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Keywords:

  • urethral meatal stenosis;
  • dilatation;
  • complications;
  • penile surgery

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

OBJECTIVES

To evaluate the efficacy of dilatation of the stenotic urethral meatus in boys at home.

PATIENTS AND METHODS

Eighteen boys aged 3–15 years, or their parents, were taught to dilate the urethral meatus at home. The cause of the stricture was balanitis xerotica obliterans (BXO) in five and consequent upon hypospadias surgery in 12, of whom two were complicated by BXO, and one after circumcision for cultural reasons. One boy was re-referred after an interval of 3 years because of apparent deterioration of the stream of urine. Meatal dilatation was taught in the home by one of the authors (J.M.S.)

RESULTS

Nine patients were cured by the first course of dilatation, four relapsed early after initial success but responded to further treatment, and three proceeded to meatoplasty because they had no response. Two relapsed late and one responded to further dilatation but the other required surgery.

CONCLUSION

Dilatation of the urethral meatus can be taught successfully to boys or their families at home, thus avoiding repeated hospital attendance and often general anaesthesia.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Urethral meatal stenosis is a relatively uncommon complication of balanitis xerotica obliterans (BXO) and hypospadias surgery in boys. Successful dilatation under anaesthesia has been described as a conservative approach [1] in children. Clean intermittent self-catheterization has been described in adults [2–4] for meatal and urethral strictures, even using balloon dilatation [5]. This report describes our experience of meatal dilatation in boys at home. The detrimental effects of hospitalization on children and their families are numerous. It is therefore advantageous to perform procedures whenever possible in the home environment and avoid repeated admissions. The establishment of paediatric urology outreach nurses has enabled more procedures to be administered at home; this not only benefits the patient but also provides significant financial savings for the health service and improves the efficiency of care [6].

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

This study describes the experience of treating 18 children with urethral meatal stenosis referred to the outreach nursing service of our hospital over a period of 7 years. The stricture followed circumcision in five patients for BXO and for cultural reasons in one. In the remaining 12 it was a complication of hypospadias surgery but in two of these evidence for BXO was also present causing or contributing to stricture formation. The age of the children at the start of treatment was 3–15 years (Fig. 1) and the follow-up 2–9 years. Two boys re-presented with a deteriorating urinary stream 3 years after an apparently successful outcome for dilatation of a stricture after hypospadias repair.

image

Figure 1. The age distribution of the children at referral for dilatation.

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All children had previously undergone examination and dilatation under anaesthesia from once to six times. The families were contacted as soon as possible after discharge. The procedure was discussed in the home setting with parents and child, and the younger ones encouraged to ‘play act’ dilatation on one of their toys. In most cases the procedure was carried out by the child himself. The technique was instituted by initially using a cut-down length of a 4 F feeding tube to obtain confidence (Fig. 2). Thereafter, a PVC Nelaton catheter was used, progressing from 6 F to 8 F in 3-year-old boys and 10 F in those older. The catheters used were either PVC lubricated with lubricating gel (eight) or local anaesthetic gel (eight), or hydrophilic catheters (two). All children used lubrication, but seven of the earlier cases using lignocaine gel abandoned this because of stinging in the urethra, the others using lubricating gel. Progress through the sizes depended on response and dilatation was performed once or twice a day, depending partly on clinical decisions and partly on the child's response to the procedure. One particularly anxious child took a month to progress through each size. Dignity and privacy, particularly for the older children, was always respected, and they were encouraged to make their own choices about technique where possible.

image

Figure 2. The portion of the 4 F feeding tube used to initiate treatment.

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RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

In nine patients the difficulty in micturition was resolved with no recurrence after self-dilatation for 4–8 weeks. In a further six cases the poor voiding stream recurred, two after 4 months, two after 8 months and two after 3 years. These children resumed self-dilatation, with a cure being achieved in all but one with late relapse whose primary diagnosis was hypospadias.

In two children the procedure failed to dilate the stricture and they underwent meatoplasty, one originally having BXO and the other hypospadias. Age seemed to bear no relation to the outcome. Only one child was unable to tolerate the procedure; he had undergone a Barcat hypospadias repair and was later found to have an anterior urethral valve that inflated on voiding, preventing a normal stream of urine. After resecting the valve he underwent dilatation under anaesthesia with resolution of the stricture. Serious reluctance was encountered in one 3-year-old but the mother persisted for a month, at which time there was an apparently normal urine stream.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

This series shows that effective dilatation of the urethral meatus with no general anaesthesia is possible in children in a home environment. The programme can only be successfully established at home by an outreach urology nursing service, reflecting adult practice [6]. We consider that the results represent a successful technique in a significant proportion of the children, even if a repeated course was necessary. This group represents all the children whose families agreed to participate in the programme, but other families felt the boy would not co-operate so were not offered this type of management. Without a control group it is not possible to be certain of the level of success compared with possible spontaneous improvement, and in one adult series there was no benefit over a control group [7]. Such a study would not be possible in children, in view of the few cases. Other authors have claimed that the use of local anaesthetic gel is helpful [8] but we found that the stinging in the urethra from lignocaine precluded its further use. We found the lack of specifically designed dilators for children to be a significant drawback and there is a need for a purpose-designed set of paediatric meatal dilators.

It is important to recognize that families may not report the difficulties that they have with this technique to the medial staff. However, parents were much more able to discuss problems with the nursing sister, an issue we have described in connection with catheterization of a Mitrofanoff stoma [9], allowing the resolution of temporary problems that otherwise would have led to failure. Families should be warned that the stricture may recur later but yet may be suitable for dilatation at home.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES