URETHRAL PROLAPSE

is a rare condition characterised by the circumferential protrusion of the urethral mucosa through the urethral meatus. Recent epidemiological data is lacking but older reports estimate a prevalence of 1:3000 children. Urethral prolapse is commonly known to occur in pre-pubertal girls with a peak incidence between 7 to 8 years old. However, cases have also been reported among infants as young as 11 months old and adolescents aged 18 years old.

The exact cause of urethral prolapse in the paediatric and adolescent population remains unknown. Various theories have been conjectured including congenital weakness of the pelvic or urethral structures, increased intra-abdominal pressure as a result of chronic cough or constipation, trauma and oestrogen deficiency.

Diagnosis is made clinically. The majority of patients with urethral prolapse present with an asymptomatic periurethral mass discovered on routine examination. In advanced cases, patients may complain of bleeding or pain. They may also report urinary symptoms such as dysuria or voiding difficulties.

Careful examination of the perineum will reveal a classic doughnut-shaped mass surrounding the urethral meatus (Figure 1 and 2). Often, the mass is erythematous, tender to palpation and bleeds upon contact. The presence of the centrally-located urethral meatus can be confirmed by either direct visualization, insertion of an instrument tip, catheterization or observation of voiding.

Extensive investigations are rarely needed. The differential diagnoses of urethral prolapse include urethral caruncles or polyps, condyloma, rhabdomyosarcoma or urethral malignancy. Patients who present late may develop necrosis, ulceration and gangrene of the mass.

In mild and asymptomatic cases, conservative and medical therapy is acceptable. Sitz bath, topical antibiotics, topical oestrogens or steroids have all been shown to help eradicate infection and reduce oedema with subsequent resolution of the prolapse. However, the rate of treatment failure and recurrence is high.

Surgical management is most effective with a high cure rate. It is indicated in advanced, refractory or recurrent cases. Most studies recommend the modified Kelly-Burnham technique which involves circular excision of the prolapsed urethral mucosa and re-approximation of the muco-cutaneous junction of the urethra. Ligation of the prolapsed urethral mucosa over a Foley catheter is also effective. However, this method is associated with more pain and longer hospital stay. Complications from surgical management include urethral stenosis, stricture, urinary incontinence and recurrence of the prolapse.

References

1. Ninomiya T, Koga H. Clinical characteristics of urethral prolapse in Japanese children. Paeds Int. 2017;59(5):578-82.

2. Liu C, Lin Y, Chen X, et al. Urethral prolapse in prepubertal females: Report of seven cases. J Obstet Gynaecol Res. 2017;44(1):175-78. https://doi.org/10.1111/jog.13467

3. Olumide A, Kayode Olusegun A, Babatola B. Urethral mucosa prolapse in an 18-year-old adolescent. Case Rep Obstet Gynecol. 2013;2013:231709. doi: 10.1155/2013/231709

4. Wei Y, Wu SD, Lin T, et al. Diagnosis and treatment of urethral prolapse in children: 16 years’ experience with 89 Chinese girls. Arab J Urol. 2017;15(3):248–53. https://doi.org/10.1016/j.aju.2017.03.004.

By Associate Professor Dr. Khadija Nuzhat Humayun