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Urine retention caused by urethral prolapse mimicking uterine prolapse
Taiwanese Journal of Obstetrics & Gynecology 59 (2020) 165e166
Contents lists available at ScienceDirect
Taiwanese Journal of Obstetrics & Gynecology journal homepage: www.tjog-online.com
Case Report
Urine retention caused by urethral prolapse mimicking uterine prolapse Tun-Chi Hu a, Chin-Ru Ker a, Cheng-Yu Long a, b, * a b
Department of Obstetrics and Gynecology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan Department of Obstetrics and Gynecology, Kaohsiung Municipal Siao-Gang Hospital, Kaohsiung, Taiwan
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 4 June 2019
Objective: Urethral prolapse is a rare clinical condition, which has been reported mostly in prepubertal girls; few menopaused and only 5 cases of premenopausal women. Strangulated urethral prolapse is even rarer. Case report: A 64-year-old woman presented with urinary retention, painful vaginal bleeding and a protruding mass. Pelvic examination revealed a reddish doughnut-shaped mass located at introitus. The patient felt uncomfortable with attempts to reduce the presumed prolapse. Urethral prolapse was impressed and topical estrogen cream was prescribed. However, urethral mucosa became congested and without shrinkage three days later. As a result, simple excision was performed. No recurrence was noted at the time of manuscript submission. Conclusion: Most common symptoms of urethral prolapse are vaginal bleeding and visible vaginal mass. Urethral prolapse can be diagnosed primarily by physical examinations. Surgical excision is a good way to treat recurrence or strangulated urethral prolapse with almost no complications and high success rate. © 2020 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: Menopause Strangulated urethral prolapse Urethral prolapse
Introduction Urethral prolapse is a rare clinical condition that is described as a round doughnut-shaped urethra mucosa protruding from external urethral meatus. Strangulated urethral prolapse is even rarer, and may easily be mistaken as a malignant lesion. Urethral prolapse has been reported mostly in prepubertal girls; few menopaused and only 5 cases of premenopausal women [1]. Adult patients are almost exclusively white. Prepubertal girls are usually asymptomatic, while postmenopausal women often symptomatic. Common symptoms include vaginal bleeding and irreducible painful mass. We here report such a case in a postmenopausal Asian woman. Case presentation A 64-year-old woman presented with urinary retention, painful vaginal bleeding and a protruding mass for a few hours. According
* Corresponding author. Department of Obstetrics and Gynecology, Kaohsiung Medical University Hospital 100 Tzyou 1st road Kaohsiung City, 80756, Taiwan. Fax: þ886 7 806 5068. E-mail address: [email protected] (C.-Y. Long).
to patient herself, she had found mild tissue protruding from private parts one year ago. Obstetric history included two vaginal deliveries and one ectopic pregnancy. She had reached menopause at the age of 53 years. She denied other systemic disease. Abdominal ultrasound showed no significant findings. Pelvic examination revealed a reddish round doughnut-shaped mass (3 2 cm) located at introitus (Fig. 1), resembling uterine cervix. However, the protruding mass could not be repositioned and the patient felt uncomfortable with attempts to reduce the presumed prolapse. A Foley catheter was inserted to confirm circumferential eversion of distal urethra (Fig. 2). Urethral prolapse was impressed. The patient was treated with topical estrogen cream and follow-up appointment arranged. Three days later, pelvic examination revealed congested urethral mucosa, necrotic and without signs of shrinkage. Considering the possibility of strangulated urethral prolapse or urethral carcinoma, she was referred to a Urologist for lesion excision. The prolapsed mass was excised by four quadrant technique under general anesthesia. After stay suturing over the prolapsed tissue, the urethral mucosa was cut and anastomosis. Histological examination reported as urethral mucosa organizing thrombus formation, congested vessels, sized 3.5 2.0 1.0 cm with brown coloration and elastic texture. There was no evidence of malignancy. Patient was
https://doi.org/10.1016/j.tjog.2019.11.029 1028-4559/© 2020 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
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T.-C. Hu et al. / Taiwanese Journal of Obstetrics & Gynecology 59 (2020) 165e166
Fig. 1. Appearance of a large round doughnut-shaped urethral prolapse.
distal urethral mucosa completely everts through the external urethral meatus and forms a circular mass around the opening of the urethra. The risk of strangulation increases as the prolapsed length increases. Physical examination usually shows round doughnut-shaped urethra mucosa protruding from the vagina with irreducible, painful and tender on touch, all of which were presented in our patient. Although rare, urethral prolapse must be considered in any female with a history of vaginal bleeding or severe urinary symptoms. Vaginal bleeding and vaginal mass are the most common presenting symptoms, followed by abnormal voiding, dysuria, or hematuria [2]. If urethral prolapse is large, mucosal mass may become ischemic, resulting in venous obstruction, thrombosis, and necrosis of the prolapsed tissue, which is called strangulated urethral prolapse. The exact etiology of urethral prolapse is unclear. Lack of estrogen and poor attachments between the inner and outer smooth muscle layers are the two most popular theories [2]. Other possible hypotheses include loosen pelvic floor musculature, sudden raised intra-abdominal pressure, poor nutrition and hygiene [1]. Diagnosis of urethral prolapse is made by direct inspection. When a mass is observed in the introitus, differential diagnoses should include uterine prolapse, urethral prolapse, urethral caruncle, leiomyoma, vaginal cyst, ectopic ureterocele, and malignancy. Uterine prolapse is almost always reducible and painless, but urethral prolapse is irreducible and tender to palpation [3,4]. Urethral caruncle is a focal outgrowth, while urethral prolapse is circumferential. If malignancy is suspected, histological examination is warranted to confirm the diagnosis. Conservative management of urethral prolapse is usually the first step in treating mild urethral prolapse. Local hygiene with sitting baths, topical antibiotics, steroid, and estrogen cream are some examples. If symptoms improve, long-term vaginal estrogen cream may be used to prevent recurrence. Surgical treatment should be considered when conservative management fails, recurrence despite of conservative management or strangulation develops. Simple excision with anastomosis is a good option that relieves symptoms without recurrence. However, some reported urethral opening stenosis after excision in prepubertal girls, which should be informed of the patient beforehand [5]. In summary, urethral prolapse not only happens in prepubertal girls and postmenopausal women, but also in premenopausal women. Most common symptoms are vaginal bleeding and visible vaginal mass. Urethral prolapse can be diagnosed primarily by physical examinations. Surgical excision is a good way to treat recurrence or strangulated urethral prolapse with almost no complications and high success rate. Declaration of Competing Interest The authors have no conflicts of interest relevant to this article. References
Fig. 2. Foley was inserted to confirm circumferential eversion of the distal urethral.
discharged after removal of urinary catheter on the third postoperative day. Topic estrogen cream was applied during follow up. She remained symptom free one year after the operation. Discussion Urethral prolapse (UP) is a rare clinical condition. Strangulated urethral prolapse is even rarer. This condition happens when the
[1] Morris LJ, Stanley Z, Osama A. A case of strangulated urethral prolapse in a premenopausal adult female. Case Rep Urol Jun 2016;20. https://doi.org/ 10.1155/2016/1802623. Published online. [2] Manupriya S, Som RM, Rashmi R, Anjali S. Strangulated uretheral prolapse in a postmenopausal woman mimicking as malignancy; a Case Report. JOJ Nurse Health Care 2017;4(4):555644. [3] Tsai MJ, Tsai KB, Liu CM, Ho ET, Long CY. Perineal ultrasonography in diagnosing anterior vaginal leiomyoma resembling a cystocele. Ultrasound Obstet Gynecol 2007;30:1013e4. [4] Long CY, Wang CL, Hsu CS. Anterior vaginal cyst mimicking a cystocele assessed by transperineal ultrasound. Eur J Obstet Gynecol Reprod Biol 2012;165(1): 128e9. [5] Charlotte H, Devesh M. Surgical management of urethral prolapse in girls: 13 years' experience. BJU Int 2012;110(1):132e4.
Contents lists available at ScienceDirect
Taiwanese Journal of Obstetrics & Gynecology journal homepage: www.tjog-online.com
Case Report
Urine retention caused by urethral prolapse mimicking uterine prolapse Tun-Chi Hu a, Chin-Ru Ker a, Cheng-Yu Long a, b, * a b
Department of Obstetrics and Gynecology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan Department of Obstetrics and Gynecology, Kaohsiung Municipal Siao-Gang Hospital, Kaohsiung, Taiwan
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 4 June 2019
Objective: Urethral prolapse is a rare clinical condition, which has been reported mostly in prepubertal girls; few menopaused and only 5 cases of premenopausal women. Strangulated urethral prolapse is even rarer. Case report: A 64-year-old woman presented with urinary retention, painful vaginal bleeding and a protruding mass. Pelvic examination revealed a reddish doughnut-shaped mass located at introitus. The patient felt uncomfortable with attempts to reduce the presumed prolapse. Urethral prolapse was impressed and topical estrogen cream was prescribed. However, urethral mucosa became congested and without shrinkage three days later. As a result, simple excision was performed. No recurrence was noted at the time of manuscript submission. Conclusion: Most common symptoms of urethral prolapse are vaginal bleeding and visible vaginal mass. Urethral prolapse can be diagnosed primarily by physical examinations. Surgical excision is a good way to treat recurrence or strangulated urethral prolapse with almost no complications and high success rate. © 2020 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: Menopause Strangulated urethral prolapse Urethral prolapse
Introduction Urethral prolapse is a rare clinical condition that is described as a round doughnut-shaped urethra mucosa protruding from external urethral meatus. Strangulated urethral prolapse is even rarer, and may easily be mistaken as a malignant lesion. Urethral prolapse has been reported mostly in prepubertal girls; few menopaused and only 5 cases of premenopausal women [1]. Adult patients are almost exclusively white. Prepubertal girls are usually asymptomatic, while postmenopausal women often symptomatic. Common symptoms include vaginal bleeding and irreducible painful mass. We here report such a case in a postmenopausal Asian woman. Case presentation A 64-year-old woman presented with urinary retention, painful vaginal bleeding and a protruding mass for a few hours. According
* Corresponding author. Department of Obstetrics and Gynecology, Kaohsiung Medical University Hospital 100 Tzyou 1st road Kaohsiung City, 80756, Taiwan. Fax: þ886 7 806 5068. E-mail address: [email protected] (C.-Y. Long).
to patient herself, she had found mild tissue protruding from private parts one year ago. Obstetric history included two vaginal deliveries and one ectopic pregnancy. She had reached menopause at the age of 53 years. She denied other systemic disease. Abdominal ultrasound showed no significant findings. Pelvic examination revealed a reddish round doughnut-shaped mass (3 2 cm) located at introitus (Fig. 1), resembling uterine cervix. However, the protruding mass could not be repositioned and the patient felt uncomfortable with attempts to reduce the presumed prolapse. A Foley catheter was inserted to confirm circumferential eversion of distal urethra (Fig. 2). Urethral prolapse was impressed. The patient was treated with topical estrogen cream and follow-up appointment arranged. Three days later, pelvic examination revealed congested urethral mucosa, necrotic and without signs of shrinkage. Considering the possibility of strangulated urethral prolapse or urethral carcinoma, she was referred to a Urologist for lesion excision. The prolapsed mass was excised by four quadrant technique under general anesthesia. After stay suturing over the prolapsed tissue, the urethral mucosa was cut and anastomosis. Histological examination reported as urethral mucosa organizing thrombus formation, congested vessels, sized 3.5 2.0 1.0 cm with brown coloration and elastic texture. There was no evidence of malignancy. Patient was
https://doi.org/10.1016/j.tjog.2019.11.029 1028-4559/© 2020 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
166
T.-C. Hu et al. / Taiwanese Journal of Obstetrics & Gynecology 59 (2020) 165e166
Fig. 1. Appearance of a large round doughnut-shaped urethral prolapse.
distal urethral mucosa completely everts through the external urethral meatus and forms a circular mass around the opening of the urethra. The risk of strangulation increases as the prolapsed length increases. Physical examination usually shows round doughnut-shaped urethra mucosa protruding from the vagina with irreducible, painful and tender on touch, all of which were presented in our patient. Although rare, urethral prolapse must be considered in any female with a history of vaginal bleeding or severe urinary symptoms. Vaginal bleeding and vaginal mass are the most common presenting symptoms, followed by abnormal voiding, dysuria, or hematuria [2]. If urethral prolapse is large, mucosal mass may become ischemic, resulting in venous obstruction, thrombosis, and necrosis of the prolapsed tissue, which is called strangulated urethral prolapse. The exact etiology of urethral prolapse is unclear. Lack of estrogen and poor attachments between the inner and outer smooth muscle layers are the two most popular theories [2]. Other possible hypotheses include loosen pelvic floor musculature, sudden raised intra-abdominal pressure, poor nutrition and hygiene [1]. Diagnosis of urethral prolapse is made by direct inspection. When a mass is observed in the introitus, differential diagnoses should include uterine prolapse, urethral prolapse, urethral caruncle, leiomyoma, vaginal cyst, ectopic ureterocele, and malignancy. Uterine prolapse is almost always reducible and painless, but urethral prolapse is irreducible and tender to palpation [3,4]. Urethral caruncle is a focal outgrowth, while urethral prolapse is circumferential. If malignancy is suspected, histological examination is warranted to confirm the diagnosis. Conservative management of urethral prolapse is usually the first step in treating mild urethral prolapse. Local hygiene with sitting baths, topical antibiotics, steroid, and estrogen cream are some examples. If symptoms improve, long-term vaginal estrogen cream may be used to prevent recurrence. Surgical treatment should be considered when conservative management fails, recurrence despite of conservative management or strangulation develops. Simple excision with anastomosis is a good option that relieves symptoms without recurrence. However, some reported urethral opening stenosis after excision in prepubertal girls, which should be informed of the patient beforehand [5]. In summary, urethral prolapse not only happens in prepubertal girls and postmenopausal women, but also in premenopausal women. Most common symptoms are vaginal bleeding and visible vaginal mass. Urethral prolapse can be diagnosed primarily by physical examinations. Surgical excision is a good way to treat recurrence or strangulated urethral prolapse with almost no complications and high success rate. Declaration of Competing Interest The authors have no conflicts of interest relevant to this article. References
Fig. 2. Foley was inserted to confirm circumferential eversion of the distal urethral.
discharged after removal of urinary catheter on the third postoperative day. Topic estrogen cream was applied during follow up. She remained symptom free one year after the operation. Discussion Urethral prolapse (UP) is a rare clinical condition. Strangulated urethral prolapse is even rarer. This condition happens when the
[1] Morris LJ, Stanley Z, Osama A. A case of strangulated urethral prolapse in a premenopausal adult female. Case Rep Urol Jun 2016;20. https://doi.org/ 10.1155/2016/1802623. Published online. [2] Manupriya S, Som RM, Rashmi R, Anjali S. Strangulated uretheral prolapse in a postmenopausal woman mimicking as malignancy; a Case Report. JOJ Nurse Health Care 2017;4(4):555644. [3] Tsai MJ, Tsai KB, Liu CM, Ho ET, Long CY. Perineal ultrasonography in diagnosing anterior vaginal leiomyoma resembling a cystocele. Ultrasound Obstet Gynecol 2007;30:1013e4. [4] Long CY, Wang CL, Hsu CS. Anterior vaginal cyst mimicking a cystocele assessed by transperineal ultrasound. Eur J Obstet Gynecol Reprod Biol 2012;165(1): 128e9. [5] Charlotte H, Devesh M. Surgical management of urethral prolapse in girls: 13 years' experience. BJU Int 2012;110(1):132e4.