Urethral prolapse is a rare occurrence with a reported incidence of approximately 1 in 3,000. It has been described as a circumferential reversion of the mucosa at the distal urethra. It is observed in a bimodal distribution in premenarchal girls and postmenopausal women. Factors thought to lead to the development of urethral prolapse include conditions with a lack of estrogen in combination with conditions associated with chronic increased intra-abdominal pressure, such as chronic constipation or chronic obstructive pulmonary disease, which may lead to disruption in the attachments between the layers of the urethral smooth muscle. There have also been some cases reporting urethral prolapse following urethral bulking agents, however clear etiology has not yet been demonstrated. When presented with a urethral mass at the meatus, the differential diagnosis most commonly includes a urethral caruncle, which is described as an eversion of a segmental portion of the distal urethra at the posterior edge of the external urethral meatus, which is in contrast to the circumferential aversion noted in urethral prolapse. This occurs mainly in postmenopausal women due to a lack of estrogen and is conservatively managed with topical medication. Condyloma acuminata may also present at the meatus, but usually demonstrates characteristic mucosal changes. While rare, malignancy should be ruled out with tissue biopsy for any suspicious findings. Biopsy may reveal urethral or vaginal pathology, including transitional cell carcinoma, sarcoma, lymphoma, melanoma, squamous cell, or metastatic disease. Fibroepithelial polyps at the meatus are usually congenital and present as an interlabial mass. Other differentials include periurethral abscess, trauma, and sexual abuse. Urethral prolapse is usually asymptomatic in premenarchal girls, however, can cause significant irritation and discomfort in postmenopausal women. Patients may report spotting from the edematous friable mucosa and lower urinary tract symptoms, including dysuria, hematuria, nocturia, urgency, and frequency. Evaluation should include a thorough history and physical with examination of the lesion, which commonly appears as a soft, round, doughnut-like friable mass at the external urethral meatus. The protrusion of the mucosa causes vascular congestion and edema of the tissue. Examination of the urethra should be performed to palpate and assess for any abscesses or induration, which may be suggestive of infection or malignancy. Evaluation should also assess for any other lesions located proximally to the meatus. External urethroscopy can be utilized to further evaluate the urethral lumen. While urethral prolapse may cause bleeding, microscopic evaluation may be warranted to rule out other etiologies of hematuria. Given the low prevalence of urethral prolapse, there are no large studies or randomized controlled trials evaluating the optimal treatment strategy. First-line management involves conservative treatment with topical estrogen. A fingertip amount is applied to the external urethral meatus and can be done daily at first and then twice a week for two to three months. SITS baths should also be encouraged. While medical management can help reduce the symptoms, recurrence rates have been reported as high as 67%. Surgical management should be reserved for symptomatic urethral prolapse that does not respond to conservative therapies. If left untreated, it may lead to strangulation and thrombosis of the prolapsed urethral tissue. A surgical procedure for the treatment of urethral prolapse described by Shurtleff and Barone is known as the four-quadrant excisional technique. The prolapse is grasped to determine the extent of the protrusion. Stay sutures are then placed inside the urethral lumen proximal to the tissue planned to be excised to prevent retraction of the mucosa in four quadrants, starting at the 12 o'clock position. The redundant tissue is excised circumferentially at the base and hemostasis is confirmed. The inner and outer edges of the mucosa are then re-approximated with interrupted sutures to complete the closure without tension. A Foley catheter is placed and maintained for a few days postoperatively. Potential complications of the surgery include urethral stricture, voiding dysfunction, and recurrence. In a retrospective review of patients who underwent surgery for symptomatic urethral prolapse, Hall et al. found that of the 24 women who underwent excision, three patients had visible recurrence, one of whom underwent repeat excision. Six patients experienced temporary postoperative bleeding and one required placement of a Foley catheter to tamponade. One patient also experienced transient postoperative urinary retention requiring temporary Foley catheter placement. It is important to counsel patients of the potential complications and manage postoperative expectations. We present a case of a 58-year-old female who had initially presented to her gynecologist and was conservatively managed with topical estrogen cream for a urethral caruncle. She denied any pain or lower urinary tract symptoms. She had also reported vaginal bulge symptoms and was noted to have a stage 3 cystocele and was fitted for a pessary, which she tried for a few months. She then noted intermittent spotting and tenderness at the urethra, prompting evaluation at the office of a urogynecologist. Examination was significant for a urethral prolapse with circumferential aversion, which was tender yet reducible. She was recommended to continue topical vaginal estrogen cream and sitz baths. After one and a half months of conservative management without improvement, the patient was consented for surgical management of the urethral prolapse. Additionally, she also desired repair of her symptomatic pelvic organ prolapse. The patient underwent a bilateral vaginal-paravaginal repair, anterior repair, and sacrospinous ligament fixation. At the conclusion, attention was then turned to the urethral prolapse. The goal of the procedure is to maintain as much urethral epithelium as possible to facilitate closure without tension. Brio-vicral stay sutures were placed at the 12, 3, 6, and 9 o'clock positions to mark the boundaries of the excision. Using a fine-tip bovie cautery, a circumferential incision was made on the urethral mucosa to excise the tissue and also maintain hemostasis. The excision is performed in quadrants delineated by the four stay sutures. Interrupted 4-0-vicral sutures are placed to re-approximate the mucosa with the vaginal epithelium to avoid retraction of the mucosa. A Foley catheter was placed and maintained post-operatively. The patient was discharged home on post-op day number one with leg bag teaching and instructed to apply topical estrogen cream to the area. The patient returned to the office on post-op day number 10 for a voiding trial, which she passed. She has been subsequently seen and is healing well without pain or recurrence and denies any lower urinary tract symptoms. For more information visit www.FEMA.gov

urethral prolapse

estrogen deficiency

chronic conditions

surgical intervention

case study