Urethral Prolapse

Urethral prolapse is eversion of the distal urethral mucosa through the external meatus, forming a circular, red, doughnut-shaped mass.

• It occurs in two groups: prepubertal girls (peak age 5 to 8 years, mostly of African descent) and postmenopausal women.
• Pathogenesis: weak attachments of the urethral mucosa to the underlying muscle, with raised intra-abdominal pressure (constipation, cough, straining) and low oestrogen (postmenopausal and prepubertal).
• Other risk factors: trauma, urethral infection, malnutrition, congenital weakness, obesity, and previous surgery.

Painless vaginal bleeding or spotting on underwear, a visible mass at the introitus, dysuria, frequency, difficulty voiding, perineal discomfort, occasional retention.

• Examination: friable, erythematous, oedematous circumferential mass with a central meatus (a central lumen helps differentiate it from other masses); may be purple-black if strangulated.
• Differential diagnosis: urethral caruncle (posterior wall, postmenopausal), urethral polyp, ureterocele (prolapsing), vaginal or cervical prolapse, sarcoma botryoides (rhabdomyosarcoma), urethral carcinoma, periurethral cyst, condylomata, sexual abuse (where suspected, examine and refer appropriately), haemangioma.
• Complications: strangulation with necrosis, infection, urinary retention, recurrent prolapse, haemorrhage, scarring and meatal stenosis.

Clinical examination in the frog-leg position (child) or lithotomy (adult), identifying a central meatus; a catheter or probe can be passed through the centre.

• Urinalysis and culture; cystoscopy or vaginoscopy if the diagnosis is uncertain; ultrasound of the bladder and kidneys when voiding symptoms.
• Biopsy for atypical lesions in adults or suspicious features; exclude malignancy.
• Evaluate for constipation and cough triggers.

Supportive: treat constipation (lactulose 5 to 10 mL twice daily in children or macrogol 0.4 to 0.8 g/kg daily), treat chronic cough, avoid straining, good perineal hygiene, warm sitz baths for 10 to 15 minutes two to three times daily.

Pharmacological

• Initial conservative therapy: topical oestrogen cream (oestradiol 0.01 percent cream or conjugated oestrogen cream 0.625 mg/g) applied in a thin layer to the prolapse and meatus once or twice daily for 2 to 4 weeks in children; estriol 0.1 percent (1 mg/g) or oestradiol 10 microgram vaginal tablet in postmenopausal women; response in 50 to 80 percent.
• Topical antibiotic or anti-inflammatory creams (fusidic acid 2 percent three times daily) if secondary infection.
• Analgesia: paracetamol 15 mg/kg in children, 1 g in adults every 6 hours.

Procedures: surgical excision for necrotic, large, symptomatic, retaining or non-responding prolapse: circumferential resection of the prolapsed mucosa over a catheter with absorbable 4-0 sutures to the normal urethral mucosa, or urethral ligation; hospital stay 1 day, catheter 24 to 48 hours; recurrence 5 to 10 percent.

Special groups: children (exclude abuse where there is other evidence, treat constipation), postmenopausal women (long term vaginal oestrogen), strangulated prolapse (urgent excision).

Red flags: black or necrotic tissue, retention, severe bleeding, mass with irregular surface (biopsy), features of abuse.

Follow-up: review at 2 to 4 weeks; recurrence advice; maintain oestrogen in postmenopausal women; manage constipation in children.