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Prolapse of the Urethra in Young Girls
THE JOURNAL OF UROLOGY
Vol. 72, No. 2, August 1954 Printed in U.S.A.
PROLAPSE OF THE URETHRA IN YOUNG GIRLS MORRIS ABRAMS
AND
H. KENT LEWIS
From the Department of Surgery (Urology) Homer G. Phillips Hospital, St. Louis, Mo.
Moffett and Banks1 recently reported 4 cases of prolapse of the urethra in Negro girls between the ages of three and seven. They stressed the relative rarity of this condition in young girls as other authors2 , 3 , 4 have done, and suggested a simple form of treatment. Within a period of 8 months we have seen and treated four young girls for a protrusion of the urethra through the meatus. The fifth case included in this series was a private patient of a member of our staff. All the patients were young, well nourished and well developed Negro girls. The youngest was 3 years of age and the oldest was eight. The purpose of this publication is to report these 5 cases of prolapse of the urethra in young girls and to re-affirm the effectiveness of simple complete circular amputation with a cautery loop in the treatment of this disease. REPORT OF CASES
Case 1. D. L., a 3 year old Negro girl, was brought into the hospital by her mother because she noticed that the child was "bleeding from her privates." The mother reported that during the previous 12 months the child had many upper respiratory infections which were usually associated with frequent bouts of severe coughing. The mother particularly noted that it was during a coughing spell that she saw blood "running" from the genitaliafor the first time. There were no associated urinary symptoms. Physical examination revealed an injected pharynx with a mucopurulent discharge from both nostrils. Examination of the vaginal introitus demonstrated a dark red edematous circular prolapse of the urethral mucosa which measured approximately 1.5 cm. in diameter and protruded about 0.5 cm. The mass was tender and bled easily when touched. After the upper respiratory infection had subsided, laboratory studies including a catheterized urine specimen, complete blood counts, Kahn test, excretory urogram and observation cystoscopy were completed and were found to be normal. The urethral lesion was first treated with hot sitz baths, and on the fifth day the entire prolapse was excised without any difficulty by the cautery loop.No approximating sutures were used. Bleeding was insignificant. The patient was allowed out of bed the evening of surgery and was discharged on the fourth postoperative day. She was last seen two months after the operation. Urinary symptoms and evidence of stricture formation were absent. Case 2. B. J. G., a 4 year old Negro girl, was admitted to the hospital because Accepted for publication July 17, 1953. 1 Moffett, J. S., and Banks, R. Jr.: Prolapse of the urethra in young girls. J.A.M.A., 146: 1288, 1951. 2 Zeigerman, J. H. and Kimbrough, R. A.: Circular prolapse of the urethra. Am. J. Obst. and Gynec., 56: 950, 1948. 3 Klaman, E. H., Mansfield, W. K. and Schoenbucher, A. K.: Circular prolapse of female urethra. South. Med. J., 42: 929, 1949. 4 Berry, N. E. and Greene, H.: Prolapse of the female urethra. J. Urol., 39: 92, 1938. 222
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of bleeding from the vagina. Her mother related that the child had had one episode of similar bleeding four months previously. This subsided spontaneously vvithout any treatment. At no time were there any urinary symptoms. Examination revealed an edematous, inflamed prolapsed urethral meatus measuring approximately 1 cm. in diameter. At the most dependent portion of the prolapse was a small ulcerated area. A catheterized urine specimen, Kahn test, observation cystoscopy and excretory urogram were normal. The patient was treated with hot sitz baths for 5 days and then the prolapsed urethral mucosa was removed flush with its base with the cautery loop. Bleeding was minimal. The patient made an uneventful recovery and was discharged on the fifth postoperative day. She was last examined 3 months following the operation and had no stricture of the urethral meatus. Case 3. J. A. S., an 8 year old Negro girl, was admitted to the hospital complaining chiefly of burning on urination of 5 days' duration. Her mother also stated that the child had a "swelling in the vagina" which she first noticed 3 years earlier following a criminal attack. The s,velling apparently had not increased in size during this interval. There were no other complaints. Examination revealed a noninflamed prolapse of the urethra. The mass measured 1 cm. in diameter and protruded approximately 0.4 cm. A catheterized urine specimen, blood counts, Kahn test and excretory urogram were all normal. Observation cystoscopy demonstrated mild trigonitis and urethritis. The lesion was first treated with hot sitz baths and on the third day, the prolapsed mucosal cuff was removed with the cautery loop. A slight amount of bleeding occurred on the day of the operation but this cleared spontaneously at the end of the 12 hours and catheterization was not necessary. The patient was discharged on the fourth postoperative day. She was examined 2 months after the operation and had no urinary difficulties or any evidence of stricture formation. A Ko. 18 infant sound was easily passed into the bladder. Figure 1 shows the preoperative and postoperative photographs. Case 4. B. B., a 3 year old Negro girl, was admitted to the hospital because her mother had noticed during the previous 2 days "spots of blood" on her under-
Fm. I. Case 3. A, preoperative photograph showing mass protruding from urethra. B, urethral meatus 2 weeks postoperative. Area has completely healed.
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clothes. Urinary symptoms or other complaints were absent. Examination revealeda dark, purplish-red mass protruding from the urethral meatus and almost completely filling the vaginal introitus. The mass was tender to touch and bled easily. A catheterized urine specimen, blood counts, Kahn test, excretory urogram and observation cystoscopy were all normal. The patient was first treated with hot sitz baths and on the third day, excision of the prolapsed mucosa was done with the cautery loop. No urinary symptoms developed and the child was discharged on the sixth day after surgery. On her last visit to the clinic, two months postoperatively, no stricture formation was noted. AN o. 16 infant sound was easily passed into the bladder. Case 5. *B. L., a 3 year old Negro girl, was admitted to the hospital with a history of bleeding from the vagina of 7 days' duration. She had no urinary complaints. The mother related that the child had sustained a hard fall on the floor 2 weeks previously. Nothing abnormal was noted at that time. Examination in the hospital revealed a prolapse of the entire circumference of the urethral mucosa through the meatus. The entire mass was acutely inflamed and completely obscured the meatal orifice. A splinter of wood was noted in the exposed mucosa and removed. The remainder of the physical examination was normal. A catheterized urine specimen, blood counts, Kahn test, observation cystoscopy and excretory urogram were normal. She was treated with hot sitz baths for 6 days and then the entire prolapsed mucosal cuff was removed ,vith the cautery loop. No bleeding occurred. The patient was discharged on the third postoperative day. Her physician reported no stricture formation on the last examination which was made 4 months postoperatively. Many predisposing and precipitating factors have been listed in the literature to explain prolapse of the urethra. In three of our cases a probable cause could be elicited. Strain from severe bouts of coughing was present in case 1: it was during a coughing spell that the mother first noted blood. Rape has been listed by Berry and Greene4 as an infrequent cause of prolapse. In case 3, the mother first noted the swelling in the vagina soon after the patient was criminally attacked. Trauma was present in case 5; the finding of a splinter of wood embedded within the prolapsed mucosa supported this belief. No apparent etiological factor could be elicited in cases 2 and 4. It was apparent from the reports in the literature that many factors may produce prolapse of the urethra. Young girls having congenitally poor tissue structure locally or an abnormal mucosal redundancy are probably more susceptible to the development of prolapse of the urethra when they are exposed to such stress or straining factors as severe coughing, constipation or trauma. The usual clinical :findings have been urethral bleeding and the presence of a mass in the vaginal introitus. Urinary symptoms have been infrequent; when present, they were mild. In all our patients catheterized urine specimens and excretory urograms were done and found to be normal. In only one case was mild trigonitis noted on observation cystoscopy. The prolapsed mucosa surrounded the entire circumference of the meatus in all our cases. * A private patient of Dr. Merle Herriford who kindly allowed us to include this case in our report.
URETHRAL PROLAPSE
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Many methods are available for the treatment of prolapse of the urethra. Our procedure has been similar to that suggested by Moffett and Banks. 1 Preoperative hot sitz baths are given for 3 to 5 days. This helps in reducing some of the inflammation and aids in establishing a line of demarcation between the normal urethral mucosa and the inflamed prolapsed mucosa. The surgical technique in removing the prolapse is simple. The prolapse is put under slight tension by grasping anteriorly and posteriorly with two Allis forceps. The cautery loop then quickly and completely removes the entire prolapsed urethra flush with its base at the line of demarcation. No sutures are used to approximate the cut edges. In none of our cases has it been necessary to use a catheter to control bleeding. Little to no discomfort has occurred during the postoperative period. On the day of discharge the urethra was dilated with infant sounds. In the 3 and 4 year old patients a No. 16 sound was used. In the 8 year old girl a No. 18 sound was used. This was repeated weekly for two visits in the out-patient clinic and then monthly for two or three visits. In none of our cases did strictures develop. SUMMARY
Five cases of prolapse of the urethra in young girls are reported. Complete circular amputation of the prolapsed mucosa with the cautery loop was found to be an effective and simple method of treatment. The postoperative course of all our patients was surprisingly free of urinary symptoms. There has been no evidence of postoperative stricture formation with this method of treatment.
Vol. 72, No. 2, August 1954 Printed in U.S.A.
PROLAPSE OF THE URETHRA IN YOUNG GIRLS MORRIS ABRAMS
AND
H. KENT LEWIS
From the Department of Surgery (Urology) Homer G. Phillips Hospital, St. Louis, Mo.
Moffett and Banks1 recently reported 4 cases of prolapse of the urethra in Negro girls between the ages of three and seven. They stressed the relative rarity of this condition in young girls as other authors2 , 3 , 4 have done, and suggested a simple form of treatment. Within a period of 8 months we have seen and treated four young girls for a protrusion of the urethra through the meatus. The fifth case included in this series was a private patient of a member of our staff. All the patients were young, well nourished and well developed Negro girls. The youngest was 3 years of age and the oldest was eight. The purpose of this publication is to report these 5 cases of prolapse of the urethra in young girls and to re-affirm the effectiveness of simple complete circular amputation with a cautery loop in the treatment of this disease. REPORT OF CASES
Case 1. D. L., a 3 year old Negro girl, was brought into the hospital by her mother because she noticed that the child was "bleeding from her privates." The mother reported that during the previous 12 months the child had many upper respiratory infections which were usually associated with frequent bouts of severe coughing. The mother particularly noted that it was during a coughing spell that she saw blood "running" from the genitaliafor the first time. There were no associated urinary symptoms. Physical examination revealed an injected pharynx with a mucopurulent discharge from both nostrils. Examination of the vaginal introitus demonstrated a dark red edematous circular prolapse of the urethral mucosa which measured approximately 1.5 cm. in diameter and protruded about 0.5 cm. The mass was tender and bled easily when touched. After the upper respiratory infection had subsided, laboratory studies including a catheterized urine specimen, complete blood counts, Kahn test, excretory urogram and observation cystoscopy were completed and were found to be normal. The urethral lesion was first treated with hot sitz baths, and on the fifth day the entire prolapse was excised without any difficulty by the cautery loop.No approximating sutures were used. Bleeding was insignificant. The patient was allowed out of bed the evening of surgery and was discharged on the fourth postoperative day. She was last seen two months after the operation. Urinary symptoms and evidence of stricture formation were absent. Case 2. B. J. G., a 4 year old Negro girl, was admitted to the hospital because Accepted for publication July 17, 1953. 1 Moffett, J. S., and Banks, R. Jr.: Prolapse of the urethra in young girls. J.A.M.A., 146: 1288, 1951. 2 Zeigerman, J. H. and Kimbrough, R. A.: Circular prolapse of the urethra. Am. J. Obst. and Gynec., 56: 950, 1948. 3 Klaman, E. H., Mansfield, W. K. and Schoenbucher, A. K.: Circular prolapse of female urethra. South. Med. J., 42: 929, 1949. 4 Berry, N. E. and Greene, H.: Prolapse of the female urethra. J. Urol., 39: 92, 1938. 222
URETHRAL PROLAPSE
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of bleeding from the vagina. Her mother related that the child had had one episode of similar bleeding four months previously. This subsided spontaneously vvithout any treatment. At no time were there any urinary symptoms. Examination revealed an edematous, inflamed prolapsed urethral meatus measuring approximately 1 cm. in diameter. At the most dependent portion of the prolapse was a small ulcerated area. A catheterized urine specimen, Kahn test, observation cystoscopy and excretory urogram were normal. The patient was treated with hot sitz baths for 5 days and then the prolapsed urethral mucosa was removed flush with its base with the cautery loop. Bleeding was minimal. The patient made an uneventful recovery and was discharged on the fifth postoperative day. She was last examined 3 months following the operation and had no stricture of the urethral meatus. Case 3. J. A. S., an 8 year old Negro girl, was admitted to the hospital complaining chiefly of burning on urination of 5 days' duration. Her mother also stated that the child had a "swelling in the vagina" which she first noticed 3 years earlier following a criminal attack. The s,velling apparently had not increased in size during this interval. There were no other complaints. Examination revealed a noninflamed prolapse of the urethra. The mass measured 1 cm. in diameter and protruded approximately 0.4 cm. A catheterized urine specimen, blood counts, Kahn test and excretory urogram were all normal. Observation cystoscopy demonstrated mild trigonitis and urethritis. The lesion was first treated with hot sitz baths and on the third day, the prolapsed mucosal cuff was removed with the cautery loop. A slight amount of bleeding occurred on the day of the operation but this cleared spontaneously at the end of the 12 hours and catheterization was not necessary. The patient was discharged on the fourth postoperative day. She was examined 2 months after the operation and had no urinary difficulties or any evidence of stricture formation. A Ko. 18 infant sound was easily passed into the bladder. Figure 1 shows the preoperative and postoperative photographs. Case 4. B. B., a 3 year old Negro girl, was admitted to the hospital because her mother had noticed during the previous 2 days "spots of blood" on her under-
Fm. I. Case 3. A, preoperative photograph showing mass protruding from urethra. B, urethral meatus 2 weeks postoperative. Area has completely healed.
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M. ABRAMS AND H. K. LEWIS
clothes. Urinary symptoms or other complaints were absent. Examination revealeda dark, purplish-red mass protruding from the urethral meatus and almost completely filling the vaginal introitus. The mass was tender to touch and bled easily. A catheterized urine specimen, blood counts, Kahn test, excretory urogram and observation cystoscopy were all normal. The patient was first treated with hot sitz baths and on the third day, excision of the prolapsed mucosa was done with the cautery loop. No urinary symptoms developed and the child was discharged on the sixth day after surgery. On her last visit to the clinic, two months postoperatively, no stricture formation was noted. AN o. 16 infant sound was easily passed into the bladder. Case 5. *B. L., a 3 year old Negro girl, was admitted to the hospital with a history of bleeding from the vagina of 7 days' duration. She had no urinary complaints. The mother related that the child had sustained a hard fall on the floor 2 weeks previously. Nothing abnormal was noted at that time. Examination in the hospital revealed a prolapse of the entire circumference of the urethral mucosa through the meatus. The entire mass was acutely inflamed and completely obscured the meatal orifice. A splinter of wood was noted in the exposed mucosa and removed. The remainder of the physical examination was normal. A catheterized urine specimen, blood counts, Kahn test, observation cystoscopy and excretory urogram were normal. She was treated with hot sitz baths for 6 days and then the entire prolapsed mucosal cuff was removed ,vith the cautery loop. No bleeding occurred. The patient was discharged on the third postoperative day. Her physician reported no stricture formation on the last examination which was made 4 months postoperatively. Many predisposing and precipitating factors have been listed in the literature to explain prolapse of the urethra. In three of our cases a probable cause could be elicited. Strain from severe bouts of coughing was present in case 1: it was during a coughing spell that the mother first noted blood. Rape has been listed by Berry and Greene4 as an infrequent cause of prolapse. In case 3, the mother first noted the swelling in the vagina soon after the patient was criminally attacked. Trauma was present in case 5; the finding of a splinter of wood embedded within the prolapsed mucosa supported this belief. No apparent etiological factor could be elicited in cases 2 and 4. It was apparent from the reports in the literature that many factors may produce prolapse of the urethra. Young girls having congenitally poor tissue structure locally or an abnormal mucosal redundancy are probably more susceptible to the development of prolapse of the urethra when they are exposed to such stress or straining factors as severe coughing, constipation or trauma. The usual clinical :findings have been urethral bleeding and the presence of a mass in the vaginal introitus. Urinary symptoms have been infrequent; when present, they were mild. In all our patients catheterized urine specimens and excretory urograms were done and found to be normal. In only one case was mild trigonitis noted on observation cystoscopy. The prolapsed mucosa surrounded the entire circumference of the meatus in all our cases. * A private patient of Dr. Merle Herriford who kindly allowed us to include this case in our report.
URETHRAL PROLAPSE
225
Many methods are available for the treatment of prolapse of the urethra. Our procedure has been similar to that suggested by Moffett and Banks. 1 Preoperative hot sitz baths are given for 3 to 5 days. This helps in reducing some of the inflammation and aids in establishing a line of demarcation between the normal urethral mucosa and the inflamed prolapsed mucosa. The surgical technique in removing the prolapse is simple. The prolapse is put under slight tension by grasping anteriorly and posteriorly with two Allis forceps. The cautery loop then quickly and completely removes the entire prolapsed urethra flush with its base at the line of demarcation. No sutures are used to approximate the cut edges. In none of our cases has it been necessary to use a catheter to control bleeding. Little to no discomfort has occurred during the postoperative period. On the day of discharge the urethra was dilated with infant sounds. In the 3 and 4 year old patients a No. 16 sound was used. In the 8 year old girl a No. 18 sound was used. This was repeated weekly for two visits in the out-patient clinic and then monthly for two or three visits. In none of our cases did strictures develop. SUMMARY
Five cases of prolapse of the urethra in young girls are reported. Complete circular amputation of the prolapsed mucosa with the cautery loop was found to be an effective and simple method of treatment. The postoperative course of all our patients was surprisingly free of urinary symptoms. There has been no evidence of postoperative stricture formation with this method of treatment.