What are the management options for urethral prolapse?

Management of Urethral Prolapse

For symptomatic urethral prolapse, begin with conservative management using Sitz baths and topical estrogen cream; if symptoms persist, are severe, or show vascular compromise, proceed to surgical excision using a four-quadrant technique, which has high success rates with minimal complications. 1, 2

Initial Assessment and Diagnosis

• Clinical diagnosis is made by physical examination alone in most cases, identifying the characteristic "doughnut sign" - a circumferential ring of congested, edematous urethral mucosa evaginating through the urethral meatus 1, 3
• The condition occurs predominantly in prepubertal Black girls (ages 2-15 years) and postmenopausal women, with premenopausal cases being extremely rare 1, 4
• Common presenting symptoms include: vaginal bleeding or spotting (most common), visible mass at the introitus, dysuria, pain, urinary retention, and discharge 1, 2, 4
• Examination under anesthesia may be required if bedside examination is not tolerated, particularly in young children 1

Conservative Management (First-Line for Mild Cases)

Conservative therapy should be attempted first in patients with mild symptoms or asymptomatic prolapse: 1, 5

• Sitz baths (warm soaks) to reduce mucosal edema and improve local hygiene 1, 3
• Topical estrogen cream to counteract estrogen deficiency, particularly in prepubertal and postmenopausal patients 1, 4, 5
• Parental reassurance and observation in pediatric cases 3
• Antibacterial wash and topical antibiotics if indicated 1

Monitor response over 3 months - most mild cases will resolve with conservative measures alone 1

Indications for Intervention

Proceed to intervention when: 1, 2, 5

• Conservative management fails after adequate trial (typically 3 months) 2, 5
• Severe symptoms present at initial evaluation (significant bleeding, severe pain, urinary retention) 2, 4
• Evidence of vascular compromise or strangulation of prolapsed tissue 4, 5
• Recurrent prolapse after previous conservative treatment 1

Surgical Management

Prolapse Reduction Under Anesthesia (Alternative to Excision)

For patients with more significant symptoms but without complete vascular compromise, manual reduction under general anesthesia is an effective alternative to surgical excision: 1

• Complete reduction was achieved in 3 of 7 patients with no recurrence 1
• Partial reduction in remaining patients led to symptom improvement and allowed continued conservative therapy with eventual resolution 1
• This approach avoids the risk of urethral stenosis associated with surgical excision 1
• Two patients with partial reduction had complete resolution within 3 months 1

Surgical Excision (Definitive Treatment)

When surgical excision is required, use the four-quadrant excisional technique: 2, 3

• Technique: Circumferential excision of prolapsed urethral mucosa with primary anastomosis of residual urethral mucosa to the meatus in four quadrants 2, 3
• This approach facilitates complete removal while maintaining urethral patency 3
• Success rate is high with minimal complications 2, 4

Postoperative Complications and Management

Common postoperative issues include: 2

• Temporary postoperative bleeding (6 of 26 patients in one series) - may require Foley catheter placement for tamponade 2
• Temporary urinary retention requiring catheterization (rare) 2
• Recurrence occurs in approximately 12% of cases (3 of 24 patients with follow-up), with only one requiring re-excision 2
• Risk of urethral stenosis exists but is uncommon with proper technique 1

Treatment Algorithm

1. Mild symptoms or asymptomatic mass: Conservative management with Sitz baths and topical estrogen for 3 months 1, 3

2. Moderate symptoms without vascular compromise: Attempt prolapse reduction under general anesthesia 1

   • If complete reduction achieved: Continue conservative management
   • If partial reduction: Continue conservative management with close follow-up

3. Severe symptoms, failed conservative management, or vascular compromise: Proceed directly to four-quadrant surgical excision 2, 4, 5

4. Recurrence after initial treatment: Surgical excision is indicated 1, 2

Critical Pitfalls to Avoid

• Do not confuse urethral prolapse with sexual abuse in pediatric patients presenting with vaginal bleeding - the circumferential doughnut appearance is pathognomonic 3
• Do not mistake urethral prolapse for uterine prolapse in adult women - careful examination identifying the urethral meatus within the prolapsed tissue confirms the diagnosis 4
• Counsel patients preoperatively about risks of postoperative bleeding and potential recurrence requiring repeat intervention 2
• Surgical excision is almost never required in pediatric cases if reduction under anesthesia is attempted first 1