Study Type -
Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Urethral
prolapse (UP) is a rare condition, with a suggested incidence of one in 3000. It occurs most often in prepubertal, primarily Black, girls. The underlying cause of this condition remains uncertain, although a lack of oestrogen is thought to have a role, owing to the preponderance of the condition in the prepubertal and postmenopausal age groups. A popular theory is that the problem arises as a consequence of poor attachments between the two layers of smooth muscle surrounding the urethra, combined with episodic increases in intraabdominal pressure. The most common presentation of UP is genital
bleeding or a mass. The classical appearance of UP (i.e. the 'doughnut' sign) enables diagnosis to be made easily on clinical grounds alone. Optimum management of UP is less certain, with opinion divided on the merits of
conservative therapy vs surgical excision.
Conservative therapy aims to reduce mucosal oedema, improve local hygiene and counteract lack of oestrogen by using a combination of any or all of the following: Sitz
baths, topical oestrogen cream, antibacterial wash/
soap and topical
antibiotics. Surgical management of UP involves excision of the prolapsed mucosa circumferentially. Several authors have reported success with surgical excision, but it carries a risk of developing
stenosis of the urethral opening. The present study supports previously reported findings by other authors in terms of demographics and clinical presentation. Patient ages ranged from 2 to 15 years and all girls were of Black race. They most commonly presented with a mass (8/21 patients) or
bleeding (6/21 patients) and diagnosis was confirmed on clinical examination, although one required a general anaesthetic (GA) to complete the examination. The present study shows that, in mild cases (usually where there is a mass without symptoms), UP can be successfully managed using conservative measures. In our practice, this involves the use of Sitz
baths. More importantly, the study shows that in cases with more symptomatic
prolapse or with evidence of vascular compromise, there is an alternative to a
surgical procedure and its potential complications. We have found reducing the
prolapse under a GA to be beneficial. Complete reduction was achieved in 3/7 patients, with no recurrence. The remaining four patients with partial reduction had improvement in symptoms, allowing
conservative therapy to continue and resulting in complete or almost complete resolution of
prolapse at follow-up. This approach has not been described previously in published literature on UP.
OBJECTIVE: A total of 21 girls, all of whom were Black and whose age range was 2-15 years, were diagnosed with UP between 1995 and 2008. Case notes were reviewed for age, symptoms, clinical findings, predisposing factors, management and outcomes.
RESULTS: Presenting symptoms were: mass (n= 8),
bleeding (n= 6),
dysuria/straining at micturition (n= 6), discharge (n= 1) and
constipation (n= 1). In all, 13 patients were managed conservatively because their symptoms were mild. Seven patients underwent
prolapse reduction under general anaesthetic (GA). In one patient, an examination under
anesthesia was done to confirm the diagnosis as bedside examination was not possible.
Prolapse reduction was complete in only three patients. Two patients had partial reduction, which resolved over the next 3 months. Two patients continue to have minimal residual
prolapse. A causative/precipitating factor was found in only one patient (severe chronic
constipation). She had a recurrence 2 years after reduction. There were no other recurrences.
CONCLUSIONS: