Benign (Not Cancerous) Urethral Lesions in Children - Boys
Irregularities of the urethra in young boys are rare. But they can cause various problems with urination. What conditions should you watch for in your child? The following information should help you understand these different benign lesions.
What happens under normal circumstances?
Every young boy should be able to urinate freely with no pain, blockage or irregular streams.
What are some types of benign lesions in boys?
Urethral polyps: A urethral polyp is an irregularity existing at birth. It is usually composed of fibrous tissue but may include some smooth muscle, small cysts or nerve tissue all covered by a protective layer of tissue. If your son has a urethral polyp, there may be blood in the urine, symptoms of a urinary tract infection or problems urinating. The latter category can include a weak or intermittent urinary stream, straining when urinating, hesitating before urine flow begins, abrupt stoppage or the stream, dribbling at the end of urination, painful urination or a sense that the bladder has not emptied. Urethral polyps are diagnosed with cystoscopy, an endoscopic technique that allows a urologist to readily view the polyp, and a voiding cystourethrogram (VCUG). By combining an X-ray of the urethra with dye in the area, the doctor can easily view the structures.
Meatal stenosis: Refers to a very small urethral opening at the tip of the penis. Meatal stenosis occurs only in males. It results from irritation of the urethral opening at the end of the penis, which leads to tissue growth and scarring across the opening. The condition is most common in circumcised males and seldom occurs in uncircumcised males. In a recently circumcised male infant, maintaining a clean, dry diaper and avoiding any type of diaper irritation usually prevent meatal stenosis. This condition can also be associated with other urological problems like hypospadias, prolonged urethral catheterization, prior hypospadias surgery, trauma and balanitis xerotica obliterans (BXO).
Although the condition is usually not recognized until toilet-training, the following symptoms are commonly associated with meatal stenosis:
- occasional burning while urinating
- prolonged urination
- extremely narrow, almost needle-fine spray of urine rather than a full stream
- misdirected (upward, sideways) urinary stream, making it difficult for boys to urinate directly into the toilet
- bloody spotting in underwear
- inability to identify the urethral opening
Congenital urethral fistula: Although rare, a congenital urethral fistula refers to an abnormal passage that that occurs during the development in-utero between the urethra and the penile skin, somewhere beneath the normal urethral opening. During urination two streams of urine may be obvious — one coming from the urethral opening and the other from the site of the abnormal opening (fistula). A diagnosis is usually made by physical examination and observation of urination.
Diverticulum of the anterior urethra: Diverticula or pouch-like enlargements of the lower urinary tract can occur in both the bladder and urethra. These abnormal protrusions represent an increase in the diameter of the urethra. It can manifest in two forms:
- Saccular. The less severe condition where the diverticula arise from the floor of the urethra, causing a weak urine stream, straining and general blockage to urine flow, and in some cases, localized swelling during urination.
- Megalourethra. A more severe form where the entire urethra is affected. Two subsets of this condition include scaphoid megalourethra, which refers to a missing corpus spongiosum, and fusiform, a condition where both the corpus spongiosum and corpora cavernosa are missing. In this case, the entire penis expands into a spindle-like form during urination.
- Postoperative: This is the most common cause of urethral diverticula. It is generally associated with prior urethral surgery, typically hypospadias surgery. It is commonly associated with a narrowing of the urethra downstream to the diverticulm which increases the pressure in the urethra and leads to ballooning of the weak urethral tissue.
The general signs of urethral diverticulum include expansion of the urethra with bulging during urination, a weak urinary stream with dribbling afterwards and other associated irregularities, such as prune belly syndrome.
Cowper's duct cyst: Cowper's glands, also known as bulbourethral glands, are about the size of a pea and are located beneath the prostate gland. Their function is to produce a clear, colorless fluid before ejaculation, which cleanses the urethra and neutralizes acid to prevent damage to sperm. This liquid also provides a small amount of lubrication for intercourse. Cowper's duct cysts are those exit passageways that expand due to abnormal narrowing. They cause discomfort during urination, bloody spotting and a weakened urinary stream with dribbling afterwards. As with other benign urological lesions, the key test for this one is a voiding cystourethrogram.
Urethral duplication: Urethral duplication is a rare condition marked by various symptoms. It can be a complete replica of the organ with one or two openings or lesser conditions, such as one extra urethra with a joined opening. While most cases of urethral duplication are diagnosed by chance, the symptoms are prevalent. They include two urinary streams, infection in the extra urethra and obstructive symptoms resulting from a buildup of material.
How are benign lesions in boys treated?
Urethral polyps: Urethral polyps are surgically removed with the aid of a fiber-optic instrument that allows the urologist easy access to the urethra through the body's natural passage. Once inserted, the doctor uses miniaturized instruments threaded through the scope to remove the growth quickly and easily. In addition, the base of the polyp is eliminated through fulguration, an electrosurgical technique of burning off the final tissue with an electric current.
Meatal stenosis: The major treatment for this condition is meatotomy, a procedure which entails crushing (to prevent bleeding) and then cutting the urethral opening down the tip of the penis for several millimeters until the opening is sufficiently widened. A topical analgesic is applied prior to the procedure to avoid any discomfort. Once completed, parents will need to separate the edges of the opening twice daily for two to four weeks and apply ointment to prevent the opening from narrowing again.
If you, or your child, oppose this in-office therapy, the doctor may suggest an alternative treatment, a urethromeatoplasty. It is a very short outpatient procedure performed under general anesthesia. Your child will be anesthetized, with a local injection placed from the urethral opening to the tip of the penis. The doctor then clamps, cuts and sutures the area so the opening will stay open.
Congenital urethral fistula: Urethral fistula repair is carried out as an outpatient procedure using techniques popular for correcting hypospadias. That correction focuses on four steps: straightening the penile shaft, closing the opening and covering the repaired urethra with skin which may be taken from the foreskin and circumcising or reconstructing the foreskin.
Diverticulum of the anterior urethra: A complete urological evaluation is necessary given the high incidence of severe problems. Those patients with a better prognosis should undergo surgical tailoring of the diverticula using techniques similar to those used to correct hypospadias. For postoperative diverticula it is essential to determine if there is a narrowing downstream to the diverticula and if so this must be addressed initially or at the time of the diverticula repair.
Cowper's duct cyst: There exists a thin common wall between the bulbous urethra and duct and its opening. Endoscopic resection of this common wall will relieve symptoms. If the duct cannot be reached with an endoscope, open surgical repair is performed.
Urethral duplication: No treatment is necessary if the extra urethra is found by chance and is not causing debilitating symptoms. If the two openings are close together, with two urinary streams, surgery can be used to convert the streams into a single one. If the problem is accompanied by curvature of the penis (chordee), the surgeon may choose to straighten the organ and remove the extra urethra.
What can be expected after treatment of benign lesions in boys?
Urethral polyps: Any symptoms prior to the procedure should resolve themselves. There should be no recurrence of the polyp.
Meatal stenosis: In the first three days after surgery, your child may exhibit mild pain or difficulty urinating. If your son is very young, he may even try to avoid urinating because of the discomfort. Having the boy urinate in a tub full of water or placing his penis in a cup full of warm water when he urinates can alleviate the burning most of the time. The burning is usually limited to the first few times they urinate. Older boys able to swallow tablets usually receive an analgesic prior to the procedure and for three days following it. This medication helps greatly in preventing painful urination. There may be minor bloody spotting over the first few days. That should be of no concern unless it turns into significant bleeding, which is rare.
But the key step to prevent recurrence during healing (seven to 10 days) is to spread the urethral opening twice daily and apply ointment to the edges. This process will prevent painful or difficult urination and spraying of the urinary stream, which can occur from the incision crusting over. Recurrence tends to be higher with meatotomy because the raw edges of the urethral opening are more likely to stick together. That is especially likely if parents are not following the doctor's instructions.
Congenital urethral fistula: The final decision as to how often your child will be monitored via return checkups — none at all or routinely through puberty — will be up to you and your son's doctor.
Diverticulum of the anterior urethra: Those patients who have a penis that has a sac-like form are not going to have a functional penis except for the passage of urine. Those experiencing only mild variants should have a satisfactory functional penis. Patients with postoperative diverticula should have a normal result assuming that the original surgery corrected the underlying problem.
Cowper's duct cyst: Symptoms are generally relieved without recurrence.
Urethral duplication: Surgery should correct the problem so that a single urinary stream results. If successful, there should be no recurrence.
Frequently asked questions:
Are urethral polyps life-threatening (malignant)?
No. These are benign growths. However, all polyps are sent for biopsy after partial surgical removal for examination.
When should treatment be instituted for meatal stenosis?
While meatal stenosis is not an emergency, you should seek relief of this condition soon after diagnosis.
Do all urethral duplications require surgery?
Surgery is necessary only under certain circumstances, such as when it is accompanied by curvature of the penis causing two urinary streams. Surgery for this problem is fairly simple, focusing on dividing a common septum to allow a single urinary stream.
Reviewed January 2011
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