DISCUSSION
The urethral opening (meatus) measured one-eighth its normal size and was almost entirely closed, supporting a diagnosis of meatal stenosis. The condition is an abnormal narrowing of the urethral opening. Significant narrowing may produce difficulty with urine flow, resulting in incomplete bladder emptying. If left untreated, meatal stenosis can lead to urinary tract infections (UTIs) and kidney problems. Meatal stenosis is often characterized by a forceful, fine stream with dysuria, frequency, urgency, and prolonged urination, as initial flow is painful. Urinary stream may have an upward deflection, causing an inability to aim properly into the toilet. This patient's history of altered stream, poor aim, and refusal to urinate because of anticipated pain support the diagnosis.1 Stenosis severity can be determined by attempting to insert a small tube into the urethral opening; however, the depth of the stenosis may be unknown until surgery is performed. Additional tests include ultrasonography of the bladder and kidneys, urinalysis for suspected infection, and/or a voiding cystourethrogram if the child has a history of UTIs.1
Meatal stenosis can occur at any age, but most symptoms manifest between the ages of 3 and 8 years, often without a history of frequent UTIs. The condition is more common in circumcised males and has an unknown etiology. Proposed theories include irritation or inflammation of the opening leading to the formation of irreversible scar tissue that continues to grow, thereby narrowing the urethra; or ischemic damage from frenular artery injury during circumcision, which results in poor blood supply to the meatus and subsequent stenosis.
Meatal stenosis is most often a result of events that occur after circumcision, such as improper toilet training. Exposure of the meatus to wet diapers disrupts the cellular lining of the distal urethra, and the loss of cell structure on the ventral side of the penis may leave a pinpoint opening at the tip of the glans. Less common causes include unsuccessful hypospadias repair, trauma, prolonged catheterization, and balanitis xerotica obliterans (a condition that causes discoloration and dryness of the glans of the penis). Meatal stenosis in adults is associated with sexually transmitted disease.1,2
Treatment This patient underwent a surgical meatotomy, an incision to enlarge the meatus, under general anesthesia. Penile pain was managed with oral analgesics and warm baths. His mother applied a triple antibiotic ointment alternating with petroleum jelly to the sutured area every 2 hours. Fluids were pushed, with avoidance of citrus juices and soda pop to reduce potential stinging. The patient experienced no bleeding, and recovery time was 1 to 2 days. JAAPA
Jodi Welt is a recent graduate of the PA program at Seton Hall University, South Orange, New Jersey. Ellen Mandel is an associate professor in the program and was faculty advisor to Ms Welt. They have indicated no relationships to disclose relating to the content of this article.
Erich Fogg, PA-C, MMSc, department editor
REFERENCES
1. Walsh PC, Retik AB, Vaughan ED Jr, et al, eds. Campbell's Urology. 8th ed. Philadelphia, PA: Saunders; 2002.
2. Elder JS. Anomalies of the penis and urethra. In: Kliegman RM, Berman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, PA: Saunders; 2007:chap 544.