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Treatment of Girls with Urethral Prolapse
0022-534 7/84/1323-0732$02.00/00 Vol. 132, October
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1984 by The Williams & Wilkins Co.
TREATMENT OF GIRLS WITH URETHRAL PROLAPSE GERALD R. JERKINS, KENNETH VERHEECK AND H. NORMAN NOE From LeBonheur Children's Hospital, Memphis, Tennessee
ABSTRACT
During the last 19 years 40 girls with urethral prolapse have been seen at our medical center. Treatment has ranged from nonoperative approaches to excision of the prolapsed urethra. A comparison of the treatment modalities indicates that patients undergoing early local excision of the prolapse have the lowest complication rate and shortest hospital stay. Urethral prolapse is an infrequent lesion in girls. Although urethral prolapse has been well described the etiology and pathophysiology of the lesion remain unclear. 1 The condition appears to affect predominantly black girls <10 years old and rarely is associated with other urinary tract abnormalities. 2 During the last 19 years 40 girls with urethral prolapse have been seen at our medical center. Various methods were used to manage patients with this lesion, which reflect the changes in recommended therapy during the last several years. We compare treatment modalities and their effectiveness in patients with urethral prolapse.
the 3 children who underwent suture ligation of the prolapse 2 had difficulty with catheter drainage and subsequent removal of the catheters. This technique involved insertion of a catheter and subsequent ligation of the prolapsed mucosa around the catheter. The average hospital stay was 4 days and these children required significant amounts of medication to manage urethral and bladder pain. Cauterization and internal urethrotomy were used in 2 children and, although there appeared to be no complications or recurrences, it is difficult to draw a conclusion from these 2 patients.
MATERIALS AND METHODS
DISCUSSION
The charts of all patients with the diagnosis of urethral prolapse treated between January 1965 and June 1983 were reviewed. Clinical presentation, evaluation, type and success of treatment, length of hospital stay, recurrence rate, age and race were compared.
Although seen rarely urethral prolapse must be considered in any girl with a history of vaginal bleeding. When such bleeding occurs careful examination of the introitus is mandatory. When a mass is observed it must be distinguished from more serious lesions, including trauma, prolapsing ureterocele, condyloma or rhabdomyosarcoma. 3 An examination may be necessary with the patient under anesthesia with attention to the vagina, bladder and urethral anatomy. We do not believe that a routine IVP or cystogram is necessary in these children unless endoscopic examination reveals abnormalities of the ureterovesical junction or bladder, which would indicate a potential associated urinary pathological condition. Our review substantiates the predominance of urethral prolapse in black girls. Although it would seem that such prolapse is secondary to deficient support of the urethra at the urogenital diaphragm the pathophysiological status of this lesion still remains unclear. Our study as well as previous reviews of this subject found no consistent predisposing factors or precipitating activities in children with prolapse. Treatment recommendations in the literature include nonoperative treatment with antibiotics and local application of steroids or antibiotic creams, reduction of the prolapse and placement of an indwelling catheter, suture ligation around a catheter, cauterization and suprapubic anterior urethropexy. 4 - 7 Since our review spans a 19-year interval treatment of these girls reflected many of the recommendations in the literature. Only in the last few years has a consistent approach to this problem been taken. Since then, the majority of these children have been managed with primary excision of the prolapse. Compared to previous methods of treatment this approach seems to be most effective, with no incidences of recurrence or complications noted to date. This treatment also requires a short hospital stay and can be done as an outpatient procedure in some cases. Although reduction of the prolapse and insertion of the catheter were effective there were 3 recurrences and these children required a longer hospital stay, averaging nearly 5 days. This therapy also was associated with expected bladder and urethral pain. Similarly, suture ligation with catheterization required a longer and frequently uncomfortable hospital
RESULTS
Of the 40 patients with urethral prolapse reviewed 36 were black girls, while only 4 were white girls. Patient age ranged from 1 to 9 years, with an average age of 4½ years. The incidence in our medical center was 2 admissions per year or approximately 2 occurrences of prolapse per 11,000 hospital admissions. The most frequent symptom at clinical presentation was bleeding, which occurred in 34 patients. The remaining 6 patients presented with complaints of dysuria, urinary frequency or introital pain. Physical examination revealed the typical edematous mass in the anterior introitus. The mucosa was ulcerated in the majority of these patients, thus, accounting for the bleeding. No apparent antecedent injuries or illnesses were noted in any child. Since multiple physicians were involved in the care of these patients during the last 19 years no consistent approach was used for evaluation. However, 16 children did undergo excretory urography (IVP) but no significant urinary tract abnormalities were found. Six treatment approaches were used. The complication rate, recurrence rate and length of hospital stay were compared (see table). Primary excision of the prolapse was performed most frequently and involved excision of the prolapsed mucosa with approximation of the mucosa! edges using interrupted absorbable sutures. There were no complications with this technique and no recurrences were identified. Hospitalization was only 1 day. Among 14 children who underwent reduction of the prolapse and catheterization the average hospital stay was 4. 7 days and 3 children suffered recurrences. Even though hospitalization was not required initially for 6 children who underwent treatment with local application of steroid creams there were 4 recurrences that subsequently required primary excision. Of Accepted for publication April 19, 1984.
732
TREATMENT OF GIRLS WITH URETHRAL PROLAPSE
Treatment of urethral prolapse
Primary excision Reduction and catheter Antibiotics/local cream Suture ligation Cauterization Internal urethrotomy
No. Pts.
Complication
Recurrence
15 14 6
0 0 0
3 1 1
0 0
0 3 4 0 0 0
2
Hospital Stay (days) 1 4.7 0 4
1 1
stay. Of these patients 2 had residual tissue and experienced difficulty with removal of the catheter. The use of antibiotics and localized creams certainly is intriguing and good results have been reported. 7 •8 However, our 6 patients had a disappointing recurrence rate of 67 per cent. These patients initially had been treated as outpatients. The recurrences were treated with local excision of the prolapse. Only 1 patient each underwent cauterization or internal urethrotomy and, although no complications or recurrences were reported, it is difficult to assess the general effectiveness of this treatment with only these 2 patients. There appears to be no clear rationale to such an approach for this lesion. Upon a review of these patients we have seen no indication to proceed with anterior urethropexy, which appears to be a much more involved procedure than the lesion warrants. If on initial examination a urethral prolapse is typical and other more serious problems can be excluded, consideration should be given to application of localized estrogen creams and followup on an outpatient basis. Even though our experience has not reflected the high success rate of others, this approach
733
would seem to be effective in children with minimal symptoms and only slight bleeding from the urethral area. Of course, if this treatment regimen is selected careful followup is important. If the lesion persists or recurs local excision should be done. If a child with bleeding from the urethral area is examined and the diagnosis of urethral prolapse is not completely certain we recommend a careful examination with the patient under general anesthesia to exclude more serious lesions. If the urethral prolapse is confirmed by this examination primary excision should be done. The catheter can be removed within a few hours and the patient may be discharged from the hospital. We believe that such an approach to these patients will minimize hospitalization and unnecessary instrumentation. REFERENCES
1. Klaus, H. and Stein, R. T.: Urethral prolapse in young girls.
Pediatrics, 52: 645, 1973. 2. Owens, S. B. and Morse, W. H.: Prolapse of the female urethra in children. J. Urol., 100: 171, 1968. 3. Nussbaum, A. R. and Lebowitz, R. L.: Interlabial masses in little girls: review and imaging recommendations. Amer. J. Roentgen., 141: 65, 1983. 4. Venable, D. D. and Markland, C.: Urethral prolapse in girls. South. Med. J., 75: 951, 1982. 5. Devine, P. C. and Kessel, H. C.: Surgical correction of urethral prolapse. J. Urol., 123: 856, 1980. 6. Turner, R. W.: Urethral prolapse in female children. Urology, 2: 530, 1973. 7. Redman, J. F.: Conservative management of urethral prolapse in female children. Urology, 19: 505, 1982. 8. Richardson, D. A., Hajj, S. N. and Herbst, A. L.: Medical treatment of urethral prolapse in children. Obst. Gynec., 59: 69, 1982.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1984 by The Williams & Wilkins Co.
TREATMENT OF GIRLS WITH URETHRAL PROLAPSE GERALD R. JERKINS, KENNETH VERHEECK AND H. NORMAN NOE From LeBonheur Children's Hospital, Memphis, Tennessee
ABSTRACT
During the last 19 years 40 girls with urethral prolapse have been seen at our medical center. Treatment has ranged from nonoperative approaches to excision of the prolapsed urethra. A comparison of the treatment modalities indicates that patients undergoing early local excision of the prolapse have the lowest complication rate and shortest hospital stay. Urethral prolapse is an infrequent lesion in girls. Although urethral prolapse has been well described the etiology and pathophysiology of the lesion remain unclear. 1 The condition appears to affect predominantly black girls <10 years old and rarely is associated with other urinary tract abnormalities. 2 During the last 19 years 40 girls with urethral prolapse have been seen at our medical center. Various methods were used to manage patients with this lesion, which reflect the changes in recommended therapy during the last several years. We compare treatment modalities and their effectiveness in patients with urethral prolapse.
the 3 children who underwent suture ligation of the prolapse 2 had difficulty with catheter drainage and subsequent removal of the catheters. This technique involved insertion of a catheter and subsequent ligation of the prolapsed mucosa around the catheter. The average hospital stay was 4 days and these children required significant amounts of medication to manage urethral and bladder pain. Cauterization and internal urethrotomy were used in 2 children and, although there appeared to be no complications or recurrences, it is difficult to draw a conclusion from these 2 patients.
MATERIALS AND METHODS
DISCUSSION
The charts of all patients with the diagnosis of urethral prolapse treated between January 1965 and June 1983 were reviewed. Clinical presentation, evaluation, type and success of treatment, length of hospital stay, recurrence rate, age and race were compared.
Although seen rarely urethral prolapse must be considered in any girl with a history of vaginal bleeding. When such bleeding occurs careful examination of the introitus is mandatory. When a mass is observed it must be distinguished from more serious lesions, including trauma, prolapsing ureterocele, condyloma or rhabdomyosarcoma. 3 An examination may be necessary with the patient under anesthesia with attention to the vagina, bladder and urethral anatomy. We do not believe that a routine IVP or cystogram is necessary in these children unless endoscopic examination reveals abnormalities of the ureterovesical junction or bladder, which would indicate a potential associated urinary pathological condition. Our review substantiates the predominance of urethral prolapse in black girls. Although it would seem that such prolapse is secondary to deficient support of the urethra at the urogenital diaphragm the pathophysiological status of this lesion still remains unclear. Our study as well as previous reviews of this subject found no consistent predisposing factors or precipitating activities in children with prolapse. Treatment recommendations in the literature include nonoperative treatment with antibiotics and local application of steroids or antibiotic creams, reduction of the prolapse and placement of an indwelling catheter, suture ligation around a catheter, cauterization and suprapubic anterior urethropexy. 4 - 7 Since our review spans a 19-year interval treatment of these girls reflected many of the recommendations in the literature. Only in the last few years has a consistent approach to this problem been taken. Since then, the majority of these children have been managed with primary excision of the prolapse. Compared to previous methods of treatment this approach seems to be most effective, with no incidences of recurrence or complications noted to date. This treatment also requires a short hospital stay and can be done as an outpatient procedure in some cases. Although reduction of the prolapse and insertion of the catheter were effective there were 3 recurrences and these children required a longer hospital stay, averaging nearly 5 days. This therapy also was associated with expected bladder and urethral pain. Similarly, suture ligation with catheterization required a longer and frequently uncomfortable hospital
RESULTS
Of the 40 patients with urethral prolapse reviewed 36 were black girls, while only 4 were white girls. Patient age ranged from 1 to 9 years, with an average age of 4½ years. The incidence in our medical center was 2 admissions per year or approximately 2 occurrences of prolapse per 11,000 hospital admissions. The most frequent symptom at clinical presentation was bleeding, which occurred in 34 patients. The remaining 6 patients presented with complaints of dysuria, urinary frequency or introital pain. Physical examination revealed the typical edematous mass in the anterior introitus. The mucosa was ulcerated in the majority of these patients, thus, accounting for the bleeding. No apparent antecedent injuries or illnesses were noted in any child. Since multiple physicians were involved in the care of these patients during the last 19 years no consistent approach was used for evaluation. However, 16 children did undergo excretory urography (IVP) but no significant urinary tract abnormalities were found. Six treatment approaches were used. The complication rate, recurrence rate and length of hospital stay were compared (see table). Primary excision of the prolapse was performed most frequently and involved excision of the prolapsed mucosa with approximation of the mucosa! edges using interrupted absorbable sutures. There were no complications with this technique and no recurrences were identified. Hospitalization was only 1 day. Among 14 children who underwent reduction of the prolapse and catheterization the average hospital stay was 4. 7 days and 3 children suffered recurrences. Even though hospitalization was not required initially for 6 children who underwent treatment with local application of steroid creams there were 4 recurrences that subsequently required primary excision. Of Accepted for publication April 19, 1984.
732
TREATMENT OF GIRLS WITH URETHRAL PROLAPSE
Treatment of urethral prolapse
Primary excision Reduction and catheter Antibiotics/local cream Suture ligation Cauterization Internal urethrotomy
No. Pts.
Complication
Recurrence
15 14 6
0 0 0
3 1 1
0 0
0 3 4 0 0 0
2
Hospital Stay (days) 1 4.7 0 4
1 1
stay. Of these patients 2 had residual tissue and experienced difficulty with removal of the catheter. The use of antibiotics and localized creams certainly is intriguing and good results have been reported. 7 •8 However, our 6 patients had a disappointing recurrence rate of 67 per cent. These patients initially had been treated as outpatients. The recurrences were treated with local excision of the prolapse. Only 1 patient each underwent cauterization or internal urethrotomy and, although no complications or recurrences were reported, it is difficult to assess the general effectiveness of this treatment with only these 2 patients. There appears to be no clear rationale to such an approach for this lesion. Upon a review of these patients we have seen no indication to proceed with anterior urethropexy, which appears to be a much more involved procedure than the lesion warrants. If on initial examination a urethral prolapse is typical and other more serious problems can be excluded, consideration should be given to application of localized estrogen creams and followup on an outpatient basis. Even though our experience has not reflected the high success rate of others, this approach
733
would seem to be effective in children with minimal symptoms and only slight bleeding from the urethral area. Of course, if this treatment regimen is selected careful followup is important. If the lesion persists or recurs local excision should be done. If a child with bleeding from the urethral area is examined and the diagnosis of urethral prolapse is not completely certain we recommend a careful examination with the patient under general anesthesia to exclude more serious lesions. If the urethral prolapse is confirmed by this examination primary excision should be done. The catheter can be removed within a few hours and the patient may be discharged from the hospital. We believe that such an approach to these patients will minimize hospitalization and unnecessary instrumentation. REFERENCES
1. Klaus, H. and Stein, R. T.: Urethral prolapse in young girls.
Pediatrics, 52: 645, 1973. 2. Owens, S. B. and Morse, W. H.: Prolapse of the female urethra in children. J. Urol., 100: 171, 1968. 3. Nussbaum, A. R. and Lebowitz, R. L.: Interlabial masses in little girls: review and imaging recommendations. Amer. J. Roentgen., 141: 65, 1983. 4. Venable, D. D. and Markland, C.: Urethral prolapse in girls. South. Med. J., 75: 951, 1982. 5. Devine, P. C. and Kessel, H. C.: Surgical correction of urethral prolapse. J. Urol., 123: 856, 1980. 6. Turner, R. W.: Urethral prolapse in female children. Urology, 2: 530, 1973. 7. Redman, J. F.: Conservative management of urethral prolapse in female children. Urology, 19: 505, 1982. 8. Richardson, D. A., Hajj, S. N. and Herbst, A. L.: Medical treatment of urethral prolapse in children. Obst. Gynec., 59: 69, 1982.