Chapter 65

### Key Points

1. Meatal stenosis is a condition that alters the direction of the urinary stream, but is not worrisome for obstruction of the urinary tract.

2. Posterior urethral valves present as a spectrum, from in utero obstruction which can be lethal due to pulmonary hypoplasia to a boy with persistent bedwetting and daytime incontinence. Long-term follow-up is critical to minimize the complications due to “valve-bladder syndrome.”

3. Dilated ureters that are discovered prenatally can be due to ectopic ureters, primary obstructed megaureters, or ureteroceles.

4. The management of megaureters has evolved, with many megaureters showing improvement and complete resolution with expectant management. Long-term follow-up is beneficial through adolescence to look for indolent obstructive changes over time.

5. Antenatal hydronephrosis can represent a ureteropelvic junction (UPJ) obstruction, but the onus is on the clinician to demonstrate the presence of obstruction since the majority of patients detected are asymptomatic.

Urinary tract obstruction in children presents in a variety of fashions, from the child who presents with episodic renal colic secondary to an intermittent ureteropelvic junction (UPJ) obstruction to the prenatal findings of a male fetus with significant bilateral hydroureteronephrosis, a distended bladder, and oligohydramnios that can be the hallmark of posterior urethral valves. This chapter will provide a broad overview of various types of obstruction and their pathophysiology, presentation, and diagnosis along with operative techniques to correct these obstructions.

### Meatal Stenosis

#### Pathophysiology

Meatal stenosis in boys is an acquired narrowing of the urethral meatus (Table 65-1). It is the result of prior episodes of meatitis in infants which occurs due to chronic irritation and ammoniacal inflammation of the meatus due to contact with urine, stool, or the diaper in infants who have been circumcised. This chronic meatal irritation leads to progressive, indolent scarring of the meatus with subsequent stenosis.

Table 65-1Normal Size of the Urethral Meatus in Boys

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