Urethral prolapse is an eversion of urethral mucosa through the distal urethra. It is a rare condition that is typically seen in post-menopausal and prepubescent African-American females. The exact etiology of urethral prolapse is unknown. One theory suggests that the prolapse occurs as a result of separation between the two muscular layers of the urethra. However, there is no evidence to support that the prolapse occurs in post-menopausal and prepubescent African-American females. This separation may be a congenital or an acquired anatomic defect. Another theory proposes a hormonal contribution with atrophy from lack of estrogen causing retraction of the epithelial edge of the external urethral meatus resulting in urethral prolapse. This hormonal theory may explain why the distribution of the urethral prolapse is bimodal. Diagnosis of urethral prolapse is made by physical examination. It is typically described as a hemorrhagic, donut-shaped vulvar mass surrounding the urethra. One must keep in mind the differential diagnosis for periurethral masses to ensure proper diagnosis. This includes urethral caruncle, urethral diverticulum, Skene's cyst or abscess, vaginal cyst, ectopic ureterocele, and malignancy. Urethral prolapse is distinguished from a urethral caruncle by encompassing the entire urethral meatus. If significant edema or anatomic distortion is noted, placement of a Foley catheter will assist with identification of pertinent anatomy. Our patient is a 62-year-old para 2 female who presented with complaints of vaginal bleeding, acute onset urinary incontinence, urinary frequency, and vaginal bulge symptoms for the past three weeks. Her past medical and surgical histories were benign. On physical exam, the urethra was found to be prolapsed approximately two centimeters with mildly hyperemic tissue. No evidence of infection or vascular compromise was noted. Conservative management is usually the first step in the treatment of uncomplicated mild urethral prolapse. This consists of topical estrogen therapy, antibiotics if an infection is present, and periodic sitz baths for symptomatic relief. If symptoms improve, long-term vaginal estrogen cream may be used to prevent recurrence. Alternatively, if symptoms are refractory to conservative measures or vascular compromise is suspected, surgical intervention is deemed appropriate. Various surgical procedures have been reported historically and include excision, ligation, fulguration, and cryotherapy. At our patient's initial visit, she was started on topical estrogen cream and given the severity of her symptoms and the extent of her urethral prolapse, surgical excision was planned. The case began with an examination under anesthesia which noted reduction of the urethral prolapse by 50% since initial presentation. Next, a Lone Star retractor was placed to assist with exposure and visualization. We proceeded with an evaluation of the lower urinary tract. A 360-degree bladder survey was performed using a 30-degree cystoscope to rule out anatomic abnormalities. The location of the bilateral ureteric orifices was visualized with no evidence of an ectopic ureter. Next, urethroscopy was performed ensuring no fissureless tracts or defects. A measurement of urethral length was made revealing an overall length of 3.5 centimeters. A 16 French Foley catheter was then placed. An injection of a hemostatic agent was performed circumferentially at the proposed new external urethral meatus. Stay sutures were placed at 12, 9, 6, and 3 o'clock using 2-0 absorbable suture. They were placed in the vaginal epithelium approximately 3 millimeters from the proposed excision line. With the use of BOVI electrocautery, the exposed urethral mucosa was excised in four quadrants. Each quadrant was then re-approximated to the vaginal epithelium using the previously placed anchoring sutures. Care was taken to ensure a full thickness approximation of the urethral mucosa to the vaginal epithelium to prevent retraction of the urethral tissue. www.ottobock.com www.ottobock.com Interrupted 3-0 absorbable sutures were placed to close the intervening sections of the incision line. Lastly, petroleum-soaked gauze was wrapped around the Foley to assist with patient discomfort upon discharge. The Foley catheter was kept in place for five days and was removed, followed by a trial of Boyd. Postoperative complications following urethral prolapse repair may include urethral stenosis and urinary incontinence. Urethral stenosis can occur from the development of scar tissue at the distal urethra. To help prevent urethral scarring, we prefer to perform this procedure on healthy estrogenized tissue and ensure complete approximation of the urethral mucosa to the vaginal epithelium. This will help with preventing the retraction of the urethral mucosa. Postoperative urinary incontinence occurs due to the diminished urethral length following excision. The severity of incontinence will depend on the amount of urethral tissue excised along with the patient's baseline urethral functioning. In conclusion, each case of urethral prolapse should be managed individually with respect to the medical history, surgical morbidity, and the severity of the symptoms. Surgical management should be considered in cases of vascular compromise, urinary retention, or failed medical management.

urethral prolapse

post-menopausal

prepubescent

African-American females

surgical intervention