral cavity connected with the urethral lumen. The operation was continued with removal of considerable tissue but not nearly all the urethral diverticulum which he failed to recognize. I saw the child the next day for the first time and found an exceeedingly small urethral meatus behind which the diverticulum had formed as a blowout process. Liberal meatotomy was performed and the channel distal to the diverticulum sac (measured 2 by 2 cm.) was kept widely dilated with sounds; 6 months later, drainage of the bladder by catheter inserted through a perineal bouttoniere was followed by excision of the sac and closure of the urethra with a most satisfactory result. Yet the child is seen periodically for prophylactic urethral dilatation. A large urethral diverticulum at the base of the penis in a 4-months-old child with persistent pyuria likewise formed asa blow-out behind a pin-point meatus (fig. 1).

In a 7-year-old boy examined because of dysuria a tight external urethral meatus was found; cystoscopy and cystography revealed widespreiad vesical sacculation with moderate dilatation.⁴ No vesico-ureteral reflex was noted. Wide meatomy and periodic progressive meatal dilatation to no. 22 F. was the treatment and was faithfully attended by the patient. Two years later irregularity of the vesical outline still existed but to far less degree than originally noted. Two girls aged 13 and 30 months respectively were examined because of so-called chronic pyelitis. Each was found to have a tight congenital stenosis of the external urethral meatus with advanced trabeculation and sacculation of the bladder wall. The cystoscopy and cystography pictures were those commonly observed in advanced prostatic obstruction. Yet simple periodic dilatation with sounds, together with administration of urinary antiseptics were curative.

Ureterectasis and hydronnephrosis develop according to the severity and duration of the obstruction. Extreme dilatation of the entire urinary tract above a stenosed urethral meatus was observed in a newborn at autopsy at Bellevue Hospital, was seen clinically at 13 days, and a few similar instances are reported in medical literature. Mild upper tract dilatation was cystographically demonstrated in a three-year-old girl with a stenosed urethral meatus. In an 18-months-old boy with a tight balanitic meatus, the entire upper tract was excessively dilated (fig. 2); the residual was 500 cc. A No. 5 F. catheter was employed indwelling for 1 week; the meatus was incised and a No. 10 F. catheter was worn for another week. Thereafter the urethra was kept dilated (meatus No. 20 F.) and the urinary infection (Steptococcus hemolyticus, Staphylococcus aureus and colon bacillus) was eradicated with sulfadiazine. Six months later the anatomic restitution was only slight. Yet the boy now empties his bladder and improvement in renal function attests successful therapy. A 6-months-old boy presented the same picture with wide dilatation of the bladder and bilateral vesicouteral reflux (fig. 3). Here, also striking functional inprovement followed wide meatotomy and periodic progressive dilatation wit sounds; considerable anatomic restoration was also observed. Vesical diverticulum was observe in the children of this series woh were cytoscropically studied, yet in 2 cases each there were vesical calculi and reduplicated ureters. In our failure to perform complete cysoscopic and urographic investigationn in all these cases, it is probable that coexisting and/or complicating urologic lesions were overlooked. Inflammatory and congestive lesions in the deep urethra were overlooked. Inflammatory and congestive lesions in the deep urethra, prostate, anterior trigone and especially the verumontanum are common with meatal stenosis. In 5 cases the enormously enlarged and engorged verumontanum extended well back into the vesical outlet.

SYMPTOMS

Dyuria, frequency of urination and hematuria are the chief symptoms; 49 of these patients were examined beacuse of so-called persistent enuresis and 16 because of "chronic pyelitis." Not only is there hesitancy in starting the stream, but the stream itself is unusually small and the pressure generated to force the urine through the tight meatus will sometimes throw this fine stream 6 to 8 feet. This is often accompanied by crying, screaming, strangury and a face red or purple from straining. As urine retained in the urethra leaks out slowly after urination there is terrminal dribbling and wetting of the clothes. Chronic or recurrent vesical retention may be accompanied by leakage or overflow incontinence and in nine of our patients the obstruction produced abdominal pain. In short, the symptoms are those common to all lower urinary tract obstructions including the systematic manifestations of complicating infection and diminished renal function. With ulceration of the meatus, and with or without scab formation or incrustation, urination is apt to be especially painful and reflexly or consciously cause teh patient to refrain from voiding. Yet as Brenneman has indicated, the application of cocaine to the tender meatus will temporarily permit painless urination. With meatal ulceration or the cracking of the scab covering the ulcer, the appearance of blood in the urine or on the child's clothing is most alarming to the parent who usually seeks medicalattention for the child at once.

DIAGNOSIS

This is by inspection and utterly simple; should diagnostic confirmation be needed, employ exploration of the stenosed meatus by surgical probe or small steel sound. When ulceration or incrustation of the meatus exist, there very presence should at once suggest the diagnosis.

TREATMENT

In males, my preference is liberal meatotomy with a fine scissors or small scalpel at the outset and subsequent progressive dilatation of the stenosed meatus with steel sounds. In children under one year of age it is our practice to keep the meatus dilated to at least No. 16 F. and in children from 2 to 5 years of age the dilatation is maintained up to No. 22 F. In females, instrumental dilatation is preferable to meatotomy In this series meatotomy alone was performed in 4 cases (3 acute gonorrhea), dilatation only was employed in 31 (including 26 females), and in the remaining 117 combined meatotomy and dilatation was the treatment.

At the time of the initial instrumentation, a small sound or bougie should be passed to the bladder to determine there are no other congenital urethral obstructions. When possible, determination of the residual urine is of added value and is usually carried out at the time of initial visit and meatotomy. In males we perform meatotomy and instrumentation without anesthesia and usually in the office. Muco-cutaneous suture of the meatus is not required. Yet it is important that the mother or nurse be instructed to separate widely with her fingers the incised meatal margins. Despite this, there is usually fairly rapid closure of the opening and 5 to 7 days after meatotomy we again dilate the meatus, at which time the healing wound will be reopened. Occasionally it is necessary to do a second meatotomy. The meatal dilatation is repeated 4 or 5 times at lengthening intervals, and I prefer to see the patient again in 4 to 6 months after he has been thought cured to ascertain the meatus is still adequately open.

Co-existing infection is treated by the administration of urinary antiseptics and failure to achieve prompt sterilization of the urine, as indicated by 2 sterile cultures, calls for a complete urologic investigation; other congenital obstructionss and/or lesions not recognized at the time of the initial examination may be present.

COMPLICATIONS

The various complications of stenosis of the exteral meatus have been considered in previous paragraphs. Of these, ulceration of the meatus merits special consideration since apparently it is mysterious and perplexing to most physicians. The ulceration appears about the periphery of the stenosed meatus and usually extends 2 or 3 mm. within this opening. Although I have seen it in the uncircumcised (3 cases in this series), it is more common in boys who have been circumcised or whose short prepuce leaves the meatus well exposed. With drying of the ulcer, a scab or incrustation forms which further diminishes the meatal caliber or may completely seal it over between voidings. With cracking of the ulcer or scab, or pulling off of the incrustation by clothing, active bleeding occurs; the blood may be in the urine or appear only on the diaper or underclothing. In the past this condition has been attributed to ammoniacal diaper, dietary indiscretion, too much cream and a host of other extraneous causes. Moreover, pediatrists who have been particularly interested in this problem, and notably Brenneman⁵ and Cook,⁶ believe that the tight meatus is the result of the ulceration and not, as we believe, the basic cause of the erosion. In short, the stricture preexists—usually congenitally; ulceration follows, and the cycle of healing and further ulceration with progressive narrowing of the orifice ensues. The application of an array of salves and ointments, powders, the sterilization of the ammoniacal diapers, and other therapies have been widely advocated, chiefly by pediatrists, but I have yet to see a case not promptly and permanently cured by the establishmentand maintenance of a wide urethral meatus.

SUMMARY

Urologic study of patients, and especially the young, with stenosis of the external meatus forcibly demonstrates the potential gravity of the obstructive lesion. In mild cases dysuria may be the only symptom; secondary ulceration of the meatus is likely to alarm the patient. Yet when eradication of the obstruction is neglected, backpressure damage to the upper urinary tract is almost certain to ensue and even death from renal failure may ultimately occur.

The diagnosis is readily made by inspection and meatotomy is the treatment. Following meatotomy it is mandatory that the orifice be kept widely patent by periodic progressive dilatation with sounds until such time as the caliberof the meatus remains generously large.

References

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