Urethral prolapse is a condition affecting women where the inner lining of the urethra, the tube that carries urine from the bladder, turns inside out and protrudes through the urinary opening. The condition is relatively rare and is most commonly observed in a bimodal distribution, affecting two distinct populations. It is seen in prepubertal girls, typically around age four, and postmenopausal women.
How Urethral Prolapse Presents
The most noticeable sign of urethral prolapse is the physical appearance of the protruding tissue at the urinary opening. This mass generally appears as a small, donut-shaped ring of tissue that is pink, reddish, or purple, depending on the degree of congestion and blood flow. In cases where the tissue becomes very congested or thrombosed, it can take on a darker, more cyanotic color.
While some individuals may experience no symptoms at all, the most frequent presenting complaint is painless interlabial bleeding or spotting. This bleeding is often noticed on underwear or a diaper, and it occurs independently of the menstrual cycle. The visible mass itself may be tender to the touch, especially when wiping after urination, due to irritation and inflammation of the exposed mucosa.
Other urinary symptoms may also be reported, including discomfort or pain during urination, known as dysuria. Patients may also experience increased urinary frequency, urgency, or nocturia (waking up at night to urinate). Because these urinary complaints can overlap with symptoms of a urinary tract infection, urethral prolapse is sometimes initially misdiagnosed.
Factors Contributing to Urethral Prolapse
The underlying cause of urethral prolapse is thought to be a combination of weakened supportive tissues around the urethra and a sudden or chronic increase in pressure. In both prepubertal girls and postmenopausal women, low levels of the hormone estrogen are a significant factor.
Estrogen plays a major role in maintaining the strength, thickness, and resilience of the periurethral connective tissue and mucosa. When estrogen levels are low, the tissues become thinner and weaker, making them more susceptible to eversion. There is also evidence suggesting that genetic predisposition may play a role in some cases.
A second category of risk factors involves any condition that repeatedly or forcefully increases intra-abdominal pressure, which can push the weakened urethral lining outward. Chronic straining from severe constipation or persistent coughing, as well as abdominal trauma or high body weight, are all established contributors. In children, managing underlying issues like constipation or dysfunctional voiding is important, as straining promotes prolapse.
Diagnosis and Treatment Options
Diagnosis of urethral prolapse is primarily clinical, confirmed through a visual inspection of the area. The key diagnostic feature is identifying the central opening, the actual urethral meatus, within the donut-shaped mass of tissue. This step is important for distinguishing urethral prolapse from other masses, such as a urethral caruncle or, in rare instances, a malignant tumor.
Treatment is divided into conservative management for mild cases and surgical intervention for severe or complicated presentations. The initial approach for uncomplicated cases involves conservative measures, including local hygiene and sitz baths. This is typically combined with a course of topical estrogen cream, applied directly to the prolapsed tissue, usually two to three times daily for two weeks.
Topical estrogen acts locally on the affected urogenital tissues to restore health. The hormone increases the thickness of the urethral mucosa and improves the resilience of the surrounding connective tissue by decreasing collagen degradation. This local application allows for a therapeutic effect with minimal systemic absorption. If the prolapse is mild, this topical therapy can result in the complete return of the tissue to its normal position, sometimes within three to six weeks.
If conservative treatment fails, or if the tissue shows signs of strangulation, necrosis, or significant bleeding, surgical excision becomes necessary. The preferred surgical method involves excising the everted mucosa, often using a technique like the Kelly-Burnham procedure, where the prolapsed tissue is removed over a thin catheter. The surgeon then carefully sutures the edges of the normal urethral mucosa to the introital mucosa. This oversewing technique restores the natural coaptation of the tissue layers and minimizes the risk of recurrence.