What are the possible causes of urinary stream spraying in an adult male patient with a history of urethral stricture or other urinary tract issues after meatoplasty (meatotomy of the urethral meatus)?

Differential Diagnosis of Urinary Stream Spraying After Meatoplasty

Urinary stream spraying after meatoplasty most commonly indicates either stricture recurrence at the meatus or proximal to it, incomplete excision of pathologic tissue (particularly in lichen sclerosus), or inadequate healing with scar tissue formation creating an irregular urethral opening.

Primary Diagnostic Considerations

Stricture Recurrence

• Recurrent meatal stenosis is the most likely cause, occurring in 3-25% of cases depending on the surgical technique used 1, 2.
• Men with lichen sclerosus have significantly higher recurrence rates (20.5% vs 7.5% in non-lichen sclerosus patients), making this a critical factor to assess 2.
• Stricture recurrence typically develops within the first year but can occur up to 10 years after surgery 3.
• The recurrence may be at the meatus itself or in the fossa navicularis proximal to the surgical site 2.

Incomplete Tissue Excision

• If the original pathology involved lichen sclerosus and all diseased tissue was not completely excised during meatoplasty, residual scarred tissue can create an irregular meatal opening causing stream spraying 2.
• Physical examination should specifically look for white, sclerotic skin changes characteristic of lichen sclerosus around the meatus 4, 5.

Irregular Healing Pattern

• Asymmetric scar formation at the meatal edges can create a bifid or irregular opening that deflects the urinary stream 1.
• This is more common when suturing was required during the original procedure versus simple excisional techniques 1.

Diagnostic Workup Algorithm

Step 1: Clinical Assessment

• Assess for obstructive symptoms beyond just spraying: decreased stream force, incomplete emptying, dysuria, or rising post-void residual 6, 4.
• Examine the meatus directly for visible stenosis, irregular edges, or signs of lichen sclerosus 4, 2.

Step 2: Objective Testing

• Perform uroflowmetry: Peak flow <12-15 mL/second suggests significant obstruction from recurrent stricture 6, 4, 5.
• Measure post-void residual by ultrasound: Elevated PVR indicates inadequate bladder emptying from obstruction 6, 4.
• If flow is normal (>15 mL/second) and PVR is low, spraying may be due to irregular meatal configuration without significant obstruction 5.

Step 3: Definitive Imaging

• Retrograde urethrography (RUG) is the gold standard to assess for stricture proximal to the meatus that may not be visible on examination 6, 4, 5.
• Urethro-cystoscopy allows direct visualization of the meatus and fossa navicularis to identify irregular tissue or early stenosis 6, 4.

Specific Etiologies to Consider

Proximal Stricture Disease

• The original pathology may have extended beyond the meatus into the fossa navicularis or penile urethra, and meatoplasty alone was insufficient 2.
• This requires RUG or cystoscopy to identify stricture length and location proximal to the meatus 6, 4.

Lichen Sclerosus Progression

• Lichen sclerosus is a progressive disease that can affect tissue proximal to the original surgical site 2.
• These strictures tend to be longer and may require more extensive reconstruction with non-genital tissue grafts 5.

Inadequate Initial Procedure

• If only meatotomy (incision) was performed rather than wedge excision of pathologic tissue, refusion of cut edges can occur 1.
• Meatoplasty with suturing has higher rates of irregular healing compared to simple excisional techniques 1.

Critical Pitfalls to Avoid

• Do not assume spraying alone indicates treatment failure—if uroflowmetry shows peak flow >15 mL/second and PVR is normal, the patient may have adequate functional outcome despite cosmetic stream irregularity 5.
• Do not miss lichen sclerosus—failure to identify and completely excise all diseased tissue leads to significantly higher recurrence rates requiring revision surgery 2.
• Do not rely solely on symptoms—asymptomatic patients may have significant residual stricture, and objective testing is essential 5.

Management Based on Findings

If Recurrent Stenosis Confirmed

• Mild stenosis without obstruction (normal flow, low PVR) may not require intervention 1.
• Symptomatic recurrence requires either repeat meatotomy for simple web formation or formal meatoplasty with possible substitution urethroplasty for longer strictures 2.
• For lichen sclerosus-related recurrence, complete excision of all involved tissue with non-genital tissue grafts is necessary 5, 2.

If Proximal Stricture Identified

• Short bulbar strictures (<2 cm) may be managed with urethral dilation or direct visual internal urethrotomy 5, 7.
• Longer or recurrent strictures require urethroplasty rather than repeated endoscopic management, which has >80% failure rate 5.