Surgical management of urethral prolapse in girls: 13 years' experience

Abstract

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 To review our experience of managing urethral prolapse (UP) in girls. PATIENTS AND METHODS 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:...

First child case of the prepubertal urethral prolapse in Turkey

“…Tüm yaş gruplarında 3000'de bir sıklığında görülmektedir (5) . Ancak prepubertal kız çocukları arasında görülme sıklığı hakkında kesin bilgi bulunmamaktadır.…”

“…Holbrook ve ark. (5) yaptıkları çalışmada, UP hastalarında tedavide öncelikli olarak manuel redüksiyon önermek-te olup, belirgin semptomu olmayanlarda medikal tedavi önermektedirler. Yaptıkları çalışmada, hiçbir hastada cerrahi tedavi gerekmediği raporlanmıştır.…”

Urethral prolapse in prepubertal females: Report of seven cases

“…So far, urethral prolapse has rarely been reported systematically in China. While the symptoms of postmenopausal urethral prolapse can be quite noticeable, prepubescent urethral prolapse is predominantly asymptomatic …”

Spontaneous Postmenopausal Urethral Prolapse Treated Surgically and Successfully

“…There is still controversy regarding treatment of this rare entity ranging from conservative treatment options (i.e., topical antibiotics, estrogen creams, and “sitz baths”) as first-line [6] to different procedures, from simple manual reduction to complete surgical excision [7]. …”