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Urethral prolapse in the premenarcheal female
Inr. J. Gynaecol. Obstet., 1987,25: 69-71 International Federation of Gynaecology & Obstetrics
69
URETHRAL PROLAPSE IN THE PREMENARCHEAL
NANCY J. CARLSON,
LANE J. MERCER
Department of Obstetrics and Gynecology, (Received (Accepted
FEMALE
and SAMIR N. HAJJ University of Chicago, Chicago, IL 60637 (USA)
May 28th, 1986) June 17th, 1986)
Abstract Carlson NJ, Mercer LJ, Hajj SN (Department o.f Obstetrics and Gynecology, University of Chicago, Chicago, IL 60637, USA). Urethral prolapse in the premenarcheal female. Int J Gynaecol Obstet 2.5: 69- 71, 1987 Urethral prolapse in the premenarcheal female manifests as vaginal bleeding and a periurethral mass. In the past, the recommended management was surgical excision or cautery. However, conservative management has been shown to have excellent results. Five premenarcheal patients with urethral prolapse treated by conservative therapy are presented. Treatment regimen consisted of local hygiene with sitz baths, hexachlorophene soap, topical providone iodine and estrogen cream. There were no complications or recurrences. Surgery is not warranted in the treatment of urethral prolapse in the premenarcheal female. Medical management is equally ejyective and less traumatic in this age group.
ment has been surgical. However, treatment of the underlying infection can lead to resolution of the lesion. Redman [ 141 treated three premenarcheal girls with topical antimicrobial ointment resulting in slow but effective resolution of the prolapse. Richardson et al. [ 151 successfully treated five similar patients using intensive local hygiene, topical estrogen, locally applied antimicrobial ointment and oral antibiotics. Other successful cases of conservatively managed urethral prolapse in children have been reported [2,3,6,9-l 11. There are no reported complications or recurrences. In spite of this evidence, surgery continues to be advocated as primary treatment for this lesion [ 1,13,16]. We add five new cases of medical management of urethral prolapse in the premenarcheal female and review the outcome of other such conservatively managed cases. Case reports Case I
Keywords: Prolapse; Premenarche. Introduction Urethral prolapse is a circumferential protrusion of the urethral mucosa through the external meatus. Often this exposed tissue becomes infected resulting in marked erythema and induration and presenting as a large bleeding, friable urethral mass. Traditionally, treat0020-7292/87/$03,50 0 1987 International Federation Published and Printed in Ireland
This &year-old, black female presented with vaginal bleeding and a tender mass. Examination revealed a 10 X 1 1 mm, friable, periurethral mass. Cultures were taken for aerobes and anaerobes (Table I). Treatment was started consisting of local hygiene with sitz baths, hexachlorophene soap, topical providone iodine ointment and estrogen cream. Symptoms rapidly subsided and within 2 weeks the mass had disappeared. Follow-up at 6 months revealed no recurrence. Inr J Gynaecol Obstet 25
of Cynaecology
& Obstetrics
70
Carlson et al.
Table 1. Bacterial isolates from symptomatic lapse in five children. Organisms isolated
urethral pro-
No. of isolates
Bacteroides fragilis E. coli
Group D Streptococcus Group B Streptococcus Gardnerella vaginalis Lactobacillus
Case 2 This 8-year-old, black female presented with vaginal bleeding and dysuria. Examination revealed a 10 X 21 mm periurethral mass. Cultures were taken. Therapy consisted of local hygiene with sitz baths, hexachlorophene soap, topical providone iodine ointment and estrogen cream. Resolution of symptoms and the mass occurred within 3 weeks. Follow-up at 7 months revealed no recurrence. Case 3 This 4-year-old, Hispanic female presented with vaginal bleeding and a 10 X 12 mm periurethral mass. She was treated as above. Symptoms resolved within 1 week. Follow-up at 1 year revealed no recurrence. Case 4 This 1O-year-old, Hispanic female presented with vaginal bleeding and a 10 X 13 mm, friable mass. Therapy was the same as Cases l-3 with the addition of oral amoxicillin. Symptoms resolved within 2 weeks. Follow-up at 3 months revealed no recurrence. Case 5 This g-year-old, Hispanic female presented with a vaginal mass. Examination revealed urethral prolapse. Cultures were taken. Therapy was the same as Cases l-3 with the addition of oral metronidazole. Resolution occurred within 1 week. Follow-up at 3 months revealed no recurrence. Int J Gynaecol Obstet 25
Discussion The exact etiology of urethral prolapse in children is unknown. It has been proposed that weakened support of the distal urethra of a congenital [51 or acquired nature may predispose to this prolapse. Of the latter, nutritional deficiency [ 12 I, local trauma [ 171, inflammation 141,and persistent increases in intra-abdominal pressure [ 41, such as chronic cough or constipation, may contribute significantly. Once the urethral mucosa is exposed, trauma, ulceration, and infection with endogenous flora occurs. Many surgical procedures [ 3,4,12,15] have been described for the treatment of urethral prolapse. They include simple incision, bladder neck suspension and plastic procedures. Frequently, they are destructive using scalpel, cautery or cryotherapy to obliterate the protruding mass. The procedure most commonly recommended is cold-knife excision with approximation of the urethral mucosa to the [ 71. Reported complications of vestibule surgical therapy are infrequent. However, they include stricture [21, infection [ 121, urinary retention [ 81, hemorrhage [ 101, and recurrence [ 2,101. Medical treatment of urethral prolapse is based on the eradication of infection in the exposed denuded mucosa. This results in decreased edema and resolution of the prolapse. Our protocol includes intense local hygiene including frequent sitz baths, topical iodine ointment and estrogen providone cream. Local hygiene acts to decrease surface contamination and prevent re-infection from the perineum. Topical antimicrobial therapy further eradicates the infection. The addition of topical estrogen cream acts to cornify the mucosa also rendering it more resistant to bacterial re-invasion. The value of systemic antibiotics is unclear. We have had success both with and without their use. With the addition of our five cases, there are now 2 1 cases of successful medical management in children (Table II). Esposito [31 reported a case of a child who had spontan-
Urethral prolapse Table II.
Review of medical
management
of urethral
prolapse
in the premenarcheal
female.
11
NR, not reported.
.Author
Esposito [ 3 ] Owens and Morse [lo] Capraro et al. 12) Jones and Fischer [6] Perelman [ 111 Redman [ 141 Richardson [ 15 ] Morris [9] Present
Cases
1 2 1 2 1 3 5 1 5
Antimicrobials
Hygiene
NR f + -
+ NR +
References Akpo EC, Aguessy-Ahyi B, Padonou N et al.: Prolapse of the urethral mucosa in children. Report from the Cotonon teaching hospitalgroup. J Uro189: 35 1, 1983. Capraro VJ, Bayonet-Rivera NP, Magoss I: Vulvar tumor in children due to prolapse of urethral mucosa. Am J Obstet GynecolIO8: 572, 1970. Esposito JM: Circular prolapse of the urethra in children: a cause of vaginal bleeding. Obstet Gynecol 31: 363, 1968. Epsteen A, Strauss B: Prolapse of female urethra with gangrene. Am J Surg 35: 563, 1937.
Topical
Systemic
NR -
NR
NR
-
-
eous resolution after postponement of surgery. Owens and Morse [4] treated two patients with sitz baths with improvement in 6-l 0 days. Capraro et al. [2] also successfully treated a patient with sitz baths alone. Jones and Fischer [6] used oral ampicillin and topical neomycin and hydrocortisone to successfully treat two patients. Perelman et al. [ 11 I had resolution in one case with topical estrogen cream alone. Redman [ 141 and Richardson treated three and five [ISI successfully patients, respectively, as previously described. And Morris [9] treated one patient with “outpatient care”. There are no documented recurrences in the literature following medical management. In the premenarcheal female urethral prolapse should be treated with conservative medical management. This management is successful, without complications, less traumatic for the young patient, and more cost effective than a surgical procedure.
Estrogen cream
10 11
12 13 14 15
16 17
+ -
+
+ + NR +
-
+ _
+ NR
+ NR +
Hepburn TN: Prolapse of the female urethra. Surg Gyneco1 Obstet 31: 83, 1920. Jones HE‘ Fischer HJ: Urethral prolapse in girls. Arch Dis Child 46: 107, 1971. Kelly HA, Burnam CF: Disease of Kidney, Ureters, and Bladder, Vol. 2, p 578. Appleton, New York, 1914. Klaus H, Stein RT: Urethral prolapse in young girls. Pediatrics 52: 645, 1973. Morris TM; Conservative management of urethral prolapse. Urology 20: 35 1, 1982. Owens SB, Morse WH: Prolapse of the female urethra in children. J Urol100: 171, 1968. Perelman R, Boralevi CI, Reinert PH et al.: A rare cause of “genital” hemorrhage in a girl. Prolapsed urethral mucsoa treated with estrogens. Ann Pediatr 16: 457, 1969. Peters WA: Prolapse of the urethral mucosa. Am J Obstet Gynecol84: 862,1962. Putz A, Jakse G: Prolapse of the urethral mucsoa. A case report. Z Kinderchir 39: 80,1984. Redman JF: Conservative management of urethral prolapse in female children. Urology 19: 50.5, 1982. Richardson DA, Hajj SN, Herbst AL: Medical treatment of urethral prolapse in children. Obstet Gynecol 59: 69, 1982. Venable DD, Markland C: Urethral prolapse in girls. South Med J 75: 951, 1982. Zeigerman JH: Prolapse of the female urethra: its differential diagnosis with report of 5 cases. Urol Cutan Rev 49: 403,1945.
Address for reprints: Lane J. Mercer, M.D. Department of Obstetrics University of Chicago 5841 S. Maryland Ave. Chicago, IL 60637, USA
and Gynecology
Int J Gynaecol Obstet 25
69
URETHRAL PROLAPSE IN THE PREMENARCHEAL
NANCY J. CARLSON,
LANE J. MERCER
Department of Obstetrics and Gynecology, (Received (Accepted
FEMALE
and SAMIR N. HAJJ University of Chicago, Chicago, IL 60637 (USA)
May 28th, 1986) June 17th, 1986)
Abstract Carlson NJ, Mercer LJ, Hajj SN (Department o.f Obstetrics and Gynecology, University of Chicago, Chicago, IL 60637, USA). Urethral prolapse in the premenarcheal female. Int J Gynaecol Obstet 2.5: 69- 71, 1987 Urethral prolapse in the premenarcheal female manifests as vaginal bleeding and a periurethral mass. In the past, the recommended management was surgical excision or cautery. However, conservative management has been shown to have excellent results. Five premenarcheal patients with urethral prolapse treated by conservative therapy are presented. Treatment regimen consisted of local hygiene with sitz baths, hexachlorophene soap, topical providone iodine and estrogen cream. There were no complications or recurrences. Surgery is not warranted in the treatment of urethral prolapse in the premenarcheal female. Medical management is equally ejyective and less traumatic in this age group.
ment has been surgical. However, treatment of the underlying infection can lead to resolution of the lesion. Redman [ 141 treated three premenarcheal girls with topical antimicrobial ointment resulting in slow but effective resolution of the prolapse. Richardson et al. [ 151 successfully treated five similar patients using intensive local hygiene, topical estrogen, locally applied antimicrobial ointment and oral antibiotics. Other successful cases of conservatively managed urethral prolapse in children have been reported [2,3,6,9-l 11. There are no reported complications or recurrences. In spite of this evidence, surgery continues to be advocated as primary treatment for this lesion [ 1,13,16]. We add five new cases of medical management of urethral prolapse in the premenarcheal female and review the outcome of other such conservatively managed cases. Case reports Case I
Keywords: Prolapse; Premenarche. Introduction Urethral prolapse is a circumferential protrusion of the urethral mucosa through the external meatus. Often this exposed tissue becomes infected resulting in marked erythema and induration and presenting as a large bleeding, friable urethral mass. Traditionally, treat0020-7292/87/$03,50 0 1987 International Federation Published and Printed in Ireland
This &year-old, black female presented with vaginal bleeding and a tender mass. Examination revealed a 10 X 1 1 mm, friable, periurethral mass. Cultures were taken for aerobes and anaerobes (Table I). Treatment was started consisting of local hygiene with sitz baths, hexachlorophene soap, topical providone iodine ointment and estrogen cream. Symptoms rapidly subsided and within 2 weeks the mass had disappeared. Follow-up at 6 months revealed no recurrence. Inr J Gynaecol Obstet 25
of Cynaecology
& Obstetrics
70
Carlson et al.
Table 1. Bacterial isolates from symptomatic lapse in five children. Organisms isolated
urethral pro-
No. of isolates
Bacteroides fragilis E. coli
Group D Streptococcus Group B Streptococcus Gardnerella vaginalis Lactobacillus
Case 2 This 8-year-old, black female presented with vaginal bleeding and dysuria. Examination revealed a 10 X 21 mm periurethral mass. Cultures were taken. Therapy consisted of local hygiene with sitz baths, hexachlorophene soap, topical providone iodine ointment and estrogen cream. Resolution of symptoms and the mass occurred within 3 weeks. Follow-up at 7 months revealed no recurrence. Case 3 This 4-year-old, Hispanic female presented with vaginal bleeding and a 10 X 12 mm periurethral mass. She was treated as above. Symptoms resolved within 1 week. Follow-up at 1 year revealed no recurrence. Case 4 This 1O-year-old, Hispanic female presented with vaginal bleeding and a 10 X 13 mm, friable mass. Therapy was the same as Cases l-3 with the addition of oral amoxicillin. Symptoms resolved within 2 weeks. Follow-up at 3 months revealed no recurrence. Case 5 This g-year-old, Hispanic female presented with a vaginal mass. Examination revealed urethral prolapse. Cultures were taken. Therapy was the same as Cases l-3 with the addition of oral metronidazole. Resolution occurred within 1 week. Follow-up at 3 months revealed no recurrence. Int J Gynaecol Obstet 25
Discussion The exact etiology of urethral prolapse in children is unknown. It has been proposed that weakened support of the distal urethra of a congenital [51 or acquired nature may predispose to this prolapse. Of the latter, nutritional deficiency [ 12 I, local trauma [ 171, inflammation 141,and persistent increases in intra-abdominal pressure [ 41, such as chronic cough or constipation, may contribute significantly. Once the urethral mucosa is exposed, trauma, ulceration, and infection with endogenous flora occurs. Many surgical procedures [ 3,4,12,15] have been described for the treatment of urethral prolapse. They include simple incision, bladder neck suspension and plastic procedures. Frequently, they are destructive using scalpel, cautery or cryotherapy to obliterate the protruding mass. The procedure most commonly recommended is cold-knife excision with approximation of the urethral mucosa to the [ 71. Reported complications of vestibule surgical therapy are infrequent. However, they include stricture [21, infection [ 121, urinary retention [ 81, hemorrhage [ 101, and recurrence [ 2,101. Medical treatment of urethral prolapse is based on the eradication of infection in the exposed denuded mucosa. This results in decreased edema and resolution of the prolapse. Our protocol includes intense local hygiene including frequent sitz baths, topical iodine ointment and estrogen providone cream. Local hygiene acts to decrease surface contamination and prevent re-infection from the perineum. Topical antimicrobial therapy further eradicates the infection. The addition of topical estrogen cream acts to cornify the mucosa also rendering it more resistant to bacterial re-invasion. The value of systemic antibiotics is unclear. We have had success both with and without their use. With the addition of our five cases, there are now 2 1 cases of successful medical management in children (Table II). Esposito [31 reported a case of a child who had spontan-
Urethral prolapse Table II.
Review of medical
management
of urethral
prolapse
in the premenarcheal
female.
11
NR, not reported.
.Author
Esposito [ 3 ] Owens and Morse [lo] Capraro et al. 12) Jones and Fischer [6] Perelman [ 111 Redman [ 141 Richardson [ 15 ] Morris [9] Present
Cases
1 2 1 2 1 3 5 1 5
Antimicrobials
Hygiene
NR f + -
+ NR +
References Akpo EC, Aguessy-Ahyi B, Padonou N et al.: Prolapse of the urethral mucosa in children. Report from the Cotonon teaching hospitalgroup. J Uro189: 35 1, 1983. Capraro VJ, Bayonet-Rivera NP, Magoss I: Vulvar tumor in children due to prolapse of urethral mucosa. Am J Obstet GynecolIO8: 572, 1970. Esposito JM: Circular prolapse of the urethra in children: a cause of vaginal bleeding. Obstet Gynecol 31: 363, 1968. Epsteen A, Strauss B: Prolapse of female urethra with gangrene. Am J Surg 35: 563, 1937.
Topical
Systemic
NR -
NR
NR
-
-
eous resolution after postponement of surgery. Owens and Morse [4] treated two patients with sitz baths with improvement in 6-l 0 days. Capraro et al. [2] also successfully treated a patient with sitz baths alone. Jones and Fischer [6] used oral ampicillin and topical neomycin and hydrocortisone to successfully treat two patients. Perelman et al. [ 11 I had resolution in one case with topical estrogen cream alone. Redman [ 141 and Richardson treated three and five [ISI successfully patients, respectively, as previously described. And Morris [9] treated one patient with “outpatient care”. There are no documented recurrences in the literature following medical management. In the premenarcheal female urethral prolapse should be treated with conservative medical management. This management is successful, without complications, less traumatic for the young patient, and more cost effective than a surgical procedure.
Estrogen cream
10 11
12 13 14 15
16 17
+ -
+
+ + NR +
-
+ _
+ NR
+ NR +
Hepburn TN: Prolapse of the female urethra. Surg Gyneco1 Obstet 31: 83, 1920. Jones HE‘ Fischer HJ: Urethral prolapse in girls. Arch Dis Child 46: 107, 1971. Kelly HA, Burnam CF: Disease of Kidney, Ureters, and Bladder, Vol. 2, p 578. Appleton, New York, 1914. Klaus H, Stein RT: Urethral prolapse in young girls. Pediatrics 52: 645, 1973. Morris TM; Conservative management of urethral prolapse. Urology 20: 35 1, 1982. Owens SB, Morse WH: Prolapse of the female urethra in children. J Urol100: 171, 1968. Perelman R, Boralevi CI, Reinert PH et al.: A rare cause of “genital” hemorrhage in a girl. Prolapsed urethral mucsoa treated with estrogens. Ann Pediatr 16: 457, 1969. Peters WA: Prolapse of the urethral mucosa. Am J Obstet Gynecol84: 862,1962. Putz A, Jakse G: Prolapse of the urethral mucsoa. A case report. Z Kinderchir 39: 80,1984. Redman JF: Conservative management of urethral prolapse in female children. Urology 19: 50.5, 1982. Richardson DA, Hajj SN, Herbst AL: Medical treatment of urethral prolapse in children. Obstet Gynecol 59: 69, 1982. Venable DD, Markland C: Urethral prolapse in girls. South Med J 75: 951, 1982. Zeigerman JH: Prolapse of the female urethra: its differential diagnosis with report of 5 cases. Urol Cutan Rev 49: 403,1945.
Address for reprints: Lane J. Mercer, M.D. Department of Obstetrics University of Chicago 5841 S. Maryland Ave. Chicago, IL 60637, USA
and Gynecology
Int J Gynaecol Obstet 25