What is the recommended management for an adult male with urethral meatus stenosis presenting with pain and dysuria but no infection?

Management of Urethral Meatus Stenosis with Pain in Adult Males

For an adult male with painful urethral meatus stenosis and dysuria without infection, surgical meatoplasty is the definitive treatment, with the Malone technique or dorsal V-meatoplasty being preferred approaches that provide excellent functional outcomes and low recurrence rates.

Initial Assessment and Diagnosis

• Confirm the diagnosis by identifying characteristic symptoms: decreased urinary stream, dysuria, urinary spraying, and meatal pain during voiding 1
• Rule out underlying lichen sclerosus (LS), which is a common cause of meatal stenosis in adults and requires specific management considerations 1
• Exclude active infection through urinalysis and urine culture before proceeding with surgical intervention 1
• Assess stricture severity by examining the meatal caliber and evaluating for any proximal urethral involvement 1

Medical Management (Limited Role)

• Topical steroids (clobetasol propionate 0.05% twice daily for 2-3 months) may be considered if lichen sclerosus is confirmed, though this approach often provides only temporary relief and disease progression commonly occurs 1
• Periodic urethral dilation is not recommended as definitive treatment due to high recurrence rates and potential for worsening fibrosis 1
• Medical therapy alone is generally insufficient for established symptomatic meatal stenosis requiring surgical correction 1

Surgical Management (Definitive Treatment)

Primary Surgical Options

Meatoplasty techniques are the gold standard for symptomatic urethral meatal stenosis:

• Malone meatoplasty involves a small ventral incision with extensive dorsal meatotomy and inverted V-shaped relieving incision, achieving 100% success rates with no recurrences and 85.7% patient satisfaction in long-term follow-up 2
• Dorsal V-meatoplasty creates adequate meatal opening while maintaining cosmetic appearance 1
• Eversion meatoplasty (EM) may be used as initial surgical treatment, with 87% success rates in complex cases, though it creates a hypospadiac meatus 1

Surgical Approach Selection

• For isolated meatal stenosis without proximal disease: Meatoplasty alone is sufficient and provides excellent functional outcomes 1, 2
• For meatal stenosis with lichen sclerosus limited to glans and foreskin: Circumcision combined with meatoplasty successfully treats 96% of patients 1
• For stenosis with suspected proximal urethral involvement: Consider urethroplasty with mucosal grafts if meatoplasty alone is inadequate 1

Stepwise Management Algorithm

1. Confirm diagnosis and assess etiology (lichen sclerosus vs. idiopathic vs. iatrogenic) 1
2. Rule out infection with urinalysis and culture 1
3. Consider trial of topical steroids only if early lichen sclerosus is confirmed and stenosis is mild 1
4. Proceed to definitive meatoplasty for symptomatic stenosis causing pain and dysuria 1, 2
5. Send all excised tissue for pathological examination to confirm diagnosis and rule out malignancy 1

Perioperative Considerations

• Antibiotic prophylaxis should follow standard surgical guidelines, with preoperative urine cultures guiding antibiotic selection 1
• Urethral catheterization is typically brief (days) following meatoplasty procedures 1
• Postoperative care includes local wound care and instructions to prevent meatal refusion 2

Expected Outcomes and Follow-Up

• Success rates for meatoplasty techniques range from 87-100% with low recurrence rates 1, 2
• Functional outcomes include restoration of normal urinary stream caliber and resolution of dysuria 2
• Cosmetic satisfaction is high (83.3%) with modern meatoplasty techniques that avoid creating hypospadiac meatus 2
• Long-term surveillance should monitor for recurrence, though this is uncommon with proper surgical technique 1, 2

Critical Pitfalls to Avoid

• Do not rely on simple ventral meatotomy alone, as this carries higher restenosis rates compared to formal meatoplasty techniques 1
• Do not perform repeated dilations as definitive management, since this perpetuates inflammation and worsening fibrosis 1
• Do not delay pathological examination of excised tissue, as lichen sclerosus carries a small risk of progression to squamous cell carcinoma 1
• Do not use potent topical steroids in pediatric patients due to risk of systemic absorption and adverse effects 1