- Email: [email protected]
Surgical Correction of Urethral Prolapse
0022-534 7/80/1235-0856$02.00/0
Vol. 123, June
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1980 by The Williams & Wilkins Co.
SURGICAL CORRECTION OF URETHRAL PROLAPSE PATRICK C. DEVINE
AND
HAMIL C. KESSEL
From the Department of Urology, Eastern Virginia Medical School, Norfolk, Virginia
ABSTRACT
Since prolapse of the female urethra is the result of inadequate pelvic attachment we believe treatment should be reduction of the herniated urethra and fixation of the bladder and urethra to the posterior surface of the symphysis and rectus abdominis muscles. Prolapse of the female urethra, which is a protrusion of all layers of the urethra through its meatus, is a result of inadequate attachment of the urethra, bladder neck and bladder to the pubic symphysis and anterior abdominal wall. The bladder may be seen below the pubic symphysis on an excretory urogram made with the patient in the supine position (fig. 1). Because of the shallow pelvis and small vagina of childhood caudal displacement of the urethra and bladder is directed
of the prolapse through a vaginal incision with suturing of the circular fibers around the distal urethra. 8 Excision is applicable when gangrene of the prolapsed tissue has occurred but this shortens the urethra and fails to repair the inadequate urethrovesical support that may contribute to stress incontinence later in life. 9 • 10 We believe the proper treatment of urethral prolapse is suprapubic reduction of the herniated urethra with fixation of
FIG. 1. Mid sagittal view of pelvis illustrates prolapse of urethra and lack of anterior support of urethra and bladder.
along the course of the urethra and since the external meatus is fixed in its position the urethra prolapses like a sleeve. When the intrapelvic attachments are insufficient any increase in intra-abdominal pressure with straining at stool, coughing, crying or sneezing may precipitate prolapse of the urethra. Methods of treatment of urethral prolapse include excision of the prolapsed segment with suturing of the urethra to the adjacent vestibule, 1• 2 ligature over a transurethral catheter,3· 4 4-point electrocoagulation, 5 circular excision of the prolapsed mucosa! cuff with the cautery loop, 6 cryosurgery 7 and reduction Accepted for publication August 3, 1979. Read at annual meeting of American Urological Association, New York, New York, May 13-17, 1979. 856
FIG. 2. Mid sagittal view of pelvis after reduction of urethral prolapse and attachment of urethra and bladder to undersurface of symphysis pubis and rectus muscles.
the bladder and urethra to the posterior surface of the symphysis pubis and rectus abdominis muscles as described by Hepburn. 11 • 12 The bladder and urethra are exposed through a transverse suprapubic incision. The prolapse is reduced by digital pressure through the vagina and siµiultaneous cephalad traction on the vesical neck. A retention catheter of appropriate size is placed through the urethra and the balloon is inflated. Sutures are placed lateral to the urethra on each side and are attached to the cartilage of the symphysis pubis, and additional sutures are placed at the vesical neck and attached to the undersurface of
SURGICAL CORRECTION OF URETHRAL PROLAPSE
the rectus muscles to support the bladder neck and urethra in the normal anatomical position (fig. 2). In summary, we believe that reduction of the prolapsed urethra with urethropexy to prevent recurrence restores the normal anatomical relationships and is the procedure of choice for treatment of urethral prolapse. REFERENCES 1. Turner,
R. W.: Urethral prolapse in female children. Urology, 2:
530, 1973. 2. Klaus, H. and Stein, R. T.: Urethral prolapse in young girls. Pediatrics, 52: 645, 1973. 3. Owens, S. B. and Morse, W. H.: Pr0lapse of the female urethra in children. J. Urol., 100: 171, 1968. 4. Serra Doria, 0. de B.: Protrusion of the female urethra. J. Urol., 68: 617, 1952.
857
5. Livermore, G. R.: The treatment of prolapse of the urethra. Surg., Gynec. & Obst., 32: 557, 1921. 6. Moffett, J. S. and Banks, R., Jr.: Prolapse of the urethra in young girls. J.A.M.A., 146: 1288, 1951. 7. Friedrich, E. G., Jr.: Cryosurgery for urethral prolapse. Obst. Gynec., 50: 359, 1977. 8. Keefe, J. W.: Prolapse of the female urethra. J.A.M.A., 69: 1935, 1917. 9. Lapides, J., Ajemian, E. P., Stewart, B. H., Lichtwardt, J. R. and Breakey, B. A.: Physiopathology of stress incontinence. Surg., Gynec. & Obst., 111: 224, 1960. 10. Leadbetter, G. W., Jr.: Surgical correction of total urinary incontinence. J. Urol., 91: 261, 1964. 11. Hepburn, T. N.: Prolapse of the female urethra. Surg., Gynec. & Obst., 31: 83, 1920. 12. Hepburn, T. N.: Prolapse of the urethra in female children. Surg., Gynec. & Obst., 44: 400, 1927.
Vol. 123, June
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1980 by The Williams & Wilkins Co.
SURGICAL CORRECTION OF URETHRAL PROLAPSE PATRICK C. DEVINE
AND
HAMIL C. KESSEL
From the Department of Urology, Eastern Virginia Medical School, Norfolk, Virginia
ABSTRACT
Since prolapse of the female urethra is the result of inadequate pelvic attachment we believe treatment should be reduction of the herniated urethra and fixation of the bladder and urethra to the posterior surface of the symphysis and rectus abdominis muscles. Prolapse of the female urethra, which is a protrusion of all layers of the urethra through its meatus, is a result of inadequate attachment of the urethra, bladder neck and bladder to the pubic symphysis and anterior abdominal wall. The bladder may be seen below the pubic symphysis on an excretory urogram made with the patient in the supine position (fig. 1). Because of the shallow pelvis and small vagina of childhood caudal displacement of the urethra and bladder is directed
of the prolapse through a vaginal incision with suturing of the circular fibers around the distal urethra. 8 Excision is applicable when gangrene of the prolapsed tissue has occurred but this shortens the urethra and fails to repair the inadequate urethrovesical support that may contribute to stress incontinence later in life. 9 • 10 We believe the proper treatment of urethral prolapse is suprapubic reduction of the herniated urethra with fixation of
FIG. 1. Mid sagittal view of pelvis illustrates prolapse of urethra and lack of anterior support of urethra and bladder.
along the course of the urethra and since the external meatus is fixed in its position the urethra prolapses like a sleeve. When the intrapelvic attachments are insufficient any increase in intra-abdominal pressure with straining at stool, coughing, crying or sneezing may precipitate prolapse of the urethra. Methods of treatment of urethral prolapse include excision of the prolapsed segment with suturing of the urethra to the adjacent vestibule, 1• 2 ligature over a transurethral catheter,3· 4 4-point electrocoagulation, 5 circular excision of the prolapsed mucosa! cuff with the cautery loop, 6 cryosurgery 7 and reduction Accepted for publication August 3, 1979. Read at annual meeting of American Urological Association, New York, New York, May 13-17, 1979. 856
FIG. 2. Mid sagittal view of pelvis after reduction of urethral prolapse and attachment of urethra and bladder to undersurface of symphysis pubis and rectus muscles.
the bladder and urethra to the posterior surface of the symphysis pubis and rectus abdominis muscles as described by Hepburn. 11 • 12 The bladder and urethra are exposed through a transverse suprapubic incision. The prolapse is reduced by digital pressure through the vagina and siµiultaneous cephalad traction on the vesical neck. A retention catheter of appropriate size is placed through the urethra and the balloon is inflated. Sutures are placed lateral to the urethra on each side and are attached to the cartilage of the symphysis pubis, and additional sutures are placed at the vesical neck and attached to the undersurface of
SURGICAL CORRECTION OF URETHRAL PROLAPSE
the rectus muscles to support the bladder neck and urethra in the normal anatomical position (fig. 2). In summary, we believe that reduction of the prolapsed urethra with urethropexy to prevent recurrence restores the normal anatomical relationships and is the procedure of choice for treatment of urethral prolapse. REFERENCES 1. Turner,
R. W.: Urethral prolapse in female children. Urology, 2:
530, 1973. 2. Klaus, H. and Stein, R. T.: Urethral prolapse in young girls. Pediatrics, 52: 645, 1973. 3. Owens, S. B. and Morse, W. H.: Pr0lapse of the female urethra in children. J. Urol., 100: 171, 1968. 4. Serra Doria, 0. de B.: Protrusion of the female urethra. J. Urol., 68: 617, 1952.
857
5. Livermore, G. R.: The treatment of prolapse of the urethra. Surg., Gynec. & Obst., 32: 557, 1921. 6. Moffett, J. S. and Banks, R., Jr.: Prolapse of the urethra in young girls. J.A.M.A., 146: 1288, 1951. 7. Friedrich, E. G., Jr.: Cryosurgery for urethral prolapse. Obst. Gynec., 50: 359, 1977. 8. Keefe, J. W.: Prolapse of the female urethra. J.A.M.A., 69: 1935, 1917. 9. Lapides, J., Ajemian, E. P., Stewart, B. H., Lichtwardt, J. R. and Breakey, B. A.: Physiopathology of stress incontinence. Surg., Gynec. & Obst., 111: 224, 1960. 10. Leadbetter, G. W., Jr.: Surgical correction of total urinary incontinence. J. Urol., 91: 261, 1964. 11. Hepburn, T. N.: Prolapse of the female urethra. Surg., Gynec. & Obst., 31: 83, 1920. 12. Hepburn, T. N.: Prolapse of the urethra in female children. Surg., Gynec. & Obst., 44: 400, 1927.