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Urethral Prolapse
J Pediatr Adolesc Gynecol (2002) 15:209-211
Original Studies Urethral Prolapse: Four Quadrant Excisional Technique Benjamin T. Shurtleff, MD a and Joseph G. Barone, MD a a
Division of Urology, Department of Surgery, University of Medicine and Dentistry of New Jersey—Robert Wood Johnson Medical School, Bristol-Myers Squibb Children’s Hospital, New Brunswick, New Jersey, USA
Abstract. Background: Urethral prolapse is a condition that occurs when urethra mucosa evaginates beyond the urethra meatus, resulting in vascular congestion and edema of the prolapsed tissue. Young females with this clinical entity often present with peri-vaginal bleeding and swelling. Urethral prolapse can be diagnosed by its typical clinical appearance and should not be confused with other causes of peri-vaginal bleeding, most importantly, sexual abuse. Case: We retrospectively evaluated the charts of three girls, ages 4, 6, and 8, who presented complaining of vaginal blood spotting. On examination, a ring of congested, edematous tissue was seen prolapsing through the urethral meatus in each patient. All patients did not respond to medical management and required surgical removal of the tissue. We herein discuss and evaluate their management and our four quadrant excisional technique. Conclusion: Urethral prolapse can be definitively diagnosed without laboratory or radiographic evaluation by demonstrating that the edematous tissue surrounds the meatus circumferentially. Initial treatment consists of parental reassurance, observation, and warm soaks. If the prolapse does not demonstrate improvement, excision of the prolapsing tissue may be necessary. We believe that our surgical technique facilitates removal of the prolapsed tissue and anastomosis of the residual urethral mucosa.
Key Words. Urethral prolapse—Urethral meatus— Peri-vaginal bleeding—Sexual abuse—Meatal stenosis—Mucosal to mucosal anastomosis
Introduction Urethral prolapse has an estimated incidence of 1 in 3000 and is seen most commonly in young black fe-
Address reprint requests to: Joseph G. Barone, MD, FACS, FAAP, Chief, Section of Pediatric Urology and Urologist-in Chief, Bristol-Myers Squibb Children’s Hospital at Robert Wood Johnson University Hospital, One Robert Wood Johnson Place, MEB 588, New Brunswick, NJ 08903-0091 © 2002 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Science Inc.
males.1 The condition occurs when urethral mucosa protrudes beyond the urethral meatus, resulting in vascular congestion and edema of the prolapsing tissue. In most cases, urethral prolapse occurs spontaneously and can present with varying degrees of bleeding and swelling of the peri-vaginal area. It is therefore important to distinguish this clinical entity from other causes of peri-vaginal bleeding, including sexual abuse. We herein present our experience with urethral prolapse and discuss its diagnosis and management. Case Three girls, ages 4, 6, and 8, presented complaining of vaginal blood spotting. Their primary care physician had previously seen all patients. The 4- and 8-year-old girls were referred for evaluation without being treated. The 6-year-old girl was seen after being treated with estrogen cream and sitz baths for 5 days. New Jersey child protective services were consulted by the 8-yearold’s primary care physician because he believed that sexual abuse may have occurred based on the physical findings. There was no history of sexual abuse in any patient. There was no history of trauma, prior bleeding, menses, abdominal straining, or other predisposing event. There was moderate bleeding noted in two patients; however, the 4-year-old was bleeding more significantly. Pain was moderate in all patients and only the 8-year-old complained of dysuria. On examination, a ring of congested, edematous tissue was seen prolapsing through the urethral meatus in each patient. The position of the meatus was confirmed by placing an 8-French feeding tube into the meatus. The remainder of the physical examination was normal in all children and no laboratory or radiographic studies were ordered. Our report to social services regarding the 8-year-old indicated that this problem was not associated with sexual abuse; however, authorities were still required to question the parents. 1083-3188/02/$22.00 PII S1083-3188(02)00157-2
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Shurtleff and Barone: Urethral Prolapse
In all cases, sitz baths were continued as the initial primary treatment. Patients were seen in follow-up in 5 to 7 days and no significant improvement was noted in any child. Excision of the prolapsing tissue was recommended to avoid further bleeding and swelling of the prolapsed tissue. Patients were brought to the operating room and underwent general anesthesia. A frog-legged position was used instead of stirrups. Holding sutures of 5-0 chromic were placed in the four quadrants of the prolapsing tissue. A curved iris scissors was used to excise the edematous tissue quadrant by quadrant. After each quadrant was excised, a mucosal to mucosal anastomosis was performed with 6-0 chromic suture, before proceeding to the next quadrant. Traction on the holding sutures allowed easy visualization of the proximal mucosa, which tended to retract towards the bladder. Not having a catheter in the operative field facilitated visualization of the mucosa and placement of the sutures. To further facilitate visualization of the mucosa while placing the sutures, loop magnification can be of assistance. Once the tissue had been excised and repaired, cystoscopy was done, and the area was injected with 0.25% bupivacaine. Patients were discharged home the same day and sitz baths were continued for one week. Antibiotics were not prescribed. At the two-week follow-up visit, all patients were voiding without difficulty and the urethra appeared normal on examination. At a followup ranging from 8 months to 2 years, there have been no recurrences or development of meatal stenosis.
Discussion Urethral prolapse results when the intra-urethral mucosa protrudes beyond the urethral meatus. The prolapse usually occurs spontaneously and may result due to a poor attachment between the urethral mucosa and the underlying muscle.2 Other possible etiologies for this problem have included a sudden increase in intra-abdominal pressure, and urethral mucosa redundancy.2 Whatever the etiology, once the mucosa prolapses, the muscular tone of the urethral meatus constricts the tissue in a circumferential pattern, resulting in varying degrees of vascular edema, congestion, and necrosis. Even though young black females are most commonly affected by this problem, there are no predisposing factors, and it is not related to sexual abuse. The prolapse results in blood spotting on the underwear or frank bleeding from the affected area. Children with urethral prolapse commonly complain of dysuria, but pain from the lesion itself is usually mild to moderate in degree. On inspection, the prolapsed tissue appears as a congested mass of tissue surrounding the urethral me-
atus (Fig. 1). It is important to identify the urethral meatus at the center of the edematous tissue as this helps establish the diagnosis. When there is severe congestion and edema, an 8-French feeding tube is helpful in locating the urethral meatus. The differential diagnosis of urethral prolapse includes urethral papilloma, caruncle, polyp, prolapsing ureterocele, vaginal rhabdomyosarcoma, imperforate hymen, and sexual abuse. These diagnoses can be excluded by demonstrating that the edematous tissue surrounds the meatus circumferentially. In contrast, a prolapsing ureterocele protrudes in an asymmetric fashion. Most of the other clinical entities described above involve the vagina primarily. The possibility of sexual abuse is usually considered in girls with perivaginal bleeding; however, sexual abuse can be excluded in girls with urethral prolapse by history and the unique physical findings associated with urethral prolapse. Management of this problem begins with sitz baths to decrease swelling and edema.3 Additionally, conjugated estrogen cream can be tried as an initial therapy, but it should not be used on a chronic basis due to absorption of the steroid. Laboratory and radiographic evaluation are not necessary if urethral prolapse can be definitively diagnosed clinically. Some children may benefit from a short trial of estrogen cream.4 If urethral prolapse does not respond to medical management, surgical removal of the prolapsing tissue may be necessary. Surgical removal of the tissue is done in the operating room under a general anesthesia. Various techniques have been described including ligation of the mucosa around a catheter, cauterization of the mucosa, and excision of the mucosa with a catheter in situ.5,6 Of these techniques, the latter technique is most popular; however, operating around a catheter in a confined area can be cumbersome, and there is noth-
Fig. 1. Urethral prolapse in a young girl. The urethral meatus can be seen in the center of the prolapsing tissue. Note the normal vaginal opening below the prolapsing urethral tissue.
Shurtleff and Barone: Urethral Prolapse
ing to prevent the proximal mucosa from retracting. If the proximal mucosa retracts, it is more difficult to achieve a mucosal to mucosal anastomosis, and this might increase the risk for postoperative meatal stenosis. Our technique avoids placement of a catheter and reduces the risk for retraction of the proximal mucosa. Four holding sutures of 5-0 chromic are placed at the 12, 3, 6, and 9 o’clock positions, without a catheter in situ. The holding sutures prevent retraction of the proximal mucosa, which is also more easily seen without a catheter in situ. Once the holding sutures are placed, each quadrant can be excised with curved iris scissors and approximated individually with 6-0 chromic, facilitating an accurate mucosal to mucosal approximation.
211
References 1. Mitre A, Nahas W, Gilbert A, et al: Urethral prolapse in girls: familial case. J Urol 1987; 137:115 2. Lowe F, Hill G, Jeffs R, et al: Urethral prolapse in children: insights into etiology and management. J Urol 1986; 135:100 3. Richardson D, Hajj S, Herbst A: Medical treatment of urethral prolapse in children. Obstet Gynecol 1982; 59:69 4. Jerkins G, Verheeck K, Noe H: Treatment of girls with urethral prolapse. J Urol 1984; 132:732 5. Fernandes E, Dekermacher S, Sabadin M, et al: Urethral prolapse in children. Urol 1993; 41:240 6. Valerie E, Gilchrist B, Frischer J, et al: Diagnosis and treatment of urethral prolapse in children. Urol 1999; 54:1082
Original Studies Urethral Prolapse: Four Quadrant Excisional Technique Benjamin T. Shurtleff, MD a and Joseph G. Barone, MD a a
Division of Urology, Department of Surgery, University of Medicine and Dentistry of New Jersey—Robert Wood Johnson Medical School, Bristol-Myers Squibb Children’s Hospital, New Brunswick, New Jersey, USA
Abstract. Background: Urethral prolapse is a condition that occurs when urethra mucosa evaginates beyond the urethra meatus, resulting in vascular congestion and edema of the prolapsed tissue. Young females with this clinical entity often present with peri-vaginal bleeding and swelling. Urethral prolapse can be diagnosed by its typical clinical appearance and should not be confused with other causes of peri-vaginal bleeding, most importantly, sexual abuse. Case: We retrospectively evaluated the charts of three girls, ages 4, 6, and 8, who presented complaining of vaginal blood spotting. On examination, a ring of congested, edematous tissue was seen prolapsing through the urethral meatus in each patient. All patients did not respond to medical management and required surgical removal of the tissue. We herein discuss and evaluate their management and our four quadrant excisional technique. Conclusion: Urethral prolapse can be definitively diagnosed without laboratory or radiographic evaluation by demonstrating that the edematous tissue surrounds the meatus circumferentially. Initial treatment consists of parental reassurance, observation, and warm soaks. If the prolapse does not demonstrate improvement, excision of the prolapsing tissue may be necessary. We believe that our surgical technique facilitates removal of the prolapsed tissue and anastomosis of the residual urethral mucosa.
Key Words. Urethral prolapse—Urethral meatus— Peri-vaginal bleeding—Sexual abuse—Meatal stenosis—Mucosal to mucosal anastomosis
Introduction Urethral prolapse has an estimated incidence of 1 in 3000 and is seen most commonly in young black fe-
Address reprint requests to: Joseph G. Barone, MD, FACS, FAAP, Chief, Section of Pediatric Urology and Urologist-in Chief, Bristol-Myers Squibb Children’s Hospital at Robert Wood Johnson University Hospital, One Robert Wood Johnson Place, MEB 588, New Brunswick, NJ 08903-0091 © 2002 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Science Inc.
males.1 The condition occurs when urethral mucosa protrudes beyond the urethral meatus, resulting in vascular congestion and edema of the prolapsing tissue. In most cases, urethral prolapse occurs spontaneously and can present with varying degrees of bleeding and swelling of the peri-vaginal area. It is therefore important to distinguish this clinical entity from other causes of peri-vaginal bleeding, including sexual abuse. We herein present our experience with urethral prolapse and discuss its diagnosis and management. Case Three girls, ages 4, 6, and 8, presented complaining of vaginal blood spotting. Their primary care physician had previously seen all patients. The 4- and 8-year-old girls were referred for evaluation without being treated. The 6-year-old girl was seen after being treated with estrogen cream and sitz baths for 5 days. New Jersey child protective services were consulted by the 8-yearold’s primary care physician because he believed that sexual abuse may have occurred based on the physical findings. There was no history of sexual abuse in any patient. There was no history of trauma, prior bleeding, menses, abdominal straining, or other predisposing event. There was moderate bleeding noted in two patients; however, the 4-year-old was bleeding more significantly. Pain was moderate in all patients and only the 8-year-old complained of dysuria. On examination, a ring of congested, edematous tissue was seen prolapsing through the urethral meatus in each patient. The position of the meatus was confirmed by placing an 8-French feeding tube into the meatus. The remainder of the physical examination was normal in all children and no laboratory or radiographic studies were ordered. Our report to social services regarding the 8-year-old indicated that this problem was not associated with sexual abuse; however, authorities were still required to question the parents. 1083-3188/02/$22.00 PII S1083-3188(02)00157-2
210
Shurtleff and Barone: Urethral Prolapse
In all cases, sitz baths were continued as the initial primary treatment. Patients were seen in follow-up in 5 to 7 days and no significant improvement was noted in any child. Excision of the prolapsing tissue was recommended to avoid further bleeding and swelling of the prolapsed tissue. Patients were brought to the operating room and underwent general anesthesia. A frog-legged position was used instead of stirrups. Holding sutures of 5-0 chromic were placed in the four quadrants of the prolapsing tissue. A curved iris scissors was used to excise the edematous tissue quadrant by quadrant. After each quadrant was excised, a mucosal to mucosal anastomosis was performed with 6-0 chromic suture, before proceeding to the next quadrant. Traction on the holding sutures allowed easy visualization of the proximal mucosa, which tended to retract towards the bladder. Not having a catheter in the operative field facilitated visualization of the mucosa and placement of the sutures. To further facilitate visualization of the mucosa while placing the sutures, loop magnification can be of assistance. Once the tissue had been excised and repaired, cystoscopy was done, and the area was injected with 0.25% bupivacaine. Patients were discharged home the same day and sitz baths were continued for one week. Antibiotics were not prescribed. At the two-week follow-up visit, all patients were voiding without difficulty and the urethra appeared normal on examination. At a followup ranging from 8 months to 2 years, there have been no recurrences or development of meatal stenosis.
Discussion Urethral prolapse results when the intra-urethral mucosa protrudes beyond the urethral meatus. The prolapse usually occurs spontaneously and may result due to a poor attachment between the urethral mucosa and the underlying muscle.2 Other possible etiologies for this problem have included a sudden increase in intra-abdominal pressure, and urethral mucosa redundancy.2 Whatever the etiology, once the mucosa prolapses, the muscular tone of the urethral meatus constricts the tissue in a circumferential pattern, resulting in varying degrees of vascular edema, congestion, and necrosis. Even though young black females are most commonly affected by this problem, there are no predisposing factors, and it is not related to sexual abuse. The prolapse results in blood spotting on the underwear or frank bleeding from the affected area. Children with urethral prolapse commonly complain of dysuria, but pain from the lesion itself is usually mild to moderate in degree. On inspection, the prolapsed tissue appears as a congested mass of tissue surrounding the urethral me-
atus (Fig. 1). It is important to identify the urethral meatus at the center of the edematous tissue as this helps establish the diagnosis. When there is severe congestion and edema, an 8-French feeding tube is helpful in locating the urethral meatus. The differential diagnosis of urethral prolapse includes urethral papilloma, caruncle, polyp, prolapsing ureterocele, vaginal rhabdomyosarcoma, imperforate hymen, and sexual abuse. These diagnoses can be excluded by demonstrating that the edematous tissue surrounds the meatus circumferentially. In contrast, a prolapsing ureterocele protrudes in an asymmetric fashion. Most of the other clinical entities described above involve the vagina primarily. The possibility of sexual abuse is usually considered in girls with perivaginal bleeding; however, sexual abuse can be excluded in girls with urethral prolapse by history and the unique physical findings associated with urethral prolapse. Management of this problem begins with sitz baths to decrease swelling and edema.3 Additionally, conjugated estrogen cream can be tried as an initial therapy, but it should not be used on a chronic basis due to absorption of the steroid. Laboratory and radiographic evaluation are not necessary if urethral prolapse can be definitively diagnosed clinically. Some children may benefit from a short trial of estrogen cream.4 If urethral prolapse does not respond to medical management, surgical removal of the prolapsing tissue may be necessary. Surgical removal of the tissue is done in the operating room under a general anesthesia. Various techniques have been described including ligation of the mucosa around a catheter, cauterization of the mucosa, and excision of the mucosa with a catheter in situ.5,6 Of these techniques, the latter technique is most popular; however, operating around a catheter in a confined area can be cumbersome, and there is noth-
Fig. 1. Urethral prolapse in a young girl. The urethral meatus can be seen in the center of the prolapsing tissue. Note the normal vaginal opening below the prolapsing urethral tissue.
Shurtleff and Barone: Urethral Prolapse
ing to prevent the proximal mucosa from retracting. If the proximal mucosa retracts, it is more difficult to achieve a mucosal to mucosal anastomosis, and this might increase the risk for postoperative meatal stenosis. Our technique avoids placement of a catheter and reduces the risk for retraction of the proximal mucosa. Four holding sutures of 5-0 chromic are placed at the 12, 3, 6, and 9 o’clock positions, without a catheter in situ. The holding sutures prevent retraction of the proximal mucosa, which is also more easily seen without a catheter in situ. Once the holding sutures are placed, each quadrant can be excised with curved iris scissors and approximated individually with 6-0 chromic, facilitating an accurate mucosal to mucosal approximation.
211
References 1. Mitre A, Nahas W, Gilbert A, et al: Urethral prolapse in girls: familial case. J Urol 1987; 137:115 2. Lowe F, Hill G, Jeffs R, et al: Urethral prolapse in children: insights into etiology and management. J Urol 1986; 135:100 3. Richardson D, Hajj S, Herbst A: Medical treatment of urethral prolapse in children. Obstet Gynecol 1982; 59:69 4. Jerkins G, Verheeck K, Noe H: Treatment of girls with urethral prolapse. J Urol 1984; 132:732 5. Fernandes E, Dekermacher S, Sabadin M, et al: Urethral prolapse in children. Urol 1993; 41:240 6. Valerie E, Gilchrist B, Frischer J, et al: Diagnosis and treatment of urethral prolapse in children. Urol 1999; 54:1082