J. K. WYATT, Ml)D
The author has carried out a clinical study on 200 females of all ages presenting with
symptoms of urethritis, urethrotrigonitis or recurrent urinary tract infection.
The significance of distal urethral stenosis and the pathogenesis of the recurrent
urinary tract infection are discussed. Eighty-nine percent of young girls, 82 percent of
young women and 83 percent of older women were markedly improved or completely
relieved of their clinical symptoms following distal urethrotomy. This study demonstrates
that distal urethral stenosis is a real entity and that its correction by distal urethrotomy
may play a significant role in managing females of all ages with symptoms of urethritis or
recurrent urinary tract infection.
Dr. Wyatt is a clinical associate
ALTHOUGH MEATAL stenosis
male, many physicians have been
reluctant to accept a diagnosis of meatal or distal urethral
stenosis in the female." 2 In part this may be due to the
greater difficulty in examining and calibrating the female
urethra. In addition, the relative stenosis in a much larger
urethral lumen is difficult to assess. Finally there is often a
paucity of urinary tract findings accompanying many cases
of distal urethral stenosis.
Over a decade ago, when the terms meatal stenosis and
external urethral meatotomy were in vogue, there was an
over simplification of the pathological process. In reality,
there are very few cases of pure meatal stenosis in the
female and most of these occur in young girls. More
frequently, the process is one of distal urethral stenosis
involving the distal 1 cm of the urethra.
Distal urethral stenosis in the female is largely develop-
mental. Its clinical significance is uncovered only when
urethritis becomes associated with it. There are many
causes of urethritis in the female; it may be inflammatory
is a well recognized
professor of surgery at the University of Western
due to associated vaginitis, the trauma of an active sex life
and delivery of children, or chemical as seen with bubble
foams. Urethritis may also be bacterial, and in these
total paraurethritis extending to the trigone level of the
degree of urethral obstruction
patients leads to a further involvement of the paraurethral
tissue, through an increased lateral intraluminal pressure
produced as a result of straining to void. Paraurethral
phragm, which consists of striated muscle, produces an
irritable and spastic type of constriction about the mid-
urethra which can be very difficult to correct and may well
persist after the distal urethral stenosis has been corrected.
Persistent urethritis can lead to posterior papillary urethritis
trigonitis including the pseudomembranous form and even-
tually, especially in older women, cystitis cystica.
I am convinced that female urethritis is the most poorly
it invades the paraurethral ducts, producing a
at the level of the female urogenital dia-
CANADIAN FAMILY PHYSICIAN/DECEMBER, 1975
Figure 1. Technique of distal urethrotomy in the female.
A. Urethral meatus picked up with mosquito forceps at 5
and 7 o'clock positions.
B. Incision of the distal urethra for at least 1 cm.
C. Mucosal edges of the urethra and vagina approximated
transversely with 0000 chromic interrupted suture.
D. Five sutures are usually adequate and demonstrate the
permanent enlargement of the distal urethra.
Clinical Presentations of 72 Young Girls
Recurrent urinary tract infections
Urethritis (frequency and urgency)
Voiding Cystourethrograms in 72 Young Girls
Endoscopic Findings in 72 Young Girls
Normal bladder and proximal urethra
with distal urethral stenosis
Total urethritis and urethrotrigonitis
Hymenal adhesions and tethering
Fibrous meatal ring
managed disease entity encountered in office urology -
largely because it is so commonplace and fraught with what
appears to be a high failure rate. I believe that the majority
of females with urethritis and associated distal urethral
stenosis can be completely relieved of their symptoms or at
least markedly improved by means of performing a distal
Clinical Material and Results
Over the past ten years I have personally performed
approximately 1000 distal urethrotomies in females of all
ages. Time did not permit a review of this total experience
and therefore 250 cases were taken in alphabetical order so
as not to preselect the patients. The results of these
patients' clinical assessment and treatment form the basis of
Distal urethral stenosis was diagnosed through gripping
of the distal urethra on the withdrawal of a bougie a boule.
In the infant, a French bougie up to size 16 should be used;
in the young girl under 16, a no. 22, while sizes up to 28
should be used in women over 16 years of age.
With the 250
accomplished in 200 (80 percent), 138 of these by office
follow up and 62 by questionnaire. The followup period
ranged from one to ten years.
The clinical picture of distal urethral stenosis divides
itself nicely into three age groups - young girls (infants to
age 16), young women (16 to 50 years) and older women
(over 50 years). In this series there were 72 young girls, 93
young women and 35 older women.
follow up was
The clinical presentation in the 72 young girls is shown
in Table 1. Enuresis occurring in 23 girls represents in most
cases urethritis in sound sleepers. If the 21 cases of daytime
frequency and urgency are combined with these enuretics,
44 of the 72 girls (61 percent) presented in this manner. Of
more interest was the fact that 23 or 32 percent of these
girls presented not with urethritis but with verified bouts of
recurrent urinary tract infection. This represents a third of
all the girls in this series.
Excretory pyelography and voiding cinecystourethro-
graphy were performed in 94 percent of the girls (i.e. 68 of
72). Excretory pyelograms were normal in 94 percent of
the cases - four girls showed radiographic evidence of
pyelonephritis with calyceal scarring and loss of renal
parenchyma. However, the voiding cinecystourethrogram,
always performed before any instrumentation, revealed
abnormal studies in 27 girls or 40 percent of the cases
The endoscopic findings are outlined in Table 3. Only
seven of these 72 girls or approximately ten percent had a
true fibrous or circular ring as previously described by other
percent had stenosis of the distal one centimeter of the
urethra. The largest group of 26 girls had distal urethral
stenosis alone; 16 girls had urethral trigonitis, while 11 had
hymenal adhesions with a tethering effect of the distal
urethra. Five girls had midurethral stenosis indicating, even
at their early age, paraurethritis with involvement of the
urogenital diaphragm. Only two of the 72 cases had cystitis
changes of the bladder usually associated with persistent
lower urinary tract infection.
The results of distal urethrotomy in these young girls are
given in Table 4. Eighty-nine percent were either markedly
i.e. true meatal stenosis. The remaining 90
CANADIAN FAMILY PHYSICIAN/DECEMBER, 1975
improved or completely relieved of their symptoms. There
was a failure rate of 11 percent.
As anticipated, the largest group consisted of the 93
females aged 16-50. The major clinical presentation was
recurrent urethritis, as seen in 88 percent of the cases.
(Table 5). Hematuria and loin pain were relatively common
associated complaints. The incontinence involved was of a
dribbling nature and not urgency or stress incontinence.
The presence of urinary tract infection was carefully
sought in this category, but since 52 of the 93 patients were
already on suppressive antimicrobial therapy when first
seen, the yield of positive cultures was relatively low (13 of
93 cases or 14 percent).
In contrast to the young girls, radiological assessment
was done less frequently in the young women. Thirty-three
patients had excretory pyelograms and all but one were
normal. One case showed a contracted small left kidney.
Only 50 percent of these 33 patients had voiding cinecysto-
urethrograms and all were normal.
revealed a higher percentage with well established urethro-
trigonitis and cystitis cystica (60 percent and five percent
respectively). The results of distal urethrotomy in the
young women revealed 76 women of the 93 (82 percent)
were improved or completely relieved. There was a failure
rate of 18 percent.
The presenting complaints in the 35 patients in this
group are shown in Table 6. Although urethritis was seen
alone in 12 cases or about 1/3 of these women, it was
usually complicated by associated symptoms of incon-
tinence in eight cases and hematuria in seven cases. Again
assessment of urine cultures was impossible, since almost 50
percent were on antimicrobial therapy and five patients had
had previous anterior bladder repairs when first seen.
Radiological findings simulated those of the young women
and were performed with even less frequency.
Endoscopic examination revealed a further increase in
the incidence of urethrotrigonitis (66 percent) and also in
the presence of cystitis cystica (11 percent). Finally the
results of distal urethrotomy in this group revealed im-
provement or complete relief in 29 of the 35 women (83
percent) with a 17 percent failure rate.
The overall endoscopic findings and results of distal
urethrotomy in the three groups are summarized in Table 7.
Female urethritis is common; in most instances it is of
short duration and easily managed. When urethritis de-
velops in a female with distal urethral stenosis, the process
persists and responds less readily to the routine measures of
urethritis and the distal stenosis lead to an increased lateral
intraluminal pressure created by frequent and forceful
micturition. This increased lateral pressure impairs the
venous, lymphatic and glandular drainage producing conges-
tion, edema and stasis in the paraurethral tissue. Introduc-
tion of bacteria
established colonization of the paraurethral glands and a
true bacterial urethritis.
Persistent urethritis and frequency of micturition may
lead to ineffectual bladder emptying with residual urine.
The colonized paraurethral glands may then allow easy
access of bacteria into a bladder with residual urine
leads toa well
Results of Distal Urethrotomy in 72 Young Girls
Presenting Complaints and Associated Findings
in 93 Young Women
Prolapsed mucosa and hematuria
Presenting Complaints in 35 Older Women
Endoscopic Findings and Results of Distal Urethrotomy
in the Three Groups, Expressed in Percentages
Results of Distal
over 50 yrs.
CANADIAN FAMILY PHYSICIAN/DECEMBER, 1975
producing recurrent bouts of bacterial cystitis.
In this study, we found that one-third of the girls had
recurrent urinary tract infection when first seen. Only four
of the 72 had radiographic evidence of pyelonephritis, the
remainder showing normal upper urinary tracts. However,
40 percent of the girls did have abnormal voiding cinecysto-
grams (Table 2). There were 17 girls with vesicoureteral
reflux, eight with marked dilation of the urethra and two
with trabeculated bladders.
McAninch3 has previously shown increased intravesical
pressures in a high percentage of girls who had both dilated
urethral and normal urethral profiles on voiding cinecysto-
graphy. In the present study, 15 of the 17 girls with
vesicoureteral reflux and all eight with dilated urethras
returned to normal after distal urethrotomy. The two with
trabeculated bladders remained unchanged by the proce-
dure. These findings suggest that if left untreated, increased
intravesical pressure found in many of these girls could lead
to a very high incidence of pyelonephritis by means of
infected residual urine in the presence of vesicoureteral
Kunin and others4 have demonstrated that in 60 percent
of girls with urinary tract infection, there was a recurrence
within one year and that 75 percent showed a recurrence
within two years. One cannot help but wonder if there were
not a large number of cases of urethritis and distal urethral
stenosis accounting for the high recurrence rate.
Many of the girls presenting with recurrent urinary tract
infections had normal excretory pyelograms and voiding
cinecystograms. I disagree with those who state that if the
excretory pyelogram and the voiding study are completely
normal, no additional information can be gained by further
examination.5 These children definitely require endoscopic
evaluation and calibration of the urethra to avoid missing
significant urethral pathology that may be responsible for
the recurrent urinary tract infection.
It was gratifying to see the complete relief of urethritis
and urethrotrigonitis in 47 percent of the girls. In addition,
there was marked improvement in 42 percent of the girls;
however, seven of them required antimicrobial therapy for
patients) who were considered unimproved, seven con-
tinued with enuresis as their only complaint while one had
continued daytime frequency. This 11 failure group all had
sterile urines without anti-microbial therapy.
The technique of distal urethrotomy is simple (see
Figure 1). In all age groups the procedure is performed
under general anesthesia. Injection of local anesthesia into
this extremely sensitive area produces further distortion of
the distal urethra and leads to inadequate urethrotomy. The
only two cases of complications following distal urethro-
tomy I have seen have been hematomas with disruption of
the repair; in both patients, the procedure had been done
with local anesthesia.
It was difficult to determine the true incidence of
recurrent urinary tract infection in 93 young women, since
52 (56 percent) were already on antimicrobial therapy for
well documented urinary tract infection. I was able to
obtain a positive urine culture in only 25 percent of these
women. However, the endoscopic findings support the
theory that with time the pathological process of urethritis
and paraurethritis extend to involve the trigone of the
bladder. Sixty percent of these 93 women had established
urethrotrigonitis (Table 7). Urethritis and urethrotrigonitis
were markedly improved or completely relieved in 82
percent of these women.
The older females in this study were similar to the
younger women in the difficulty of defining significant
recurrent urinary tract infection, because 50 percent were
on antimicrobial therapy when first seen. Again, continued
progression of the underlying pathology was evident in that
66 percent of these women over 50 years of age had well
established urethrotrigonitis and 11 percent had cystitis
The results of distal urethrotomy were most rewarding
in the older age group. Although only 29 percent were
completely relieved, 54 percent were markedly improved -
a total of 83 percent, which is almost identical with the
The adult females who remained unchanged following
distal urethrotomy (17 young women and six older women)
have been followed over the years. They show intermittent
recurrent urinary tract infection. Further calibration and
dilatation of the proximal urethra in these women reveals
urethral sounds at the level of the
urogenital diaphragm. I believe most of these failures result
spasm of the striated muscle of the urogenital diaphragm.
The author has been reluctant to subject this group of
patients to internal urethrotomy. Their subsequent manage-
ment has been periodic dilatation of the proximal urethra,
low dosage suppressive antimicrobial therapy and periodic
endoscopic evaluation especially in those females with
established cystitis cystica.
infection and subsequent
Distal urethral stenosis is usually not clinically signi-
ficant until there is associated urethritis. The pathological
consequences of this association are the establishment of
paraurethral inflammation and bacterial infection. I have
shown that a large percentage of recurrent urinary infection
in females of all ages has been totally corrected or markedly
improved by distal urethrotomy. In addition, 89 percent of
young girls, 82 percent of young women and 83 percent of
older women were markedly improved or completely
relieved of their clinical symptoms.
Although there are many causes of urethritis in the
female, persistent symptoms and presence of recurrent
urinary tract infection should suggest associated distal
Finally, I feel that this study demonstrates that distal
urethral stenosis is a real entity and that its correction by
distal urethrotomy may play a significant role in managing
females of all ages with symptoms of urethritis or recurrent
urinary tract infection.
The author is indebted to Miss Catherine Wyatt for the
research work on the clinical records.
1. KEITZER, W. A., and BENA VENT, C.: Bladder neck obstruc-
tions in children. J. Urol. 89:384:1963.
2. ARNOLD, S. J.: Stenotic meatus in children: an analysis of160
cases. J. Urol. 91:357, 1964.
3. McANINCH, L. N.: External meatotomy in the female. Can. J.
Seurg. 8:382, 1965.
4. KUNIN, C. M., DEUTSCHER, R., and PAQUIN, A. J.: Urinary
Medicine (Bait.) 43:91, 1964.
S. HOLLAND, N. H. and WEST, C. D.: Prevention of recurrent
urinary tract infections in girls. Am. J. Di.s. Child. JO.S:S60, 1963.
CANADIAN FAMILY PHYSICIAN/DECEMBER, 1975