External Meatus Research Articles

PETAL – LIKE OTOPLASTY IN THE TREATMENT OF PROTRUDING EARS

Introduction. Approximately 5% of humanity suffers from inborn protruding ears, and usually this condition causes marked psychosomatic disorders. Despite years of experience gained in aesthetic surgery, optimal technique of otoplasty is yet to be elaborated. The Aim of the Research. To develop a method of surgical correction of congenital bulging ears in order to optimize the immediate and long-term results of otoplasty. Material and methods. We have analysed the outcomes of 120 patients operated for congenital protruding ears at Lviv City Cosmetologic Hospital between 2020 and 2023. Distance between mastoid process and the concha exceeding 20 mm, and auriculo-cephalic angle over 30° were used as objective criteria of protruding ears. Surgical improvement of tall concha and increased auriculo-cephalic angle were identified as key vectors in elaboration of the original otoplasty technique. Results of the Research. With local anaesthesia, an S-shaped incision is made to the depth of perichondrium of posterior surface of the cartilage of the ear. Once subcutaneous dissection is completed, preoperative markup is transferred with injection needles from anterior surface to posterior surface of the conchal cartilage. A full depth arch-shaped incision of conchal cartilage is made. Perichondrium and skin of anterior surface of the concha are mobilized with a raspatory, from the chondral «petal» to the margin of external meatus. Basis of the chondral «petal» is dissected by 2/3 of its depth along the vertical axis between the pedicle of the helix, and the antitragus. In order to reliably fix the auricula, the cartilage is stitched to the mastoid process with three mattress sutures on the ventral surface of the «petal». Finally, excessive skin is carefully resected, and the wound is closed with continuous suture, with dead space elimination for hematoma prevention. Our technique has the following significant advantages: Unique conchal cartilage is kept entirely, therefore it can be used as auto-transplant in the future. The technique does not significantly affect the rheology of auricula. With this technique correction and modification of antihelical curve and radius is possible; if necessary, width of auricula can be corrected, and auricular height to width ratio can be modified. The proposed «petal» technique significantly reduces the rate of postoperative complications, such as recurrent protruding ears. Postoperatively, the size of external meatus is not reduced, hence no hearing deterioration. The outcomes of the technique we have developed were assessed 6 months after otoplasty as good, satisfactory and unsatisfactory. Good outcome: preservation of symmetry and anatomical «standard» of both auriculas, no recurrence throughout follow-up, and no impairment of sensation in the external ear. Satisfactory outcome: anatomical «standard» of the organ is preserved, with permissible error of up to 3 mm in the symmetrical points on the right and left auriculas, not requiring additional correction. Conclusions. 98 (81,3%) patients operated by the proposed «petal» technique assessed their otoplasty outcome as good, 17 (14,3%) of patients assessed the outcome of surgery as satisfactory. 5 (4,3%) patients were not satisfied with the outcome of surgery. These patients were operated during the early period of development of the technique.

“Close-loop Urethral Stricture:" A Variant of Multiple Urethral Stricture Disease - Its Description, Management and Outcome: A Case Report

Abstract Urethral stricture disease is an abnormal narrowing and loss of distensibility of the urethra due to spongiofibrosis. It is commoner in young adult males. The management of this condition is diverse with various factors influencing the choice of treatment. However, length of the stricture is a major determinant of the choice of treatment. Two or more stricture sites close together are also treated as long segment stricture. Our aim is to describe a variant of multiple urethral strictures consisting of two short segment complete strictures involving the proximal bulbar urethral and urethral meatus with intervening significant length of normal urethra "close-loop stricture" in a 46-year old man who had traumatic urethral catheterization and was referred to the urology clinic six months following suprapubic tube cystostomy. KeywordsStricture, Meatotomy, Urethroplasty, Catheterization, Bouginage

Epispadias, a correctable cause of structural infertility in a middle-aged man: a case report

BackgroundEpispadias is a rare form of genito-urinary congenital anomaly and presentation in the middle-ages is even rarer. The reproductive outcome of treatment which was almost immediate, highlights the life changing effect of appropriate treatment for this condition in a middle-aged patient. We hereby report this rare case of a middle-aged man presenting with complete male epispadias with background infertility and the outcome of effective treatment. (Reviewer #1. Comment 1).Case presentationOur patient is a 54-year-old security guard who presented to our facility in February 2022 (Reviewer #1. Comment 3) with passage of urine from an abnormal opening since birth. Examination revealed a middle-aged man having ammoniacal smell. He had a spade like glans penis, ventral hooding, urethral meatus at the root of the penis dorsally with no chordee. He was diagnosed to have complete male epispadias (CME) for which he eventually had a modified Cantwell–Ransley procedure under general anaesthesia. About 3 months after the procedure, patient was able to impregnate his wife, a feat he will be achieving for the first time in his life.ConclusionsThe right treatment irrespective of age at presentation could significantly improve the quality of life of patients as evidenced by our patient whom after surgery was able to impregnate his wife for the first time at 54 years of age.

Anterior deflected urinary stream in female children: description of a unique clinical entity and surgical management.

To investigate the clinical presentation and outcomes for a series of female pediatric patients with severe anterior deflection of the urinary stream (ADUS) who were managed via urethromeatoplasty. This single institution retrospective cohort study used the institutional billing database to identify female patients ≤18 years who received a urethromeatoplasty (CPT 53450) from 2007 to 2022. Patients were included if a substantial anterior deflection of their urinary stream was the primary indication for surgery. Patients were excluded if they were >18 years of age, had a history of prior genital trauma, or underwent surgery for an indication other than a deflected urinary stream. Twenty female patients underwent urethromeatoplasty between 2007 and 2022, with a median age of 3 years old. All patients presented with difficulty aiming the urinary stream during toilet training and demonstrated a web of tissue along the posterior aspect of the urethral orifice. 19/20 patients noted immediate response (i.e., normal, non-deflected urinary stream) after the urethromeatoplasty with no further urinary complaints. There were no post-operative complications within a 90-day period. ADUS is a clinical entity characterized by a web of deflecting tissue at the female posterior urethral meatus that causes severe urinary deflection without other urologic symptoms. This is not well-described in the literature. Surgical correction via urethromeatoplasty is safe and effective.

Scoring System for Evaluating Cosmetic Appearance in Operated Hypospadias Patients

Background: Hypospadias is a common congenital anomaly affecting male infants, characterized by abnormal positioning of the urethral meatus. Surgical correction aims to achieve both functional and cosmetic outcomes.Objective: To evaluate the cosmetic outcomes of hypospadias surgery using a standardized scoring system.Methods: A prospective observational study was conducted at Shaheed Mohtarma Benazir Bhutto Institute of Trauma from January to July 2023, including 154 male infants and young children who underwent primary hypospadias repair.The surgeries performed were Tubularized Incised Plate (TIP) urethroplasty, Onlay Island Flap, and Mathieu repair. Cosmetic outcomes were assessed using the Hypospadias Objective Scoring Evaluation (HOSE) system. Data were analyzed using SPSS version 25.Results: The mean age at surgery was 2.8 years. Distal hypospadias was most common (62%), followed by midshaft (28%) and proximal (10%). TIP urethroplasty had the highest mean HOSE score (15.4 ± 1.0), with 86% achieving satisfactory outcomes. Onlay Island Flap scored 14.9 ± 1.2, and Mathieu repair scored 14.2 ± 1.5. Residual penile curvature was noted in 15% and scarring in 12% of cases.Conclusion: TIP urethroplasty yielded the most favorable cosmetic outcomes in distal hypospadias. Standardized scoring systems are crucial for evaluating surgical success.

Application of modified grafted tubularized incised plate urethroplasty in hypospadias

To investigate the clinical feasibility and effectiveness of the modified grafted tubularized incised plate urethroplasty (G-TIP), namely "glans G-TIP (GG-TIP) ", in treatment of hypospadias. A clinical data of 137 children with hypospadias qualified by the selection criteria between January 2021 and June 2023 was retrospectively analyzed. Among them, 75 children were treated with GG-TIP (GG-TIP group) and 62 with G-TIP (G-TIP group). There was no significant difference ( P>0.05) between the two groups in terms of age, hypospadias type, penile length, penile head width, penile head height, penile curvature, meatus-apex distance, urethral plate width, and distance from the distal endpoint of navicular groove to the dorsal or ventral midline point of the glans corona, and the difference between the two. The operation time, reconstructed urethral length, distance from meatus to ventral glans corona, postoperative complications, maximum urinary flow rate at 2 weeks after operation, and the hypospadias objective scoring evaluation (HOSE) score at 6 months after operation in the two groups were recorded and analyzed. The operation time was significantly shorter in GG-TIP group than in G-TIP group ( P<0.05); but there was no significant difference ( P>0.05) between the two groups in terms of reconstructed urethral length and distance from meatus to ventral glans corona. All urinary meatus located at the tip of glans with vertical fissure shape. All children in the two groups were followed up 6-35 months (median, 26 months). During follow-up, there were 3 cases of urethral fistula, 2 cases of urethral stricture, and 1 case of glans separation in GG-TIP group, and 3, 3, and 1 cases in the G-TIP group, respectively. There was no significant difference in the incidence of complications between the two groups ( P>0.05). The maximum urinary flow rate at 2 weeks and the HOSE score at 6 months after operation were significantly higher in GG-TIP group than in G-TIP group ( P<0.05). GG-TIP is safe and effective for repairing hypospadias in children. Compared with G-TIP, it has the advantages of relatively simple operation, shortened operation time, significant improvement in urinary flow rate, and better cosmetic results.

Comparison of the Vaginal and Labial Dimensions of Ethnic Chinese and Western Nullipara.

Vaginal dimensions have clinical and surgical implications. We sought to quantify the differences between vaginal and labial dimensions in healthy ethnic Chinese and Western women with normal pelvic organ support. This is a cross-sectional study of a convenience sample of ethnic Chinese nulliparas (n = 33) and Western nulliparas (n = 33) recruited for research purposes. For each subject, magnetic resonance imaging was used to quantify the vaginal and labial dimensions. Specifically, we identified the anterior and posterior vaginal wall, the outline of the cervix in the mid-sagittal and coronal planes, and the distance from the labia majora to the hymenal ring at the urethral meatus. There were significant differences in age and weight between groups. Substantial variation in vaginal and labial dimensions was found within each group. The vaginal and labial dimensions of ethnic Chinese women ranged from 9-21% smaller than those of Western women; In the ethnic Chinese group, increasing weight and BMI correlated with greater labial distance (r = 0.66 and r = 0.63 respectively); as did height and the distance from the vaginal opening to the cervical os (r = 0.5). In the Western group, only weight correlated with the labial distance (r = 0.51). Significant group differences in vaginal and labial dimensions were found, with the dimensions of Chinese nulliparas being up to 21% smaller than those of Western nulliparas.

The Development of a Biomimetic Model of Bacteria Migration on Indwelling Urinary Catheter Surfaces.

The aim of this study was to develop a novel biomimetic in vitro extraluminal migration model to observe the migration of bacteria along indwelling urinary catheters within the urethra and assess the efficacy of a prototype chlorhexidine diacetate (CHX) coating to prevent this migration. The in vitro urethra model utilised chromogenic agar. A catheter was inserted into each in vitro urethra. One side of the urethra was then inoculated with bacteria to replicate a contaminated urethral meatus. The models were then incubated for 30 days (d), with the migration distance recorded each day. Four indwelling catheter types were used to validate the in vitro urethra model and methodology. Using the biomimetic in vitro urethra model, E. coli and S. aureus migrated the entire length of a control catheter within 24-48 h (h). In the presence of a prototype CHX coating, full migration of the channel was prevented for 30 d. The results of this study support the hypothesis that catheter-associated urinary tract infections (CAUTIs) could be prevented by targeting catheter-mediated extraluminal microbial migration from outside of the urinary tract into the bladder.

Dissection of the Male Urethra Demonstrating Its Topographical Specificity.

The urethra is a long muscular tubular organ that changes its internal configuration as it traversesdifferent regions. Therefore, the pathology of each region is distinctive, and regional characteristics may influence exploration and treatment. We set out to perform detailed dissections of the male urethra and illustrate the regional specificity for each urethral segment. Therefore, we dissected the vesical cervix, showing both the normal appearance and the appearance of prostatic middle lobe adenoma. We dissected the prostatic urethra, showing the seminal colliculus, ejaculatory ducts, and prostatic utricle. We revealed the membranous urethra surrounded by the striated sphincter. We have shown the appearance of the spongy urethral bulb with its cul-de-sac appearance, the aspect of the urethral lacunae, the navicular fossa, and the external urethral meatus. We performed cross-sections through the prostatic urethra as well as dissection of the bulbourethral glands at the level of the urogenital diaphragm. All the information obtained through dissection is illustrated in high-quality graphic form and correlated with clinical applications, making this work valuable teaching material.

Ultrasonographic features of female urethral caruncle: a retrospective study of 20 patients

Female urethral caruncle is the most common urethral mass in postmenopausal women, yet there is a lack of studies on its imaging. The aim of this study was to provide a summary of the clinical and ultrasound features as well as the precise location of female urethral caruncle. This study reviewed the clinical and ultrasonographic records of 20 consecutive women with pathologically confirmed urethral caruncle. Data on patient demographics, symptoms, and transperineal and transrectal ultrasound imaging features, including location, shape, margin, size, blood flow, and inner echo of the caruncle, were extracted. Each patient presented with only one mass at the urethral meatus. Most caruncles were located on the posterior lip (75%) of the urethra, presenting as oval (80%), mixed-echoic (50%), or hypo-echoic (40%) nodules with abundant linear (40%) or dendritic (60%) blood flow. The average distance between the bladder neck and the cranial end of the masses was 28 mm. Hyper-echogenic spots, cystic echo areas, and macrocalcifications were detected in thirteen caruncles (70%). This study shows that transperineal combined with transrectal ultrasound can be used to assess female urethral caruncle, and its relative location to the urethra can be accurately described, which is helpful for surgeons making preoperative localization and conversations.

Urethral caruncle causes acute urinary retention

IntroductionWe encountered a case of urinary retention caused by a urethral caruncle.Case presentationAn 86‐year‐old woman presented to our hospital with urinary retention. When the urinary bladder catheter was placed, a smooth, well‐defined mass 20 mm in diameter was detected on the posterior wall of the external urethral meatus. The patient was diagnosed with urinary retention due to a urethral caruncle, and the mass was resected. The mass was pathologically compatible with a urethral caruncle. The patient could urinate postoperatively. Ultrasound test after surgery showed residual urine volume was 100 mL.ConclusionInspecting the urethral meatus is vital in the clinical examination of older women with voiding symptoms. A urethral caruncle is a rare cause of urinary retention. However, large urethral caruncles are at risk of causing urinary retention suggesting that resecting the urethral caruncles at an appropriate time is desirable.

Urethral prolapse in a 4-year-old girl: A case report

Background: Urethral prolapse is a rare cause of vaginal bleeding in prepubertal females and occursmore commonly in black girls. It is characterized by protrusion of the distal urethral mucosa at orbeyond the level of the urethral meatus. It is often mistaken for sexual abuse in children because itpresents with vaginal bleeding, creating anxiety among parents and confusion among clinicians.Case presentation: A 4-year-old girl presented to the outpatient department with a 2-day history ofvaginal bleeding. However, no lower abdominal pain was reported. Sexual abuse was initiallysuspected. A diagnosis of urethral prolapse was made during examination under anesthesia.Surgical excision and postoperative care were performed.Conclusion: Urethral prolapse, although rare, can occur in prepubertal black girls and is managedeither surgically or through conservative approaches.

Understanding the Endocrine and Molecular Signaling Cascade Regulation Pathways in Children with Hypospadias.

Hypospadias (HS) is a congenital defect that occurs due to defective androgenization. It is characterized by the aberrant location of the urinary meatus on the ventral aspect of the penis with various degrees of severity. The molecular mechanisms and genetic associations underlying the condition remain largely unknown. Existing literature revolves around surgical and medical management of the condition. Human chorionic gonadotropin pretreatment in HS is proposed to decrease the severity of the anomaly and improve the clinical outcome of surgery. The underlying mechanisms that drive these outcomes have not been explored. Few studies have explored the endocrine signaling and pathways which lead to the development of the condition. Hence, a prospective study was conducted to understand the same. Eighteen children with mid or proximal penile HS were included as cases, and nine children undergoing circumcision for phimosis (nonpathological) were included as controls. Serum samples from all these children and preputial skin samples taken during surgery were used in the analysis. The hormonal milieu was normal in all children in our cohort. A comparison of previously reported genes with our cohort sequencing revealed changes in several major pathways involved in cell proliferation and differentiation, cell signaling, angiogenesis, and immune response pathways. Compared with healthy controls, HS subjects had 152 differentially expressed genes. Of these, 93 genes were up-regulated, and 59 genes were found to be significantly down-regulated. The gene expression evaluation also showed changes in expression patterns in inflammatory genes and link RNAs, unlike previously reported genes.

Efficacy comparison between Mathieu combined urethral plate incision and onlay island flap urethroplasty for distal hypospadias in patients with urethral plate stenosis.

The aim of the study was to compare the efficacy of Mathieu combined urethral plate incision (Mathieu-IP) versus onlay island flap urethroplasty in patients with distal hypospadias complicated by urethral stenosis. The clinical data of 70 patients with distal hypospadias complicated by urethral plate stenosis treated in the Department of Urology, Anhui Provincial Children's Hospital (Hefei, China), from May 2019 to May 2022, were retrospectively analyzed. Thirty-eight patients underwent Mathieu-IP (Mathieu-IP group) and 32 underwent onlay island flap urethroplasty (Onlay group). Follow-ups at 1 month, 6 months, and 12 months postoperatively assessed operative time, complications, urethral meatus morphology, and family satisfaction. The Mathieu-IP group had significantly shorter operative time (mean ± standard deviation [s.d.]: 81.58 ± 5.18 min) versus the Onlay group (mean ± s.d.: 110.75 ± 6.05 min; P < 0.05). Surgical success rates were 78.9% (Mathieu-IP group) and 75.0% (Onlay group), with no significant difference ( P > 0.05). Complications were comparable between the groups. The Mathieu-IP group resulted in a vertical slit-shaped urethral meatus in 89.5% versus 13.8% in the Onlay group ( P < 0.05). Family satisfaction with general penile appearance and skin shape showed no significant differences, but the Mathieu-IP group had higher satisfaction with meatal position ( P < 0.05). Mathieu-IP offers simplicity, safety, and shorter operative time compared to Onlay. Both the techniques effectively treat urethral plate stenosis in distal hypospadias, with reduced postoperative complications compared to tubularized incised plate urethroplasty. Mathieu-IP results in a vertical slit-shaped urethral meatus which enhances urinary stream, indicating its potential for broader adoption.

Optimizing Mouse Urodynamic Techniques for Improved Accuracy.

Accurate measurement of urinary parameters in awake mice is crucial for understanding lower urinary tract (LUT) dysfunction, particularly in conditions like neurogenic bladder post-traumatic spinal cord injury (SCI). However, conducting cystometry recordings in mice presents notable challenges. When mice are in a prone and restricted position during recording sessions, urine tends to be absorbed by the fur and skin, leading to an underestimation of voided volume (VV). The goal of this study was to enhance the accuracy of cystometry and external urethral sphincter electromyography (EUS-EMG) recordings in awake mice. We developed a unique method utilizing cyanoacrylate adhesive to create a waterproof skin barrier around the urethral meatus and abdomen, preventing urine absorption and ensuring precise measurements. Results show that after applying the cyanoacrylate, the sum of VV and RV remained consistent with the infused saline volume, and there were no wet areas observed post-experiment, indicating successful prevention of urine absorption. Additionally, the method simultaneously stabilized the electrodes connected with the external urethral sphincter (EUS), ensured stable electromyography (EMG) signals, and minimized artifacts caused by the movement of the awakened mouse and manipulation of the experimenter. Methodological details, results, and implications are discussed, highlighting the importance of improving urodynamic techniques in preclinical research.

A case report of urethral prolapse in young girls: Clinical manifestations and surgical management

Background and importanceUrethral Prolapse (UP), first described by Solinger in 1732, is a rare condition characterized by the circular protrusion of the distal urethral mucosa through the external meatus, forming a hemorrhagic, sensitive vulvar mass. This condition is most commonly observed in prepubertal black females. This case report details the clinical manifestations and surgical management of UP in three young girls. Cases presentationThree girls, aged 4, 5, and 6 years, were admitted with symptoms of vaginal blood spotting. Physical examinations revealed moderate bleeding and a red ring of congested, edematous tissue prolapsing through the urethral meatus. Diagnostic procedures confirmed UP, and surgical management was undertaken. The surgical approach involved the complete excision of the prolapsed tissue and mucosal-to-mucosal anastomosis under general anaesthesia. Postoperative follow-up over a mean period of 11 years showed no recurrence or urethral stricture. Clinical discussionUP is a rare benign condition primarily affecting the female urethra, with several hypothesized etiologies, including weak pelvic floor structures and increased intraabdominal pressure. The typical presentation includes vaginal bleeding and a doughnut-shaped mass around the urethral meatus. Conservative management may be considered for mild cases, but surgical excision is recommended for severe cases, offering a safe and effective solution with low recurrence rates. ConclusionsUP in children, although rare, should be considered in cases of unexplained vaginal bleeding. Diagnosis is primarily clinical, and surgical resection provides a definitive and cost-effective treatment.

A Case of Urethral Foreign Body from 40 Years Ago with Scrotum Abscess and Urethroscrotal Fistula

A 70-year-old male came to our clinic with a high fever and left scrotal swelling. Following a diagnosis of left-side epididymitis, antibiotic treatment was started, though the swelling did not improve. Since an additional examination revealed an abscess in the left scrotum, scrotal incision and drainage were performed. Although the symptoms subsided, urine outflow from the incision was observed. The patient then noted that he had inserted a glass ball into the urethral meatus when he was about 30 years old. It was considered that an abscess and fistula had formed due to inflammation caused by the foreign body. Thus a transurethral surgical procedure was used for crushing and removal. The fistula disappeared within three months after the operation and the patient has not been affected by dysuria since that time. Symptoms may appear several years following insertion of a foreign body into the urethra. To the best of our knowledge, the present case is the longest term of indwelling, approximately 40 years, following insertion of a foreign body reported in Japan.

The role of vaginal ectopia of the external urethral orifice in the development of morphologic changes bladder of the mucosa in women

The role of vaginal ectopia of the external urethral orifice in the development of morphologic changes bladder of the mucosa in women

Congenital aural atresia in a 4‐month‐old Dalmatian

AbstractA 4‐month‐old female entire Dalmatian was presented for persistently excessive ceruminous discharge, suspected left aural malformation and decreased hearing. Otoscopic examination of the left ear showed a normal external meatus with an abnormal ending of the ear canal in a cul‐de‐sac. Computed tomography (CT) study of the head showed a diffusely tortuous and convoluted external ear canal with saccular distension and a stenotic area with the presence of a septum. Based on the clinical presentation and imaging findings, total ear canal ablation and lateral bulla osteotomy were performed. Macroscopically, the ear canal appeared to be sigmoid, as in the CT study. Notably, in the stenotic area, there was a membrane separating the vertical and horizontal ear canals. The histopathology of the external ear canal was consistent with that of hyperplastic otitis externa. No growth was observed on bacterial culture. The dog recovered uneventfully and no abnormalities were detected on re‐examination 2 weeks post‐surgery.

Rates of Urinary Tract Infection in Transgender Women Postvaginoplasty vs Cisgender Women: A Retrospective Cohort Study in a Large US Health Network

ObjectivesTo describe UTI risk 3-months post-vaginoplasty (VP) in transgender women (TW) compared to cis women (CW). MethodsUsing TriNetX (TriNetX, Inc., Cambridge, MA, USA), we built cohorts of 2,041 TW and 48,374,745 CW. Outcomes were ≥1 instance of UTI or Cystitis, and assessed from 3-6, 3-12, 3-36 months, and 3 months-10 years post-VP. TW and CW were age-cohorted (18-39, 40-59, 60-74) and compared at each time interval. Kaplan-Meier was used to account for loss to follow up, along with Hazard Ratios (HR) and log-rank tests to determine significance (p<0.05). ResultsFor all time intervals and age ranges, TW had a significantly (p<0.0001-p=0.0088) higher probability of developing a UTI compared to CW. The largest difference was ages 40-59 ten-years post-vaginoplasty. In this analysis, CW and TW had a 12.96% and 29.34% cumulative outcome incidence, respectively.Cox proportional hazard analysis demonstrated increased hazard for TW compared to CW. HRs between CW and TW ranged from 1.363 (ages 18-39 at 10 years, 95%CI:1.119,1.660) to 3.522 (ages 60-74 at 12 months, 95%CI:1.951,6.360). ConclusionsWe found a significantly higher probability of TW developing UTIs compared to age-cohorted CW.Contributing factors may include difficulties with neovaginal perineal hygiene, lack of commensal bacteria and vaginal mucosa, larger urethral meatus, high rates of meatal stenosis, and nonnative bacteria introduced through dilators and douching. These findings may help improve quality of post-operative care in TW.