What are the management and treatment options for a patient with a split urethral meatus, considering their age, medical history, and symptoms?

Management of Split Urethral Meatus

For a split urethral meatus, initial management should begin with high-potency topical corticosteroid therapy (clobetasol propionate 0.05% ointment once daily for 1-3 months) if lichen sclerosus is suspected, followed by surgical intervention (meatotomy or meatoplasty) for cases with persistent obstruction, recurrent symptoms, or failure of medical management. 1

Initial Diagnostic Assessment

The term "split meatus" typically indicates either a congenital meatal web causing stream deflection or acquired meatal stenosis with associated scarring. The critical first step is determining the underlying etiology:

• Examine for lichen sclerosus (LS): Look for porcelain-white plaques, areas of ecchymosis, hyperkeratosis, or scarring around the meatus, as LS is a common cause of meatal pathology and requires specific management 1
• Assess urinary stream pattern: Observe for deflection, splitting, weak stream, or upward direction—all indicators of meatal stenosis 1, 2
• Evaluate for obstructive symptoms: Check for straining, dysuria, prolonged urination, or recurrent urinary tract infections 2
• Measure post-void residual volume: Elevated PVR indicates significant obstruction requiring urological referral 1

Medical Management (First-Line for LS-Related Cases)

If lichen sclerosus is suspected based on clinical appearance:

• Initiate clobetasol propionate 0.05% ointment once daily for 1-3 months as first-line therapy 1
• This approach is particularly important in males with LS, as topical steroids of adequate potency and duration should be used prior to considering circumcision or surgical intervention 3
• Monitor response at 3 months: If disease responds well, continue follow-up at 6 months before considering discharge 3
• Patients with persistent active disease despite topical steroids require long-term follow-up and may need surgical intervention 3

Surgical Management

For Meatal Web or Simple Stenosis

Wedge urethral meatotomy is the preferred technique for thin ventral webs causing meatal stenosis:

• This involves V-shaped excision (2-3 mm) of the ventral meatal web after applying hemostatic crushes 2
• Advantages over traditional meatotomy: No suturing required, no catheterization needed, and lower reoperation rates (3% vs. traditional meatotomy reoperation rates of 2-2.2%) 2
• Operative time is brief (4-6 minutes), and the procedure can be performed under general anesthesia 2
• Post-operative care: Parents should separate meatal edges three times daily for 10 days with topical antibiotic ointment 2

For Recurrent or LS-Associated Meatal Stenosis

Urethroplasty should be offered for recurrent meatal or fossa navicularis strictures rather than repeated endoscopic treatments:

• Meatal strictures refractory to endoscopic procedures are unlikely to respond to further endoscopic treatments 3
• First-time uncomplicated meatal strictures may be treated with simple dilation or meatotomy 3
• Patients with previous hypospadias repair, prior failed endoscopic manipulation, or LS should be offered urethroplasty as definitive treatment 3
• Urethroplasty is the best option for obliterated strictures or those associated with LS 3

Alternative Conservative Approach

Home dilatation may be considered in select cases:

• Can be taught successfully to boys or their families, avoiding repeated hospital visits 4
• Success rate: approximately 50% cure with first course, with some requiring repeat courses 4
• Most appropriate for cases without LS or complex scarring 4

Red Flags Requiring Urgent Urological Referral

• Progressive urinary retention or significantly elevated post-void residual 1
• Suspected malignant change: Persistent hyperkeratosis or new warty/papular lesions in the setting of LS 1
• Severe meatal stenosis with obstructive symptoms requiring immediate surgical intervention 1
• Urethral stricture extending beyond the meatus: These require more complex reconstruction and should not be managed with simple meatotomy 3

Critical Pitfalls to Avoid

• Do not perform repeated endoscopic treatments for LS-associated meatal stenosis, as this may compromise subsequent reconstructive procedures 3
• Avoid using genital skin for reconstruction in LS patients—all 12 patients treated with genital skin flaps in one series failed, requiring further surgery 3
• Do not use blind basketing or manipulation without direct visualization 3
• Ensure adequate topical steroid trial before proceeding to surgery in suspected LS cases, as premature surgery without medical optimization may lead to recurrence 3
• Send all circumcision or surgical specimens for histology to confirm LS diagnosis and exclude malignancy, which aids future management 3

Follow-Up Protocol

• For LS patients: Review at 3 months after initial treatment, then at 6 months if responding well 3
• Post-surgical patients: Monitor for recurrence, assess urinary stream, and check for residual disease 3
• Provide written discharge information outlining symptoms suggesting disease relapse or malignant change 3
• Long-term surveillance: Patients with ongoing active LS require indefinite follow-up due to malignancy risk 3