Congenital Meatal Urethral Stenosis in a Female Patient: A Case Report

We present the case of a 6-year-old girl who presented with alterations in the voiding stream. On physical examination, a very small urethral meatus was identified at the expense of a membrane. The renovesical ultrasound showed no alterations. An uroflowmetric study was performed, showing a bladder outlet obstruction pattern. The urethral meatus was calibrated and a ventral meatotomy was performed. The histological study of the resected membrane showed a transitional urethral mucosa with chronic focal inflammation and discrete hyperplasia. The patient evolved favorably, with resolution of the symptoms and no notable complications. This is, to the best of our knowledge, the first reported case with a histological study of a congenital meatal urethral stenosis. In the presence of lower urinary tract obstruction, this entity should be considered in the differential diagnosis. Surgical treatment is curative.

Free tubularised vesical mucosa graft for congenital stenosis of the urethra in children

BACKGROUND

Reconstruction of urethral strictures in children remains a challenge to the pediatric surgeon as these are often related to different rare congenital anomalies with various clinical presentations that endanger renal function and should be repaired in young children. Multiple techniques have been described for their repair. We aimed to determine whether the use of a free tubularised bladder mucosal graft associated to a prior tubeless vesicostomy was feasible and sure, as this technique of reconstruction using tubularised grafts has not been described yet in young children.

RESULTS

Two newborn male patients were referred to our department. Both presented a congenital stenosis of the urethra as a part of a complex urethral malformation. Surgery involved prior tubeless vesicostomy, free bladder mucosal graft for urethral reconstruction, and vesicostomy closure for both children. Postoperative evolution was satisfying in both children and cystourethroscopy showed permeable urethra. Satisfying cosmetic and functional results have been obtained in the two cases.

CONCLUSIONS

The prior vesicostomy prevents kidney damage in the context of complex genital and urinary malformations. Bladder mucosa's immunohistological properties are the most similar to those of the urethral tissue, and are appropriate for this type of correction, making our technique feasible and sure.

LEVEL OF EVIDENCE

5.

Congenital urethral stenosis in a male miniature piglet

A 2-month-old male miniature pig showed progressive abdominal pain, pollakiuria, and stranguria that progressed to complete urinary obstruction. Postmortem examination revealed idiopathic urethral stenosis at the level of the recess, of probable congenital origin. Urinary tract malformations should be included in the differential diagnosis of miniature piglets with urinary disorders.

Posterior urethral valves: long-term outcome

Posterior urethral valves represent the most common cause of bladder outlet obstruction in infancy that impairs renal and bladder function. Long-term outcome of patients with previous PUV is evaluated. Patients over 18 years of age, treated from 1982 to 1995 before the age of 3 years were considered. Previous surgery, renal function, bladder activity, urinary incontinence, and fertility/sexual activity were evaluated. Clinical interview, creatinine clearance, uroflowmetry with ultrasound post-void urine residue, and self-administered questionnaire were recorded. Out of 45 identified records, 24 patients (53.3%) accepted to be enrolled (age 18-34 years, mean 23 years). The mean follow-up was 19.5 years (16-30 years). Out of the 21 excluded patients, 20 did not reply to the clinical interview and 1 died at age of 6 years. All the 24 patients had early endoscopic section of PUV; nine also received transient ureterocutaneostomy or vesicostomy. Ureteroneocystostomy was performed in five patients and ureterocystoplasty with unilateral nephrectomy in two. At follow-up chronic renal failure was detected in 13 patients (54.1%) and 9 (37.5%) had arterial hypertension. End-stage renal disease developed in five patients (20.8%): three had successful renal transplantation and two were in dialysis. Lower urinary tract symptoms were present in seven patients (29.1%). No significant fertility deficit and sexual dysfunction were observed in 23 patients, while 1 patient was azoospermic. No paternity was reported so far. Long-term outcome of patients with previously treated PUV is mandatory. Kidney, bladder, and sexual functions should be monitored till adulthood to verify any modified behaviour.

[Pre-emptive renal transplantation in a boy with obstructive uropathy following reconstruction procedures]

Patients with bladder dysfunction comprise over 30% of pediatric patients on renal replacement therapy. We report on a successful cadaveric pre-emptive renal transplantation performed in a boy born with posterior urethral valve. Following bilateral ureterocutaneostomies, left nephrectomy and valve resection, at 6 years of age a continent ileocolonocystoplasty was performed. The boy started intermittent daytime catheterization, passing urine both via urethra and fistula. At the age of 18 he received a renal transplant. Continuing the previous regime, at 1.5 years follow up his graft is well functioning (GFR >75 ml/min/1.73 m2) with sporadic episodes of urinary tract infection.

[Megalourethra in association with VACTER syndrome]

The megalourethra is an uncommon congenital anomally. It is a consecuence of the abnormal development of the corpus spongiosum and, occasionally, also the abnormal development of the corpora cavernosum. It is specially common in association with the Prune-Belly syndrome, and with upper tract abnormalities. We present a bizarre case because of its association with a VACTER syndrome.

Ten cases of congenital urethral stricture in childhood with enuresis

BACKGROUND

To report short-term clinical outcomes of endoscopic correction of congenital urethral stricture in 10 boys who suffer from enuresis resistant to conservative therapy.

METHODS

Fifteen boys ranging between 5 and 15 years old consulted our clinics for nocturnal and diurnal enuresis which had not been improved by medication and behavioral therapy. Among them, voiding cystography revealed bulbar narrowing (Cobb's Collar) in 10 cases and vesico-ureteral reflux was found in four cases (seven ureters). Endoscopically, this lesion was recognized as a ring-form stenosis just distal to the urethral sphincter. It was incised with infantile urethrotome.

RESULTS

Vesico-ureteral reflux was resolved in four ureters and improved in one. In all cases, daytime enuresis resolved dramatically and night enuresis became controllable.

CONCLUSIONS

Boys who suffer from diurnal enuresis should immediately be explored for the existence of congenital urethral stenosis. Early resolution may bring about better urinary behavior.

[Occurrence, diagnostics and therapeutic management of hydronephrosis in pediatric patients in Germany]

As urinary tract obstruction in children may impair renal function, the early detection and evaluation of the degree of obstruction using adequate diagnostic tools is necessary for the choice of the optimal therapeutic procedure. This study describes diagnostic and therapeutic standards in relation to the quality of management of pediatric hydronephrosis in Germany in the first 6 months of the year 2000. In our study 407 of 711 (57.2%) children with a hydronephrotic condition were detected by routine ultrasound. This, and the fact that 25% of the patients, who were prenatally detected, had a diagnosis of vesicoureteral reflux, underlines the importance of this routine procedure. Our study illustrates the panel of diagnostic and therapeutic procedures used in the management of pediatric hydronephrosis in Germany.

[Three cases of congenital urethral stricture in childhood]

We report three cases of congenital urethral stricture in boys. They were 8, 7 and 5 years old. They complained of enuresis both day and night. Voiding cystography revealed bulbar narrowing (Cobb's Collar) in all cases, and vesico-ureteral reflux (VUR) occurred in two cases (three ureters). Endoscopically this lesion showed ring-form stenosis just distal to the urethral sphincter, and incised by using an infantile urethrotome. After the operation, VUR resolved in two ureters and improved in one. In all cases, daytime enuresis resolved dramatically, and night enuresis became controllable. Congenital urethral stenosis in boys is an important clinical entity in pediatric urology, and is not such a rare disease.

The practice of urethral dilation for voiding dysfunction among fellows of the Section on Urology of the American Academy of Pediatrics

PURPOSE

Review of the literature reveals little scientific evidence to prove or disprove the efficacy of urethral dilation for children with dysfunctional voiding and recurrent urinary tract infections. We ascertain the current practice of urethral dilation among pediatric urologists.

MATERIALS AND METHODS

An anonymous questionnaire regarding the practice of urethral dilation was mailed to all fellows in the Section on Urology of the American Academy of Pediatrics. The questionnaire contained 14 questions and included biographical information.

RESULTS

The questionnaire response rate was 64%. When asked how one would treat a typical female child with classic voiding dysfunction, 87% responded with timed voiding and relaxation techniques with or without anticholinergics. Only 2.5% would proceed directly to cytoscopy and urethral dilation. For patients who did not respond to initial treatment, 67% would proceed with either urodynamics or biofeedback and only 10% would then perform urethral dilation. Of responders 61% do not practice urethral dilation under any circumstance, 36% will use it when all other means of therapy have failed, while only 2% use urethral dilation regularly and 2% find it helpful and will occasionally use it. Among physicians who perform urethral dilation 63% believed that less than half of the patients experienced long-term improvement. Overall, there was no consensus as to mechanism of action of urethral dilation.

CONCLUSIONS

Urethral dilation is rarely used as primary treatment for pediatric voiding dysfunction, is usually reserved until all other treatments have failed and appears to have long-term efficacy in less than 50% of patients. To define better the need for this treatment modality and its efficacy, a randomized prospective trial is mandatory.

Impact of congenital narrowing of the bulbar urethra (Cobb's collar) and its transurethral incision in children

OBJECTIVES

We described the clinical manifestation and outcome after transurethral incision (TUI) of a congenital narrowing of the bulbar urethra (Cobb's collar).

MATERIALS AND METHODS

Over a period of 11 years a total of 74 boys, from 3 months to 16 years old with a mean age of 5 years, were subjected to TUI. A febrile urinary tract infection (UTI) was the most common symptom in 40 cases, enuresis in 15, urinary incontinence in 11, hematuria in 9, antenatally diagnosed dilated urinary tract in 4 and others in 9. Concurrent bladder instability was detected by cystometry in 27/31 boys older than 3 years with suspicious bladder urgency. When the bulbar narrowing was detected by cystourethroscopy under 8 Fr, the lesion was simultaneously incised by using an infantile resectoscope (Olympus 10 Fr with a knife electrode or Storz 10 F with a cold knife).

RESULTS

Vesicoureteral refluxes (VURs) occurred in 39 cases (53%) and it was diminished in 11 and improved in 25 after TUI. Of the 40 cases, 38 (95%) were free from UTI after TUI. For enuresis and urinary incontinence, 14/15 and all 11, respectively, thrived after TUI and the anticholinergic supplement. Although 61 cases were primarily cured with no complications, insufficient cutting and recurrence of the stricture required an additional TUI in 13 cases for whom the knife electrode was mostly used. Overall clinical improvement was obtained in 71/74 (93%) cases after TUI.

CONCLUSION

Meticulous cystourethroscopy is indispensable for detecting a clinically significant bulbar narrowing. TUI of the lesion is useful as a primary treatment in the majority of cases even with concurrent VUR and unstable bladder. A cold knife is preferable to electrocautery in incising this fine anterior urethral lesion.

Duplications of the male urethra--two case reports

Duplications of the male urethra are rare congenital malformations. They do not represent a uniform entity making it difficult to find an unequivocal and comprehensive classification. Management is directed by the individual functional situation. In this presentation two morphologically and functionally differing cases of a sagittal urethral duplication are described and aspects of diagnosis and treatment discussed.

Cobb's collar and syringocele with stone

We report a case of unusual syringocele with a stone and Cobb's collar. Tubular or cystic dilatation of Cowper's gland duct has been called a syringocele. Congenital urethral narrowing is known as Cobb's collar. This paper presents a rare case of adult syringocele with stone and Cobb's collar. We analysed the clinical, radiological and therapeutic aspects of this entity.

Congenital bulbar urethral strictures occurring in three brothers

Three brothers with identical congenital bulbar urethral strictures are presented. These rare lesions are distinct from posterior urethral valves although the exact embryological origin is uncertain. The current literature is also reviewed.

[Congenital urethral strictures]

We present 12 patients with presumed congenital urethral stricture (mean age at diagnosis 20 years). They complained of various urological symptoms, including dysuria, transient urinary retention, urgency and reduced flow. The time from onset of symptoms to diagnosis averaged 18 months. The strictures were presumed congenital because no patient had a history of urethral infection or of instrumentation, and all the strictures were at the proximal bulbar urethra, as has been described for congenital, bulbar, urethral stricture. We treated 5 patients initially by internal urethrotomy, of whom 2 required transurethral dilatation at follow-up. 7 others were treated initially by transurethral dilatation, 4 of whom required more than 1 treatment. Follow-up has averaged 21 months. In 8 of 10 patients the maximal urinary flow at latest follow-up is greater than 20 ml/sec.

Familial occurrence of congenital stricture of bulbar urethra

We report on the familial occurrence of congenital bulbar urethral stricture in 2 brothers. Embryological mechanisms are briefly discussed and the literature reviewed.

Congenital stricture of the urethra

Three patients with presumed congenital urethral strictures are presented. The strictures were all in the bulbar urethra and were demonstrated by micturating cysto-urethrography. A further child is described with a normal urethra in whom the appearances mimicked a proximal bulbar stricture.

[Two cases of congenital urethral stenosis complicated with vesicoureteral reflux]

Secondary vesicoureteral reflux (VUR) is not uncommon, but is rarely accompanied by congenital urethral stenosis in children. We report 2 cases. Case 1 was in a 3-year-old boy who had congenital anterior urethral stenosis accompanied by VUR. Urethroplasty by Johanson's operation was performed and 6 years later VUR disappeared. Case 2 was in a 7-year-old girl, who had congenital peripheral urethral stenosis accompanied by VUR. The urethra was dilated by a balloon-dilator and about 1 year later VUR disappeared.

Cobb's collar--a forgotten entity

Cobb's collar or Moormann's ring is a stricture of the bulbar urethra which is largely unrecognised but has considerable relevance urologically as the site of congenital or post-instrumental strictures. The history, anatomy, embryology and surgical importance are reported.

[Treatment of congenital urethral stenosis (urethral ring) in children. Optic internal urethrotomy in the congenital bulbar urethral stenosis in boys]

Congenital urethral stenosis in boys occurs at the junction of the entodermal primary urethra and ectodermal secondary urethra. Endoscopically this lesion is recognized as a ring-form stenosis just distal to the external urethral sphincter. It has been considered as rare congenital anomaly in American literature. But in our experience congenital urethral stenosis is an important cause of recurrent urinary tract infections, enuresis, pollakisuria or hematuria in pediatric urological practice. It also disturbs spontaneous healing of vesicoureteral reflux. The most effective treatment of this lesion is optic internal urethrotomy under direct vision. We would like to report our experience of optic internal urethrotomy for congenital urethral stenosis in boys. From 1974 to 1986, 226 boys with congenital bulbar urethral stenosis were treated in our clinic. Optic internal urethrotomy was performed using a Sachse urethrotome with a 10 or 13 Fr. sheath. Of the 176 ureters with vesicoureteral reflux, spontaneous disappearance of reflux after optic internal urethrotomy was noted in 62.5% of Grade I-II, 65.0% of Grade III, 28.9% of Grade IV and 16.7% of Grade V ureters. These spontaneous disappearance rates were significantly higher than those of primary vesicoureteral reflux in Grade III, IV and V ureters. Of the drug-resistant enuretic boys with a congenital bulbar urethral stenosis, enuresis disappeared or ameliorated in 69.4% after optic internal urethrotomy. Furthermore, urinary tract infections were mostly prevented by optic internal urethrotomy, irrespective of the presence or absence of vesicoureteral reflux. Our results support the view that congenital urethral stenosis (urethral ring) is an important clinical entity in pediatric urology.

Congenital bulbar urethral stricture occurring in two brothers

Two cases of apparently congenital bulbar urethral stricture occurring in brothers are presented. Such a finding has been rarely reported. Congenital strictures may be more common than previously thought and a full history is essential in such cases when the aetiology remains uncertain. Biopsy of the stricture may be of value.

Surgical therapy of congenital distal urethral stenoses in girls by meatoplasty

In girls there are three distinct morphological kinds of congenital distal urethral stenoses in the broad sense. Incomplete meatal stenoses are the most frequent of these. Calibration of the urethra appeared to be the most reliable diagnostic tool in revealing distal urethral obstructions. To relieve the urodynamically interfering urethral stenoses we developed a resecting surgical technique. In a retrospective study the follow-up after meatoplasty of 163 girls with recurrent urinary tract infections was analysed. The long-term success rate totals up to 83.5%.

Urethral strictures in children

During a 12-year period 57 children presented for treatment of urethral strictures. The patients ranged in age from 2 months to 18 years and there was 1 girl. Of the strictures 8 were congenital, 34 were iatrogenic, 4 were inflammatory and 11 were traumatic. Diagnosis can be suspected from the history and physical examination (observation of the voided stream), and confirmed radiographically and endoscopically. Urethral dilation was definitive treatment in only 28.6 per cent of the patients in whom it was used. Of 4 inflammatory strictures 2 responded to dilation as the only treatment, while only 1 of 5 congenital strictures and 1 of 5 iatrogenic strictures responded to dilation. Direct vision urethrotomy was successful in 1 of 2 congenital and in 5 of 5 iatrogenic bulbar strictures. A 1-stage urethroplasty seems preferable to multistaged procedures, since only 2 of 7 patients managed with staged procedures were treated successfully in 2 operations, while 5 of 9 treated with a 1-stage procedure have required no further intervention.

Apparent congenital anterior urethral stricture in brothers

Anterior urethral strictures of apparent congenital origin are reported in brothers and the literature is reviewed.

[Congenital distal stenosis of the female urethra and reflux (author's transl)]

The diagnosis and the results of treatment of congenital distal stricture of the urethra and vesicorenal reflux are reported. In 31% of our patients with congenital distal urethral stenosis a vesico ureteral or vesico-renal reflux was found. Following distal urethrotomy the reflux healed spontaneously in 40% of the patients. It is emphasized that before an antireflux plasty a subvesicale obstruction should be ruled out. This includes distal congenital stricture of the urethra and when this diagnosis is suspected a reflux cystogram should be carried out.

Posterior urethral stenosis in newborn with renal nonfunction syndrome

A newborn male infant presented with the "renal nonfunction syndrome" and subsequently was found at autopsy to have congenital stenosis of the posterior urethra. Additional urinary tract malformations included a prostatic diverticulum, bladder hypertrophy, bilateral hydroureter, and bilateral renal hypoplasia with dysplasia. Autopsy evidence suggested that the urethral stenosis had manifested itself very early during embryologic development and accounted for the associated urinary anomalies. The infant had the physical stigmata, clinical course, and pulmonary hypoplasia commonly observed in "Potter's" or the "renal nonfunction syndrome."

Neonatal hydronephrosis: 146 cases

Recognition and precise etiologic diagnosis of neonatal hydronephrosis is worthwhile since, although often severe, it is usually treatable with at least partial success. This relatively favorable prognosis, despite dilatation that may be marked, suggests a greater regenerative capacity at this age, or may be due to the relative infrequency or short duration of the infection.

Prednisone-responsive congenital erythroid hypoplasia

A 24-year-old woman had congenital hypoplastic anemia (Blackfan-Diamond syndrome). Anemia was discovered at the age of 12 months and persisted thereafter. The patient had associated congenital abnormalities of urethral stricture, hypoplastic thumb, and absent radial pulse. Her erythroid hypoplasia responded favorably to treatment with prednisone.

[Congenital bllbar urethral stenosis and its therapy by means of internal urethrotomy under direct vision (according to Sachse) (author's transl)]

Congenital bulbar urethral stenosis arises from incomplete opening of the urogenital membrane. The etiology may possibly be genetic or else a disturbance in the maternal hormones during the embryonic phase. The diagnosis from other types of stenosis is made by urethroscopy. The urodynamic consequences are a compensatory hypertrophy of bladder muscle, in extreme cases finally followed by hydronephrosis. Symptoms of stenosis include dysuria, polyuria, enuresis, and recurrent urinary tract infection. The whole urinary tract should be investigated. At present, the operation of choice for dealing with this type of stenosis, is internal urethrotomy under direct vision (Sachse's operation). Short-term indwelling catheterization, prophylaxis against infection, and hydraulic auto-bougination (raising the internal urethral pressure by compressing the penis during micturition) help to ensure success. The percentage of complications is low. The risk of recurrence is less than with the use of electrocautery.

Congenital stricture of male urethra

Seven cases of anterior urethral stricture were studied. The diagnosis was made by exclusion of the inflammatory and traumatic causes. In three cases the stricture was located in the bulbar and in four cases in the penile urethra. The results obtained were good, with a follow-up of 5 to 50 months. Considerations are made about embryogenic, diagnostic, clinical picture and treatment. The verification of extensive lesions of the urethra determined the use of more complex surgical techniques of Johansen's urethroplasty devised for the treatment of this kind of pathology.

Fibroelastosis of the posterior urethra associated with urinary, cardiac and digestive anomalies

A case of fibroelastosis of the posterior urethra associated with ectopic opening of the ureter of a solitary kidney in the urethra is described. Oesophageal atresia and anomalous origin of the left coronary artery were also observed. Management of fibroelastosis is pointed out.

Congenital proximal bulbar stricture in adults

Congenital proximal bulbar stricture in adults is a definite clinical entity and should be looked for in adults with obscure urinary symptoms. The stricture is usually short and can be demonstrated with a voiding cystogram, urethrogram, and urethroscopy. The condition is thought to be due to incomplete rupture of the cloacal membrane at its junction with the urogenital sinus. The stricture can be treated easily by internal urethrotomy and/or urethral dilatation.