Meatal stenosis after newborn circumcision is common and usually presents after potty training with a deflected stream.
Although reports of any serious consequences (bladder or kidney problems) from meatal stenosis after circumcision are not evident in the literature (as opposed to meatal stenosis secondary to surgery to correct penile congenital anomalies), treatment is commonly offered to families when urinary deflection prevents normal voiding or when the child presents with recurrent crusting of the meatus accompanied by pain at the start of urination.
In 1996, Cartwright et al. (1) published the results of a series of 58 boys who underwent clinic meatotomy (CM) using only topical anesthesia. During the period of the study, only one operation was performed in the operating room, related to behavioral concerns about the patient. Two other patients had midazolam (medicine to calm the nerves) by parent request. Three out of fifty-eight (5%) had some discomfort during the procedure, and at a minimum follow-up of 3 months, 57 out of 58 (98%) did not have a recurrence.
Despite the findings of Cartwright et al., which robustly make a case in favor of CM and the abandonment of meatotomy under general anesthesia (GA), it appears that at the present time, 50% of meatotomies are still done under GA (2). Even those performed in the clinic are often augmented with sedation, either with nitrous oxide or midazolam (3), despite Cartwright’s (1) reporting that just 5% of patients have discomfort.
Meatotomy done at the first consultation in the office saves time for the parents and decreases costs by about 10 Fold. At our institution the cost of an office meatotomy is in between 300-500 dollars versus the cost in the OR is around 6000 dollars (cost might be lower in outpatient surgery centers). When a meatotomy is done at the first visit, the patient is only charged for the meatotomy. When the meatotomy is done under general anesthesia, the first visit is charged as a consultation and then more charges are incurred the day of the actual surgery of which the meatotomy is actually just a minor part of the bill.
|Clinic Meatotomy same day of visit||Meatotomy under general anesthesia|
|Charge for meatotomy||Yes||Yes|
|Charge for initial consultation||No||Yes|
|Hospital Charges/Facility fees||No||Yes|
|Time away from work for family||1 hr on one day||15 min on one day
3-6 hrs on a separate day
In the past 3 years we have offered CM to all our patients presenting with meatal stenosis.
90% of our patients have seen either complete resolution or improvement in their symptoms.
The meatotomy in the clinic is done by first applying EMLA cream to the penis and covering the penis with a tegaderm (transparent plastic dressing) for 20-60 minutes. The tegaderm is then partially or fully removed to allow the performance of the meatotomy.
Over the past 3 years we have documented the presence or absence of pain during the CM and defined it as any sound, grimace, or movement during the procedure. If the patient laid still during the procedure without any of the above, this was classified as “no pain.” Pain during the removal of the tegaderm was not taken into consideration. We do have observed that that nearly all of the boys complained mildly during the removal of the tegaderm.
About 80% of our patients have had no pain as defined above. In the other 20% the pain was mild enough that we were still able to complete the procedure and no procedure had to be stopped and done in the operating room under general anesthesia so far.
Our results augment the body of evidence now documenting the safety and efficacy of CM. We now make parents aware of these results, and since we started doing that no one has requested a meatotomy under GA. We believe the literature does not support a role for GA in the management of meatal stenosis.,
Assuming a birth rate in the US of 2 million boys per year, with 60% who will be circumcised, and 7.3% of whom will develop meatal stenosis (5), that would account for 87,600 meatotomies a year in the US. Assuming a cost of $500 dollars for the office meatotomy and $5000 dollars for an meatotomy under GA, as well as 10% recurrence rate requiring meatoplasty under GA, avoiding GA for the initial meatotomies would save $350 million dollars a year in the US, not including other financial losses such as lost work time and the like.
For the patients clinic meatotomy is safer since GA is not used.
(1) Cartwright PC, Snow BW, McNees DC. Urethral meatotomy in the office using topical EMLA cream for anesthesia. J Urol 1996 Aug;156(2 Pt 2):857-8; discussion 858-9.
(2) Godley SP, Sturm RM, Durbin-Johnson B, Kurzrock EA. Meatal stenosis: a retrospective analysis of over 4000 patients. J Pediatr Urol 2015 Feb;11(1):38.e1-38.e6.
(3) Ben-Meir D, Livne PM, Feigin E, Djerassi R, Efrat R. Meatotomy using local anesthesia and sedation or general anesthesia with or without penile block in children: a prospective randomized study. J Urol 2011 Feb;185(2):654-657.
(4) Priyadarshi V, Puri A, Singh JP, Mishra S, Pal DK, Kundu AK. Meatotomy using topical anesthesia: A painless option. Urol Ann 2015 Jan-Mar;7(1):67-70.
(5) Van Howe RS. Incidence of meatal stenosis following neonatal circumcision in a primary care setting. Clin Pediatr (Phila) 2006 Jan-Feb;45(1):49-54.