Uroflowmetry Before and After Meatotomy in Boys with Symptomatic Meatal Stenosis Following Neonatal Circumcision - A Long-term Prospective Study

Is there a correlation between meatal stenosis severity, lower urinary tract symptoms and uroflowmetry?

INTRODUCTION

We have recently validated a meatal Stenosis (MS) severity grading system that is based on physical examination.

OBJECTIVES

The study objective was to examine the correlation between this grading system, patients' urinary symptoms, uroflowmetry and postvoid residual parameters.

STUDY DESIGN

Patients referred for our clinic for urinary and non-urinary complaints, were prospectively enrolled. Urinary symptoms questionnaire, uroflowmetry parameters and post-voiding residuals (PVR) were assessed, and photographs of the urethral meatus were taken for each patient. The photographs were graded blindly according to the previously validated grading system and correlated with urinary symptoms, uroflowmetry parameters and PVR.

RESULTS

Overall, 75 patients were assessed (20 grade 0, 23 grade 1 and 32 grade 2). When using grade 0 as a reference, the odds ratio (OR) for reporting narrow stream was 6.4 (95%CI 1.65-24.77) and 4 (95%CI 1.18-14.16) for grade 1 and 2 respectively. OR for prolonged urination was 6 (95% CI 1.47-24.89) for Grade 1 and 2; OR for upward stream deviation was10.08 (95%CI -2.43-41.82) for grade 1 and 15.12 (95%CI - 3.74-61.17) for grade 2. Uroflowmetry results showed lower Qmax from 16.8(SD ± 8.0) ml/sec in grade 0-9.6 ml/s on grade 1 and 2 (p < 0.001) (Figure 1). PVR was not statistically different in the three groups.

DISCUSSION

Our main findings were that meatal stenosis severity grade is associated with narrow stream as reported by parent, prolonged urination, and upward deviation of urinary stream, with increasing severity with worsening stenosis. MS grade was also associated with significant worsening of uroflow measures: a lower Qmax, Qmean and a longer time-to-Qmax. Post-void residual volume was not significantly different between the different severity grades. This study showed the clinical significance of the grading system. With subjective and objective measures. The implementation of this grading system in clinics, may aid in decision making regarding surgical intervention in the appropriate patients, and avoid unnecessary procedures.

CONCLUSION

The Severity of MS seen on physical examination correlates well with obstructive symptoms and decrease of urine stream seen on uroflowmetry. These findings confirm the importance of the grading system in the evaluation of patients with MS and may be additional measure that assist in consulting parents on the indications to meatotomy.

Prevalence and causes of meatal stenosis in circumcised boys

INTRODUCTION

The prevalence of meatal stenosis after circumcision remains unclear, and its causes are unknown.

OBJECTIVE

To know the prevalence and the causes of meatal stenosis after circumcision in boys.

STUDY DESIGN

Between October 2018 and April 2019, we carried out a prospective cross-sectional study on 1031 circumcised boys, aged 5-8 years (mean age 6.1 years ± 0.3 years), enrolled in the first level of primary school. All enrolled children underwent genitourinary examination. Moreover, an anonymous questionnaire was filled-in by one of the parents.

RESULTS

The screening revealed the presence of meatal stenosis in 185 children, representing a prevalence of 17.9% of cases (95% CI = 15.6-20.3). Analysis of the results using both the univariate and multivariate mode brought out some common risk factors such as a foreskin that completely adheres to the glans with forceful retraction of the prepuce and the use of a healing product: Beta-sitosterol and Hydrocotyl (Centella Asiatica), rarely Trolamine. In addition, this study showed that boys circumcised during their first week of life are twice as likely to develop meatal stenosis than those circumcised between 7 and 12 months (OR = 2.08; 95% CI = 1.10-3.92, p = 0.021).

DISCUSSION

We believe that when the foreskin is fully attached to the glans, forced retraction of the prepuce most often causes a loss of the mucous membrane that covers the glans, making the glans less resistant to chemical attack, and therefore may play an important role in the development of meatal stenosis. However, This study is limited by the absence of a cohort of uncircumcised boys for comparison to see if the small diameter of the meatus is also present in this group.

CONCLUSIONS

This study showed that stenosis of the urethral meatus is a frequent complication of circumcision. Circumcision in the first week of life, complete adhesion of the foreskin to the glans, and the use of a healing product were associated with the risk of stenosis development.

Optimal clamping time in meatotomy procedure for children with meatal stenosis: Experience with 120 cases

OBJECTIVE

During meatotomy procedure for children with meatal stenosis (MS), a straight clamp used as a hemostat on the ventrum of the meatus before incised with scissors for clamping and holding bleeding from the site of operation. The aim of this study was to evaluate the optimum clamping time for meatotomy in children with MS.

MATERIALS AND METHODS

All the patients with MS between 2014 to 2019 were enrolled in this retrospective study. Patients with uncircumcised penis, traumatic catheterization, any kind of penile abnormality such as hypospadias or penile curvature, and active urinary tract infection (UTI) were excluded. The indication of meatotomy was a pinpoint meatus that develops with dorsal or lateral deflection of the urinary stream and high-velocity urine flow. During meatotomy procedure, clamping time was examined in different groups such as 2, 3, and 4 minutes. The main symptoms of presentation and ultrasonography (US) findings were recorded and compared between groups. To assess the optimum time clamping, postoperative bleeding was noted carefully in all groups. The success rate was recorded at onemonth postoperative follow-up in the clinic.

RESULTS

Of the 120 patients with MS who underwent a meatotomy procedure, there were 40 (33.3%) participants in each group. The main symptoms were painful urination and urine stream deviation that represented in 54 (46%) patients. Bladder wall thickness was the main pre-operation finding in the US which was observed in 67 (55.8%) patients. In comparison between the groups related to clamping time, bleeding was observed and required suturing when clamping was applied for 2 minutes in 4 (3.3%) patients (p = 0.016). With a minimum follow-up of 12 months, no recurrent meatal stenosis was reported.

CONCLUSIONS

Clamping time for more than 2 minutes may prevent bleeding during and after meatotomy.

Meatal stenosis posttraditional neonatal circumcision-cross-sectional study

Context:

Circumcision holds a unique place in the daily practice of urology. Heat cautery device is the most common local technique used, we found it can cause meatal stenosis (MS) and its sequels.

Aim:

The study aims to determine the incidence, presenting symptoms of MS and its relation to local traditional neonatal circumcision techniques among our children.

Settings and Design:

This study was retrospectively study.

Materials and Methods:

A total of 150 children who circumcised during the infancy period, outside medical institutes, and they circumcised using local traditional techniques either heating cautery devices or surgical knives.

Statistical Analysis:

Of data were carried out using the Statistical Packages for the Social Sciences - version 25 (IBM Corporation).

Results:

Of 150 children, 60 (40%) had MS. The mean age at the time of diagnosis was 5.98 ± 3.06 years (range 1–13 years) and the majority of patients were within the age group of 5–9 years (n = 31, 51.7%), median 6.0 years. The incidence of MS was significantly higher (P = 0.037) among a group of children circumcised with a heating device in comparison with the circumcised group with other methods. Forty-six children (76.7%) were symptomatic and fourteen children (23.3%) diagnosis of MS had performed incidentally.

Conclusions:

MS is a long-term complication of neonatal circumcision with a late presentation and sequels. It is more common among group circumcised using heating cautery. We recommend using heating cautery cautiously.