What are the treatment options for a 31-year-old male with spontaneous meatal stenosis?

Treatment of Spontaneous Meatal Stenosis in a 31-Year-Old Male

For a first-time presentation of uncomplicated meatal stenosis in this 31-year-old male, initial treatment should be either urethral dilation or meatotomy, as these minimally invasive approaches are appropriate first-line options. 1

Initial Treatment Approach

For an adult male presenting with spontaneous meatal stenosis without complicating factors (no prior hypospadias repair, no previous failed procedures, no lichen sclerosus), the treatment algorithm follows a stepwise approach:

First-Line Options

• Simple dilation or meatotomy can be performed with or without guidewire placement for uncomplicated meatal strictures confined to the meatus or fossa navicularis. 1
• Both procedures have comparable success rates and can be used interchangeably based on surgeon preference and patient anatomy. 1
• These procedures can often be performed under local anesthesia with sedation, reducing anesthesia requirements and costs. 2

Important Caveat: Rule Out Lichen Sclerosus

Before proceeding with any intervention, you must consider whether lichen sclerosus (LS) is the underlying etiology, particularly in spontaneous cases without clear iatrogenic cause. 1

• Biopsy should be performed if LS is suspected or if the stenosis fails to respond to initial treatment. 1
• LS-related meatal stenosis has different treatment implications, as these cases are more likely to require urethroplasty and have higher recurrence rates with simple endoscopic procedures. 1
• If LS is confirmed, topical corticosteroids (clobetasol propionate 0.05%) may be used as adjunctive therapy, though structural changes from scarring often require surgical intervention. 1

Management of Recurrent Stenosis

If the meatal stenosis recurs after initial dilation or meatotomy, urethroplasty should be offered rather than repeated endoscopic procedures. 1

Why Urethroplasty for Recurrence

• Meatal and fossa navicularis strictures refractory to endoscopic procedures are unlikely to respond to further endoscopic treatments. 1
• Repeated endoscopic treatments or intermittent self-dilation may compromise the success of subsequent reconstructive procedures. 1
• Urethroplasty is the definitive treatment for obliterated strictures or those associated with LS. 1

Surgical Techniques for Definitive Repair

• Eversion meatoplasty is a simple technique that can be performed under local anesthesia with excellent results and minimal restenosis rates. 3
• Wedge urethral meatotomy (V-shaped excision of stenotic tissue) has shown 97% success rates without requiring suturing or catheterization. 4
• For more complex cases with inflammation, a V-flap technique can be used, where a V-shaped glans flap is raised and the stenosis is incised into non-inflamed tissue, with the flap tip sutured to prevent recurrent stenosis. 5

Clinical Pitfalls to Avoid

• Do not perform repeated meatotomies in the presence of active inflammation, as this leads to recurrent stenosis; wait for inflammation to resolve or use tissue transfer techniques. 5
• Do not delay definitive reconstruction if the patient has already failed one endoscopic attempt, as multiple failures worsen outcomes. 1
• Always send circumcision or meatotomy tissue for pathological review to confirm or exclude LS, as this changes management. 1
• Avoid hair-bearing skin if substitution urethroplasty is required, as this causes urethral calculi and recurrent infections. 1

Post-Procedure Management

• Urethral catheters can be safely removed within 72 hours following urethral stricture procedures. 1
• For meatotomy procedures, parents/patients should be instructed to separate meatal edges three times daily for 10 days with topical antibiotic ointment to prevent re-adhesion. 4
• Temporary dysuria occurs in approximately 38% of patients in the first 2-3 days postoperatively but resolves spontaneously. 4