Urethral strictures in male children denote narrowing of the lumen of the urethra which can be of either congenital or acquired origin [
D. C., an 8-year-old male, was referred from the Yaoundé Central Hospital for the management of posterior urethral valves. The history revealed the onset of symptoms goes back to about a year before with obstructive voiding symptoms (straining to urinate and urinary intermittency). This prompted the diagnosis of a urinary tract infection for which he was treated with parenteral antibiotics without any improvement. An intravenous urography done thereafter was consistent with posterior urethral valves motivating admission. His past history was noncontributive, without any history of penile trauma. Circumcision had been performed during the neonatal period without any complications. Balanitis xerotica obliterans was not observed before the circumcision. On admission his physical examination was normal, except for suprapubic tenderness and a painful micturition test with a weak urinary stream. Our presumptive diagnosis was meatal stenosis or posterior urethral valves. Imaging investigations included an ultrasonography of the urinary tract that did not show any sign of urethral stenosis and a retrograde urethrocystography highlighted a stenosed anterior bulbomembranous urethra but no tight stricture (Figure
Stricture of the bulbous urethra as shown on the miction cystourethrogram (Case
K. T., aged 13 years, was admitted to the Emergency Department of Yaoundé Gynaeco-Obstetrics and Pediatric Hospital for acute urinary retention. The history revealed that the onset of symptoms dated back to a year before; he presented with lower urinary tract symptoms and overflow incontinence. His medical history revealed a history of mental retardation (probably related to fragile X mental retardation syndrome) but he had never been a subject to any genitourinary trauma nor urethral instrumentation. Circumcision had been performed during the neonatal period without any complications. Balanitis xerotica obliterans was not observed before the circumcision. On entry, the patient presented with mild fever (37.8°C) and especially a painful convex median suprapubic mass consistent with a fully distended bladder. There was no blood in the urine. The rest of his physical examination was normal. A presumptive diagnosis of urethral calculi was evoked. Initial management included suprapubic catheterization after failure of urethral catheterization. The urinary tract ultrasound did not visualize any calculi but revealed ureterohydronephrosis with enlarged kidneys (126 mm right and 129 mm left) and a thickened irregular bladder wall. The urine culture was positive for
Multiple strictures of the penile and posterior urethra shown on an AP view (Case
B. A., at the age 5 of years, experienced pain and difficulty on voiding. The mother reported previous similar symptoms at 8 months of age. The diagnosis of urethral meatal stricture was made. A meatotomy was performed at 2 years. The patient continued to have symptoms and presented with persistent daytime incontinence at our outpatient department. The mother denied any history of trauma but he did have a decreased force of stream and urinary terminal dribbling. Routine circumcision had been carried out during neonatal period without any complications. Lichen sclerosus was not reported before circumcision. Initial evaluation on admission revealed a palpable distended bladder and absence of urine stream. This clinical presentation was highly suggestive of urethral stricture. Ultrasonography of the lower urinary tract showed a distended bladder with an irregular thickened wall. Ultrasound studies of the upper urinary tract were normal and calcium stones were identified in the proximal urethra. A cystourethrogram demonstrated a pear shaped bladder and irregularity of the urethra: dilatation proximal and distal to two urethral strictures (Figures
Stricture of the posterior urethra as shown on the lateral view of the MCUG (Case
Multiple strictures of the urethra with a dilated bladder shown on MCUG (Case
Endoscopic view of an inflammatory urethra (Case
F. I., a 14-year-old teenager, presented with symptoms of painful urination, dribbling, and difficulty starting his urinary stream. The onset of symptoms had been gradual over the past 4 years. He gave no history of pyelonephritis, chills, fever, nor previous trauma. Routine circumcision had been carried out previously without any complications. Lichen sclerosus was not reported before circumcision. At the age of 10 years he experienced difficulty in voiding and acute urinary retention that requires suprapubic drainage. The diagnosis of urethral meatal stricture was made. Four years prior to admission, meatal reconstruction was realized. The biologic markers of inflammation were positive; urine studies and renal function were normal. Under general anesthesia, endoscopic evaluations demonstrated a hypertrophied bladder and a diffuse inflammation of the urethra and confirmed the presence of a stricture at the bulbous region of the urethra. The stricture area was dilated using the endoscope and a hinge 12 Foley catheter was left indwelling for 8 days. Following removal of the catheter, the patient voided normally and 12 months postoperatively, the patient has no symptoms and voids with a good stream.
E. D., at the age of 07 years, presented with haematuria, frequency, difficulty in voiding, and overflow incontinence. Three weeks prior to admission, he experienced dribbling and difficult urination. The mother reported previous difficulty from infancy and recurrent urinary tract infections; she denied any fever or chills. Ultrasound studies of the lower urinary tract showed a distended thick-walled bladder and the patient was admitted at the Pediatric Surgery Service for evaluation. Routine circumcision had been carried out previously without any complications. Lichen sclerosus was not reported before circumcision. On admission, the patient presented with a good general condition. Vital signs were normal: weight: 48 kg and temperature: 37°C; the rest of the physical exam was nonsuggestive. A retrograde cystourethrogram demonstrated stricture of the posterior urethra with a diverticulum of the bladder. The etiology of this stricture was not clear; the posterior location could presume posterior urethral valves as well as an infectious stricture. The urine was sterile and renal function was normal despite the raised markers of inflammation. A vesicostomy was first performed and the postoperative course was uneventful. At cystoscopic evaluation three months later, the urethra was patent and accepted a 16 F sound. A left lateral diverticulum of the bladder probably due to obstruction was seen. This was treated by placement of an indwelling catheter and closure of the vesicostomy was done during the same procedure. The catheter was removed 5 days later and the patient was discharged. At the four-month postoperative review, his urine stream was normal and urine culture negative.
Diagnostic difficulties in the reported cases focused on the origin of the urethral stenosis as the latter determines the management. The causes of the male urethra strictures are, indeed, a major issue in pediatric urology as they condition the treatment. The most common causes of acquired urethral strictures today are traumatic or iatrogenic [
Nontraumatic acquired strictures of the male urethra pose difficult diagnostic and therapeutic problems in our setting. There seem to be more arguments in favor of an inflammatory origin. The findings pointing to this origin will need a larger sample size to be confirmed. In the absence of urethrocystoscopy the vesicostomy remains the best option to prevent damage of the upper urinary tract.
The authors declare that they have no competing interests.
The authors thank the Swiss NGO children’s action and Pr Maurice Sosso who reviewed the paper.