THE CIRCUMCISION REFERENCE LIBRARY
Department of Paediatric Urology, Addenbrooke's Hospital, Cambridge, UK.
OBJECTIVE: To describe the clinical presentation and pathophysiology of meatal stenosis occurring after circumcision.
PATIENTS AND METHODS: The clinical presentation and operative findings are reported in 12 children who presented with meatal stenosis over a period of 3 years.
The cardinal symptoms of meatal stenosis were penile pain at the initiation of micturition (12 of 12), narrow, high velocity stream (8 of 12) and the need to sit or stand back from the toilet bowl to urinate (6 of 12). Following surgical correction with meatotomy there was no recurrence of stenosis after a mean follow-up of 13 months. Traumatic meatitis of the unprotected post-circumcision urethral meatus and/or meatal ischaemia following damage to the frenular artery at circumcision are suggested as possible causes of meatal stenosis.
Preservation of the frenular artery at circumcision, or the use of an alternative procedure (preputial plasty), may be advisable when foreskin surgery is required, to avoid meatal stenosis after circumcision.
Meatal stenosis is reported by some 1 to be the commonest complication of circumcision, although its incidence is unclear. Some major series analysing the results of circumcision 2,3 have even failed to recognize meatal stenosis as a possible complication. The clinical presentation of 12 patients with meatal stenosis following circumcision is discussed, together with the pathophysiology of this condition.
Over a period of 3 years (1991-1993), 12 children whose ages at circumcision ranged from 2 to 10 years (mean 4.5) presented subsequently with meatal stenosis. All had undergone circumcisions and none had had preputial plasty. The original indications for circumcision were recurrent balanitis (five patients), tight and scarred foreskin (five) and cultural reasons (two). In no patient was balanitis xerotica obliterans the indication for surgery.
Acute penile or glanular pain at initiation of micturition was found in all 12 patients. A narrow high velocity urinary stream was noted by the parents is eight cases and was associated with urine spillage around the bowl in six, forcing the child to sit or stand back from the toilet bowl to avoid spillage (six or eight patients). One child had recurrent minimal urethal bleeding. The interval to onset of symptoms after circumcision varied from 4 months to 8 years (mean 25.3 months).
Clinical examination in all 12 children showed a normal glanular mucosa (with no macroscopic evidence of balanitis xerotica obliterans) and a pinhole meatus, the lower margins of which were bridged by a thin filmy membrane (Fig. 1) No sign of meatal infection was noted. No paraclinical investigations were performed (in particular no urethogram and no ultrasound scan of the urinary tract).
All patients were treated by meatotomy with complete resolution of all symptoms. No recurrence of meatal stenosis has been found after a mean follow-up of 13 months (range 5-33).
Meatal stenosis as a complication is often missed by the clinician because children do not usually have late follow-up after circumcision. The symptoms of pain are often mistaken for symptoms of a lower urinary tract infection and symptoms of distal urethral impairment of urinary flow are usually ignored for many months until parents witness the child's voiding habit.
No meatal stenosis was reported by Thomas et al.3 in a series of 100157 circumcisions performed before 1 month of age, although these children were not followed up on a long term basis. Therefore it is difficult to evaluate the incidence of this complication. 88 circumcisions (and 91 preputial plasties) were performed at this institution: seven of these patients (8%) presented with meatal stenosis. The other five children with meatal stenosis were circumcised before this period by other surgeons.
The pathophysiology of post-circumcision meatal stenosis is debatable. Two possible causes are discussed: meatitis and meatal ischaemia.
Fig. 1 Meatal stenosis after circumcision. The
moiety of the meatal slit is bridged by a filmy membrane.
Non-specific inflammation of the meatus is the commonest explanation reported in the literature 1. Careful examination of all normal male children shows that there is always a physiological eversion of the distal urethral mucosa through the urethral meatus (`lips' of the meatus), and this mucosal eversion varies in magnitude between children (Fig. 2). Excision of the foreskin exposes this everted mucosa to the constant forces of friction and trauma from the children's underwear. This could support the suggestion that meatitis is the underlying aetiology of this complication.
Fig. 2. Physiological eversion of the meatal
and anatomical disposition of the frenular artery.
Fig. 3 Translumination of the frenulum (`mesoartery')
carries the frenular artery from the penile shaft to the
penile core. The frenulum is often damaged at circumcision.
Another explanation of post-circumcision meatal stenosis could be ischaemia of the meatal mucosa, as several techniques of circumcision involve damage to the frenular artery. The area of vascularization supplied by the frenular artery has not been clearly described to date. However, the frenular artery is possibly the vascular supply to the urethral meatus and perhaps to a larger area of the distal male urethra. The frenular artery is always absent in hypospadiac patients even when the foreskin is complete, possibly indicating its important role in the development of the distal male urethra. The frenulum could be considered the `mesoartery' which links the vascularization of the penile shaft to that of the penile core (Fig.,3)
Balanitis xerotica obliterans 4 is unlikely to have been an aetiological agent in the series of patients under consideration as none of them had the macroscopic changes of balanitis xerotica obliterans at the time of circumcision. In addition, no recurrence of meatal stenosis following meatotomy has been found, although this might have been expected if any of the patients had had balanitis xerotica obliterans.
Although none of these pathophysiological hypotheses has been verified, it may be advisable either to preserve the frenular artery at circumcision or to choose an alternative procedure (such as preputial plasty) 5 when foreskin surgery is required.
Correspondance: Mr. P.D.E. Mouriquand, 1 Marfleet Close, Great Shelford, Cambridge CB2 5LA, UK.
Accepted for publication 21 July 1994
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