Management of Meatal Stenosis in Port Harcourt: A Ten-Year Retrospective Study

Background: Circumcision is the removal of the fore skin of the penis. It is one of the commonest operations performed worldwide. Meatal stenosis is an uncommon long-term complication of circumcision that can lead to prob-lems voiding. Aim: To identify the clinical presentations and management of meatal stenosis in Port Harcourt. Materials and Methods: This was a retrospective study of patients who presented with features of meatal stenosis between January 2012 and December 2021. The patients’ history, physical examination findings, investigations and treatment received were analysed. Results: A total of 52 patients with features of meatal stenosis were recruited for the study. The number of patients less than a year old, between a year and 5 years, between 6 and 10 years and greater than 11 years were 8, 12, 28 and 4 respectively. Only 8 patients presented within 6 months of onset of symptoms. The most common symptom was poor urine stream, followed by straining. Meatotomy was the most commonly performed procedure for meatal stenosis 24 (46.15%). The patients were followed up for at least 6 months. Six patients had recurrence after treatment of meatal stenosis. Three patients each had a recurrence following dilatation and meatotomy. No patient had recurrence after meatoplasty. Conclusion: Meatal stenosis is an uncommon complication post circumcision. Patients usually present late to the hospital in our study. Meatoplasty had the best outcome. After treatment of meatal stenosis patients should be followed up for 6 months.


Introduction
Circumcision has a long history and is a ritual for such religions as Judaism, How to cite this paper: Francis, G.I. and Circumcision is one of the commonest surgical operations performed worldwide and it is a subject of considerable debate [1] [2]. Circumcision is carried out for religious reasons, hygienic reasons, control of Human Immunodeficiency Virus (HIV) [3] [4], recurrent urinary tract infection [5], recurrent balanitis [5], phimosis, paraphimosis [5] and prevent penile cancers [6].
Circumcision in newborns almost entirely eliminates the risk of penile cancer [5] [6]. Circumcision before puberty may reduce the risk of penile squamous cell carcinoma but men circumcised after puberty has the same risk of penile SCC as uncircumcised men [6]. Therefore, circumcision during the neonatal period is very important and also more cost effective [7].
Circumcision is largely free of complications in majority of patients, but can result in mild complications such as excessive or inadequate skin removal, pain, haemorrhage, wound infections, skin bridge, meatal stenosis, meatal ulcers and loss of penile sensitivity [8]. Severe complications such as urethrocutaneous fistula, sexual dysfunction and penile amputation may also occur [8].
Meatal stenosis is believed to be a complication of circumcision [1]. Meatal stenosis is defined to be a change in the appearance of the delicate lips of the urinary meatus, with loss of the elliptical shape to circular shape because of fibrosis or scarring, with visually apparent narrowing [1] [9]. Injury to the frenular artery is largely believed to be the culprit of post circumcision meatal stenosis [1]. Meatal stenosis is almost never seen in uncircumcised men [10]. This study aims to identify the clinical presentations and management of meatal stenosis in Port Harcourt.

Materials and Methods
This was a retrospective study. All patients who presented with features of meatal stenosis between January 2012 and December 2021 were included in the study.
Port Harcourt is a major capital city in the Niger Delta, the oil and gas zone in Nigeria. Data was obtained from ward admission registers, theatre, and discharge records. The information gotten included history, duration of symptoms, examination findings and treatment received. Patients who were circumcised outside the neonatal period were excluded from the study. All patients with incomplete records were also excluded from the study.
All the boys were circumcised using an appropriately sized plastibel. Urine microscopy culture and sensitivity were done and an appropriate antibiotic given to the boys before repair of meatal stenosis. Patients who had dilatation and meatotomy had a penile block with plain lidocaine for anaesthesia with sedation using diazepam. Dilatation is done to the size appropriate for the child's age (10 French for 6 months to 3 years and 12 French for 4 to 10 years. Patients who had meatotomy had a hemostat applied to the ventral aspect of the stenosed orifice for about 5 mins before a ventral slit was made with sharp scissors to widen the Results were presented in tables and charts.

Results [Tables 1-5]
The total number of boys delivered in the hospital during the study period was 8095. Thirty-four were uncircumcised for religious reasons and 42 were not circumcised for health reasons. A total of 8019 boys were circumcised during the study period. Fifty-two of the boys circumcised had meatal stenosis and this puts the incidence of meatal stenosis in University of Port Harcourt Teaching Hospital (UPTH) as 6.48 per 1000.

Discussion
The diagnosis of meatal stenosis is clinical. With changes to the urethral meatus  In our study an incidence of 6.48 per 1000 was noticed. This is low compared to studies carried out in Iran by Joudi et al. [11] who had an incidence of 27 out of 132 boys between five and 10 years. Another author in sacramento, California had an incidence rate of 3 to 8 percent [12]. Sometimes it takes a while for symptoms to develop. In our study, the six to ten-year-old patients had the highest frequency with 53.84% of patients with meatal stenosis presenting within that age group and an age range of 10 months to 14 years. In a study carried out in New Zealand by Upadhyay et al. [9]   Poor stream or weak stream is a reduced urine flow compared to previous performance or to others [17]. Poor stream is due to reduced stream of urine secondary to the outlet obstruction [18]. Straining is the use of the muscles of the abdomen to initiate, maintain or improve urine stream thereby overcoming the bladder outlet obstruction [17]. The most common symptom in our study was poor stream which was followed closely by straining. Another author also noted that patients with meatal stenosis present with an upward, thin, poor urine stream [19]. With the scarring at the urethral meatus leading to fibrosis and narrowing of the meatus the urine stream becomes progressively poorer.
The bladder initially compensates and hypertrophies to enable it empty ade-  [21]. This leads to significant post void residual urine.
The bladder continues to decompensate till its contraction can no longer completely empty the bladder [18] [20]. This can lead to changes in the upper tract such as hydronephrosis, urinary tract infection, urosepsis and renal failure and even death [22]. In boys with an obstruction at the urethra, at the end of micturition the urine between the sphincters and the obstruction trickles out as post micturition dribbling [18]. In our study, post micturition dribbling was the least prevalent symptom. We also noted that some patients presented without symptoms and were only diagnosed during examination before catheterization. Adequate preoperative investigation is very important. Due to obstruction in the flow of urine some patients may present with features of urinary tract infection. The flow of urine helps to prevent stasis and colonization of urine by microorganisms [20] [23]. Adequate culture directed preoperative antibiotics are important in preventing and treating Urinary Tract Infection (UTI) in patients with meatal stenosis. We avoided the use of fluroquinolones in children because of premature closure of the epiphyseal plates.
Treatment for patients with meatal stenosis include any form of treatment that will make the meatus elliptical, prevent further narrowing and allow better flow of urine from the urethra. In our study, the three-treatment employed were dilatation (30.77%), meatotomy (46.15%) and meatoplasty (23.38%) as shown in Table 4(a).
Dilatation is the use of serial dilators to widen the meatus and aid better egress of urine. However, it may result in minor tears in the mucosa and lead to restenosis of the urethra. In our study three patients out of 16 (18.75% restenosis) who had urethral dilatation had restenosis following urethral dilatation. Meatotomy involves making an incision on the ventral surface of the urethral meatus. This helps widen the stenosis and was done as an office procedure. Re-stenosis following meatotomy is also possible [23]. In our study three patients out of 24 (12.5% restenosis) who had meatotomy had restenosis. We carried out meatal dilatation and meatotomy as office procedures using penile block and without general anaesthesia as seen in Table 4(c). This considerably reduced the hospital stay and cost of treatment. Another author also noted low cost of treatment with meatotomy without general anaesthesia [12]. The drawback is that some patients may have a restenosis which may require a meatoplasty [24]. Meatotomy with local anaesthesia is believed to be 10 times cheaper than a meatoplasty or meatotomy with general anesthesia [25], it is also a good form of treatment if the child cooperates and the anatomy is appropriate [12].
Patients who had meatoplasty needed general anaesthesia in theatre and this made treatment more expensive [12]. Patients who had meatoplasty had a low re operation rate [12]. In this study no patient who had meatoplasty developed a restenosis as shown in Table 4(b).
After treatment for meatal stenosis, patients were advised to use a lubricating gel to prevent adhesion of the edges. They were also followed up for 6 months. Some authors have acknowledged the need for follow up genital examination even after circumcision to identify meatal stenosis [11]. Follow up should also be instituted after treatment of meatal stenosis to identify re-stenosis. The prognosis seemed to be better for patients who had meatoplasty, than meatotomy and worse for patients with meatal dilatation as shown in the study in Table 4(b). The suturing of the mucosa to the skin tends to prevent re-stenosis since healing will be by primary intention with minimal scarring. In meatotomy the healing is by secondary intention and can cause excessive scarring and hence re-stenosis.
Most patients who presented with meatal stenosis had no other associated anomaly as shown in Table 5. However, 12 had hernia and 8 had undescended testes. A hernia may have resulted from the increased intraabdominal pressure used to aid voiding in these patients with meatal stenosis. No association was found between the patients with undescended testes and meatal stenosis.
In medical practice prevention is always better than cure. Post circumcision meatal stenosis can be avoided by application of petroleum jelly after circumcision [26] [27] [28]. Some authors have advocated the use of steroid based agents but this has been controversial. Some say it is not successful [29] while others believe that it can be useful [30]. In our study steroid based creams were not used because of the potential complications of steroid use such as weight gain, roundness of the face, mood changes, slower growth rate, osteoporosis and cataracts. Human amniotic membrane is believed to prevent meatal stenosis [31]. Human amniotic membrane is unavailable for use in our centre. Its use may be associated with a number of ethical issues. Some authors have argued that meatal stenosis is rarely present in uncircumcised boys but others have reported the fact that meatal stenosis following circumcision is low [26]. The advantages of circumcision seem to outweigh the disadvantages. The authors tend to favor circumcision because of its numerous advantages. A recent study carried out in Algeria found out that meatal stenosis is more common when circumcision is carried out in the first week, there is use of healing agents and when there is prior adhesion of the foreskin to the glans [32]. In our hospital we used petroleum jelly after circumcision and also after surgery for meatal stenosis. This is believed to prevent the edges from sticking back together thereby, preventing meatal stenosis after circumcision or restenosis after repair of meatal stenosis.

Limitations of the Study
This was a retrospective study and we could not get some of the information sought. Different cadres of health professionals carried out the circumcision, meatal dilatation, meatotomy and meatoplasty. These included junior residents, senior residents and consultants. The skill and experience of more qualified doctors will lead to a better outcome compared to the less experienced doctors.

Conclusion
Meatal stenosis is an uncommon complication post circumcision. Patients usually