Anomalies of the external urethral meatus in girls with non-neurogenic bladder sphincter dysfunction



The authors of this paper [1] are to be commended for their concern about difficult urination in infant girls, attesting to their concept that these difficulties are not primarily of neurogenic origin. However, my appreciation of what they seem to have accomplished is sorely tested when I recognize that they have not been conscientious in their reading of the literature. They state that Emil Tanagho and I were among the first to draw attention to the distal urethra as the agent of difficult urination [2]. They then continue by stating that we initiated urethral dilatation and internal urethrotomy as therapy. Let me correct this error, in itself suggesting that the listing of our work as a reference does not indicate that it has been read by the authors. Our recommendation was that dilatation be taken to the point that the distal urethral membrane ruptures, rendering it asymptomatic. In a thorough report on distal urethral stenosis [3], internal urethrotomy as described by Leadbetter is discussed but not recommended. Indeed, we were critical of the procedure, based on our experience with animal models [4]. In our practice, each child received a careful entroital examination. On occasion, the hymenal membrane rode a little high, but in our view it only provided a hindrance to flow if the flow had already been compromised by the time it exited the urethra. Thus, our attention remained directed at the irritative effects of the symptomatic membranous ring.


I thank Dr Lyon for the comment on this paper. However, there still seems to be some misunderstanding. We wanted to credit Drs Tanagho and Lyon for their concept of urethral dilation and the criticism they developed to the concept of distal urethral stenosis. Currently in my country, too many urethrotomies for distal urethral stenosis are performed each year, suggesting that the only message that persisted was that distal urethral stenosis could be treated by urethrotomy. The later message that it might not be useful to undertake this procedure did not reach the urological community. Many girls worldwide undergo this useless procedure. Our comment was not meant to criticise Tanagho and Lyon, but rather to criticise all urologists who continue to use Otis urethrotomy in girls; it is they who are not conscientious in research. I apologise for having not expressed myself clearly about the work of Tanagho and Lyon, which I fully appreciate.

P. Hoebeke

Department of Paediatric Urology, University Hospital, De Pintelaan 185, Gent, Belgium