He Just Makes a Mess!

Patient Presentation
An almost 4-year-old male came to his well child visit. His mother complained that he “just makes a mess” every time he urinates into the toilet since he was toilet trained at age 3. She says that she and her husband have tried to work with him, but he seems to spray urine all over the back of the toilet. They have tried to assist him and to be able to urinate into the toilet bowl he needs to position his penis almost totally downward, otherwise in a semi-horizontal position his urinary stream to points upward. She denies that he has a splayed urinary stream. He denies any urgency, frequency, pain, pruritis, nor diurnal or nocturnal enuresis. She states that he urinates every 3-5 hours, and has soft bowel movements every day to every other day. His mother reported that he seemed to take a long time urinating and that if he was outside “he could hit a tree or rock several feet away.”

The past medical history is unremarkable.
The family history is negative for any genitourinary problems except for a great grandfather with benign prostatic hypertrophy and difficulty voiding in later life. There were no hearing problems. The review of systems was negative.

The pertinent physical exam showed a happy child who was growing and developing normally. He also had normal blood pressure readings during this and previous visits. The penile meatus was located at the tip of the penis and showed a small amount of extra tissue ventrally at the tip of the meatus (resembling a ski-ramp). The meatal diameter was small. His penis and testes were normal and he had a normal cremasteric reflex. The diagnosis of meatal stenosis was confirmed when the physician watched the child urinate as he had an upwardly-deflected, non-splayed urinary stream. The patient was referred to a urologist and the patient’s clinical course showed that he had a meatotomy without complications. At his 5 year well child examination, he reported no urinary problems or “making a mess.”

Meatal stenosis is a common problem. It can occur in up to 10% of circumcised boys. It is also more common in circumcised boys. This may be due to chronic irritation of the delicate tissues of the meatus caused by exposure to urine in the diaper and mechanical irritation of the diaper itself. Families may not notice the problem until the child is toilet training or afterwards because they do not witness the urinary stream and its deflection. Another potential mechanism is frenular artery damage during circumcision which results in ischemia and subsequent stenosis.

The history usually includes symptoms that the urinary stream is defected upwards and is high-velocity (= long distance). There may be pain or burning with urination, blood spotted underwear, and urgency, frequency or emptying of the bladder may be prolonged. Some children will sit during urination to alleviate the symptoms or need to move farther away from the toilet to aim the stream into the toilet. Depending on the tissues involved, some families may also report a splayed urinary stream.

Treatment includes possible dilatation with lubricated feeding tubes and followup lubrication of the site, or meatotomy which is curative and rarely has recurrence of the stenosis.

Learning Point
Ventral or dorsal displacement of the urinary stream can be caused by meatal stenosis, epispadias, and hypospadias. Splaying of the urinary stream can be seen in patients with meatal stenosis and congenital urethral polyps

Questions for Further Discussion
1. At what ag are most females or male children toilet trained for daytime urine?
2. What are indications for medical circumcision?

Related Cases


To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Penis Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Angel CA. Meatal Stenosis. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/1016016-overview (rev. 06/12/2006, cited 5/7/09).

Cooper C, Nepple KG, Hellerstein S. Voiding Dysfunction. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/1016198-overview (rev. 06/24/2008, cited 5/7/09).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital