Five-year-old Billy came in for his kindergarten physical. Mom said that he made it through the winter without any significant illness other than a persistent cough. His growth and development were right on target, and he was certainly ready for kindergarten from an emotional and intellectual standpoint.
As I was going through the review of systems, a checklist to include everything, we came to the genito-urinary system. Asking if he had ever had a urinary tract infection, mom said no. Had there been any accidents at night, or any bedwetting? After a long pause she looked at Billy and said, “Do you want to tell the doctor about when you go pee?” He didn’t say anything. Then mom said dismissively, “Oh, it’s not a big thing.”
This obviously perked my interest, so I asked him to explain what was going on. Billy said that he had to urinate often, and that he frequently had to leave class to go to the bathroom. But it was hard to “get the urine out”…it took a long time. And he felt as if he still had to go.
When Billy was so open in talking about this, mom jumped in. “His teacher says he frequently asks to go to the bathroom and he seems to be in there for a while. And at home it is the same thing. He even gets up during the night to urinate. But he never wets the bed.”
I asked if he had any pain when he urinated. Billy denied this, but said it tingled at times.
Did he have a steady stream when he urinated? He looked down and didn’t answer, and seemed a bit embarrassed. Glancing at mom, she seemed flummoxed that she didn’t know the answer. “I guess I should know the answer but I’m not sure…I really don’t know.”
Not wanting to put Billy on the spot I asked if the urine came out in a straight stream when he gave the sample in the office today. He said no. The urine comes out in a spray and literally shoots off to the side. “It is hard to hit the toilet bowl”
His mom sat up, seemingly amazed by this grand revelation, and exclaimed, “I never knew that. Wait until I tell your father about this. We never could figure out why you were such a bad aim.” She went on to say how they could always tell when Billy went to the bathroom because he seemed to hit everything except the toilet. She joked that her husband threatened many times to have a bull’s eye painted in the toilet bowl. She added, “We just thought it was a boy thing but were getting concerned as it wasn’t getting any better.”
Billy seemed relieved when I told him that I thought he might have a condition that was not at all serious and easily fixed. It is known as meatal stenosis. My exam revealed a small opening at the tip of the penis which confirmed my suspicions. I referred him to a pediatric urologist. It was repaired in an outpatient procedure.
Meatal stenosis is a condition that is seen in males, usually between the ages of three and seven years. It is not that common, but occurs mostly in boys who have been circumcised. The urethra is the tube that courses through the penis and through which the urine passes from the bladder. The meatus is the opening of the urethra at the tip of the penis. No one knows the exact cause of meatal stenosis. But some theorize that it may be from chronic irritation of the meatus caused by rubbing against diapers. This ultimately forms mild scarring which narrows the opening. That may explain why it is not very common in males that were not circumcised.
Meatal stenosis may caused a male to need to void frequently because they can’t fully empty their bladder. There may be discomfort or tingling with voiding. The urine usually comes out in a spray, or shoots off to the side or even upwards. Some boys have to bend forward and point to the floor just to hit the toilet bowl. In some cases there may be a drop of blood occasionally at the tip of the penis.
This is a benign condition that is easily treated by a pediatric urologist. Quite often it can be fixed in the office or by a brief outpatient procedure. After adequately numbing the meatus, the urologist breaks down the adhesions or scars, and re-establishes the opening. The recovery from this procedure is usually painless and not a big deal.