Complex systems work best when everything is in its respective place. The human body is no exception and we’ve all had to manage problems when “parts” are out of place. We’ve discussed dislocated body parts (ex, Shoulder, Patella, Knee, Hip, Clavicular Head) and even prolapsed body parts (ex, Rectal Prolapse). These conditions have management challenges, but not necessarily diagnostic challenges (“That patella is not where it is supposed to be.”); however, when some structures are “out of place” it can be a little more confusing. Let us consider one such structure so that we may be more familiar with it – Urethral Prolapse:

Urethral Prolapse: Basics

• Urethral Prolapse is the protrusion of the distal urethra through the external urethral meatus. [McCaskill, 2018; Liu, 2018]
  • Most often seen in preadolescent and postmenopausal patients.
  • The distal portion of the urethra has a high concentration of estrogen receptors present.
  • The relative estrogen deficiency in young children (and elderly patients) increases their risk for prolapse.
  • Those with constipation (or conditions leading to increased abdominal pressure, like persistent coughing) are also at increased risk for developing urethral prolapse.

• Symptoms of Urethral Prolapse: [Liu, 2018]
  • Genital Bleeding (may be described as “vaginal bleeding“)
  • Dysuria
  • Urinary Frequency and Urgency

• Signs and Stages of Urethral Prolapse: [Liu, 2018]
  1. Small circular or partial prolapse
  2. Circular prolapse with edema
  3. Bulge protruding beyond the labia minora
  4. Prolapse with hemorrhage, necrosis, or ulceration

Urethral Prolapse: DDx

Urogenital Bleeding Ddx: [McCaskill, 2018]

• Trauma (ex, straddle injury, abuse)
• Infection (ex, Group A beta-hemolytic Strep)
• Structural (ex, Cervical prolapse, vaginal prolapse, cysts)
• Hematologic (ex, coagulation disorders)
• Endocrine (ex, Precocious puberty, estrogen-secreting tumor)
• Neoplasm (ex, rhabdomyosarcoma, sarcoma botryoides)

Urogenital Mass Ddx: [Liu, 2018]

• Urethral Caruncle
  • Mass may protrude through urethral meatus and bleeds easily.
  • Often smaller than Urethral Prolapse.
  • Attached to wall of urethra, so when catheter placed in urethra, the mass is observed on one side of the catheter rather than surrounding it.

• Ectopic Ureterocele
  • Appears similar to urethral prolapse.
  • Often spontaneously resolves.

• Vaginal Rhabdomyosarcoma
  • Neoplasm of the vulva
  • Seen in infants and young children.
  • Tissue bleeds easily.
  • Good visualization will help to distinguish origin of mass.
  • Observing the child urinate may also help distinguish whether the mass is associated with the vagina or urethral orifice.

It is incredibly important to get a good visualization of the genital area in order to help distinguish urethral pathology from vaginal pathology. [McCaskill, 2018]

• Knee Chest Position
• Frog-Leg Position
• Gentle downward and lateral traction of the vulva in both positions helps to improve identification of structures.
• Ensure you have optimal lighting.
• Ensure you keep the patient safe and comfortable (not an exam it be abrupt with)… ideally include you Child Life specialists!!

Urethral Prolapse: Management

• There are several therapeutic options, but with minor (less severe) cases a conservative approach is initially taken. [Liu, 2018]
  • Topical Estrogen creams (up to 6 weeks)
  • Sitz baths
  • Treatment of suspected UTI with antibiotics

• Surgical interventions used for:
  • Cases that failed conservative therapy
  • More severe cases (ex, Stage 4 urethral prolapse)
  • Urethral prolapse that is tender is considered more severe also.

Moral of the Morsel

• Anatomy Matters! Genital bleeding can lead to lots of concern, but keep your Ddx open an know your anatomy.
• Visualization Matters! Ensure optimal lighting and keep the patient comfortable throughout the examination.
• Estrogen for the win! Topical estrogen cream may be all that is needed… along with close follow-up!

References