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Factitious Dysuria in Boys
0022-534 7/82/1283-0558$02.00/0
THE
Vol. 128, September Printed in U.S.A.
JOURNAL OF UROLOGY
Copyright© 1982 by The Williams & Wilkins Co.
FACTITIOUS DYSURIA IN BOYS A. BARRY BELMAN From the Departments of Urology, Children's Hospital National Medical Center and George Washington University School for Health Sciences, Washington, D. C.
ABSTRACT
Dysuria sufficiently severe to provoke manual compression of the urethra to disrupt the urinary stream is reported in 5 boys between 6 and 11 years old. This cycle of dysuria, acute urethral dilatation secondary to acute transient urethral obstruction, was broken by counseling the boys to cease urethral compression. No underlying cause was noted in 1 child evaluated extensively. The remainder had cessation of symptoms with local therapy and counseling. Mild intermittent dysuria in prepubertal boys is a common complaint that rarely justifies medical consultation. However, patients occasionally complain of severe dysuria compelling one to attempt determination of the underlying cause. Several such cases recently were encountered leading to an interesting discovery.
hemorrhages nor ecchymoses were present in any but the habit pattern was discovered to be the same. All were advised to discontinue squeezing the penis and at followup 6 months after the initial presentation the symptoms had completely resolved in 2. The third patient had moved from the area and followup was not possible.
CASE REPORTS
DISCUSSION
Case 1. An 11-year-old boy was seen on July 1, 1980 with a 1-year history of severe intermittent dysuria. Other than periodic blood staining on his undershorts he denied hematuria, urinary tract infections, a diminished stream or enuresis. Previous urologic evaluation elsewhere had included excretory urography (IVP) and cystourethroscopy. No cause for his complaints had been discovered. A separate voiding cystourethrogram had not been performed. Treatment with phenazopyridine hydrochloride had not relieved the symptom. Examination of the abdomen was negative. The penis was circumcised and the urethral meatus appeared to be of adequate caliber. However, petechial hemorrhages were noted on the right side of the distal shaft and glans penis. Urinalysis was negative. The patient denied penile trauma and stated that he had been unaware of the presence of the petechiae on the penis. Upon questioning the boy further in an effort to explain the symptoms and the etiology of the petechiae, it was discovered that he compressed the glans while voiding to interrupt the stream. He stated that this was in response to the severity of the dysuria. He was counseled to desist in this practice, soak in the tub if he had dysuria and to report back in 2 weeks on his status. No further episodes of dysuria occurred during the following 12 months. Case 2. A 6-year-old boy presented on December 18, 1980 with severe intermittent dysuria of sufficient magnitude to evoke tears. There was no history of a diminished urinary stream, urinary tract infection or hematuria. Physical examination revealed a healthy, cooperative boy with no abdominal masses or tenderness and a circumcised penis with an adequate appearing urethral meatus. An ecchymosis, about 1 cm. in diameter, was noted on the right lateral aspect of the distal shaft and glans penis. Urinalysis was negative. The child was then asked if the dysuria was sufficiently severe for him to squeeze the penis to prevent urination, to which he responded in the affirmative. He was then instructed to stop this practice and no further evaluation was done. Although the child complained of occasional episodes of dysuria during the next 10 months, these were mild and unassociated with urethral compression, and abated spontaneously. Subsequently, 3 additional patients, between 8 and 9 years old, with similar complaints have been seen. Neither petechial
Intermittent mild dysuria is a complaint of young boys heard frequently by pediatricians and pediatric urologists. In the vast majority this condition appears to be of no consequence and in the absence of culture-documented urinary tract infection or gross hematuria would not appear to require evaluation. The etiology is unknown but one would assume that it is a consequence of urethral irritation. Post-micturition urethral bleeding (urethrorrhagia) is also a relatively frequently encountered complaint in a pediatric urologic practice, the cause of which is also not understood. It has been suggested that urethrorrhagia is the result of a proximal urethral inflammatory process. However, the underlying agent has not been identified. 1 Another explanation for this symptom is the presence of a dorsal diverticulum in the region of the fossa navicularis. 2 Certainly, urethral stimulation by a foreign body would account for either symptom but all of the aforementioned children denied this as a possible etiology. A forceful urinary stream in association with a relative meatal stenosis could, potentially, cause urethral dilatation along with mucosal irritation and bleeding. No evidence exists to support this theory objectively. Nevertheless, overstretching of the urethral mucosa in response to a forceful urinary stream may be the underlying cause. Response of the children presented herein suggests that, occasionally, dysuria can become sufficiently severe to motivate manual disruption of the urinary stream. Abrupt discontinuation of the stream in this manner causes hydrodynamic urethral stretching and apparently increases urethral irritation. The result is a cycle that ultimately exacerbates the underlying symptom. Sitz baths and frequent voiding appear to be adequate therapy, assuming the manual urethral compression is discontinued by the patient. Radiographic evaluation should be reserved for those with actual gross hematuria or documented urinary tract infection. It is doubtful that endoscopy has a role in finding an underlying cause for this problem. REFERENCES l. Kaplan, G. W. and Brock, W. A.: Deep urethral inflammatory
disease. Read at annual meeting of Academy of Pediatrics, Detroit, Michigan, October 25-30, 1980. 2. Sommer, J. T. and Stephens, F. D.: Dorsal urethral diverticulum of the fossa navicularis: symptoms, diagnosis and treatment. J. Urol., 124: 94, 1980.
Accepted for publication December 23, 1981. 558
THE
Vol. 128, September Printed in U.S.A.
JOURNAL OF UROLOGY
Copyright© 1982 by The Williams & Wilkins Co.
FACTITIOUS DYSURIA IN BOYS A. BARRY BELMAN From the Departments of Urology, Children's Hospital National Medical Center and George Washington University School for Health Sciences, Washington, D. C.
ABSTRACT
Dysuria sufficiently severe to provoke manual compression of the urethra to disrupt the urinary stream is reported in 5 boys between 6 and 11 years old. This cycle of dysuria, acute urethral dilatation secondary to acute transient urethral obstruction, was broken by counseling the boys to cease urethral compression. No underlying cause was noted in 1 child evaluated extensively. The remainder had cessation of symptoms with local therapy and counseling. Mild intermittent dysuria in prepubertal boys is a common complaint that rarely justifies medical consultation. However, patients occasionally complain of severe dysuria compelling one to attempt determination of the underlying cause. Several such cases recently were encountered leading to an interesting discovery.
hemorrhages nor ecchymoses were present in any but the habit pattern was discovered to be the same. All were advised to discontinue squeezing the penis and at followup 6 months after the initial presentation the symptoms had completely resolved in 2. The third patient had moved from the area and followup was not possible.
CASE REPORTS
DISCUSSION
Case 1. An 11-year-old boy was seen on July 1, 1980 with a 1-year history of severe intermittent dysuria. Other than periodic blood staining on his undershorts he denied hematuria, urinary tract infections, a diminished stream or enuresis. Previous urologic evaluation elsewhere had included excretory urography (IVP) and cystourethroscopy. No cause for his complaints had been discovered. A separate voiding cystourethrogram had not been performed. Treatment with phenazopyridine hydrochloride had not relieved the symptom. Examination of the abdomen was negative. The penis was circumcised and the urethral meatus appeared to be of adequate caliber. However, petechial hemorrhages were noted on the right side of the distal shaft and glans penis. Urinalysis was negative. The patient denied penile trauma and stated that he had been unaware of the presence of the petechiae on the penis. Upon questioning the boy further in an effort to explain the symptoms and the etiology of the petechiae, it was discovered that he compressed the glans while voiding to interrupt the stream. He stated that this was in response to the severity of the dysuria. He was counseled to desist in this practice, soak in the tub if he had dysuria and to report back in 2 weeks on his status. No further episodes of dysuria occurred during the following 12 months. Case 2. A 6-year-old boy presented on December 18, 1980 with severe intermittent dysuria of sufficient magnitude to evoke tears. There was no history of a diminished urinary stream, urinary tract infection or hematuria. Physical examination revealed a healthy, cooperative boy with no abdominal masses or tenderness and a circumcised penis with an adequate appearing urethral meatus. An ecchymosis, about 1 cm. in diameter, was noted on the right lateral aspect of the distal shaft and glans penis. Urinalysis was negative. The child was then asked if the dysuria was sufficiently severe for him to squeeze the penis to prevent urination, to which he responded in the affirmative. He was then instructed to stop this practice and no further evaluation was done. Although the child complained of occasional episodes of dysuria during the next 10 months, these were mild and unassociated with urethral compression, and abated spontaneously. Subsequently, 3 additional patients, between 8 and 9 years old, with similar complaints have been seen. Neither petechial
Intermittent mild dysuria is a complaint of young boys heard frequently by pediatricians and pediatric urologists. In the vast majority this condition appears to be of no consequence and in the absence of culture-documented urinary tract infection or gross hematuria would not appear to require evaluation. The etiology is unknown but one would assume that it is a consequence of urethral irritation. Post-micturition urethral bleeding (urethrorrhagia) is also a relatively frequently encountered complaint in a pediatric urologic practice, the cause of which is also not understood. It has been suggested that urethrorrhagia is the result of a proximal urethral inflammatory process. However, the underlying agent has not been identified. 1 Another explanation for this symptom is the presence of a dorsal diverticulum in the region of the fossa navicularis. 2 Certainly, urethral stimulation by a foreign body would account for either symptom but all of the aforementioned children denied this as a possible etiology. A forceful urinary stream in association with a relative meatal stenosis could, potentially, cause urethral dilatation along with mucosal irritation and bleeding. No evidence exists to support this theory objectively. Nevertheless, overstretching of the urethral mucosa in response to a forceful urinary stream may be the underlying cause. Response of the children presented herein suggests that, occasionally, dysuria can become sufficiently severe to motivate manual disruption of the urinary stream. Abrupt discontinuation of the stream in this manner causes hydrodynamic urethral stretching and apparently increases urethral irritation. The result is a cycle that ultimately exacerbates the underlying symptom. Sitz baths and frequent voiding appear to be adequate therapy, assuming the manual urethral compression is discontinued by the patient. Radiographic evaluation should be reserved for those with actual gross hematuria or documented urinary tract infection. It is doubtful that endoscopy has a role in finding an underlying cause for this problem. REFERENCES l. Kaplan, G. W. and Brock, W. A.: Deep urethral inflammatory
disease. Read at annual meeting of Academy of Pediatrics, Detroit, Michigan, October 25-30, 1980. 2. Sommer, J. T. and Stephens, F. D.: Dorsal urethral diverticulum of the fossa navicularis: symptoms, diagnosis and treatment. J. Urol., 124: 94, 1980.
Accepted for publication December 23, 1981. 558