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Urethral Prolapse

Urethral prolapse is complete circumferential eversion of urethral mucosa through the external urethral meatus. The prolapsed mucosa becomes congested, edematous, and friable, producing the classic dark red or purple "doughnut" of tissue surrounding a central urethral opening.[1][2][3]

For the reconstructive urologist and urogynecologist, the diagnosis matters because it is visual, uncommon, and easy to mislabel. In prepubertal girls it can mimic vaginal bleeding from trauma or abuse; in postmenopausal women it can be confused with urethral caruncle, urethral malignancy, or pelvic organ prolapse. Treatment is usually simple once the anatomy is recognized.

Definition and Terminology​

Urethral prolapse is a 360-degree mucosal eversion. This is the key distinction from a urethral caruncle.

FeatureUrethral prolapseUrethral caruncle
MorphologyCircumferential mucosal eversionFocal polypoid lesion
LocationSurrounds the entire urethral meatusUsually posterior lip of the meatus
Age patternPrepubertal girls and postmenopausal womenMostly postmenopausal women
AppearanceDoughnut-shaped, congested, dark red/purple ringFleshy red polypoid outgrowth
Central openingUrethral meatus visible in the centerLesion sits on one aspect of the meatus

Caruncle, prolapse, and malignancy can all bleed. When the lesion is not clearly circumferential and benign-appearing, biopsy or excision should be considered, especially in adults.[4][5][6]

Epidemiology​

Urethral prolapse is rare, with an estimated incidence around 1 in 3,000 in girls.[1][2]

The age distribution is bimodal:

  • Prepubertal girls — the most common group; typical ages 2-15 years, often around early school age.
  • Postmenopausal women — second peak, usually in the setting of hypoestrogenism and tissue atrophy.[1][2][7]

Older literature emphasized a strong association with Black girls. More recent series confirm that the condition occurs across racial groups, though it remains disproportionately reported in Black pediatric patients.[1][8][9]

Etiology and Pathophysiology​

The cause is multifactorial. The two recurring themes are hypoestrogenic mucosal vulnerability and poor support between urethral smooth-muscle layers.

Proposed mechanisms include:

  • Estrogen deficiency — prepubertal and postmenopausal states share relative hypoestrogenism, causing mucosal fragility and reduced periurethral support.
  • Weak smooth-muscle attachments — a cleavage plane between inner longitudinal and outer circular-oblique urethral smooth muscle may permit mucosal eversion.
  • Increased intra-abdominal pressure — constipation, cough, respiratory infection, heavy straining, trauma, or voiding strain may precipitate prolapse.
  • Venous congestion — once prolapsed, edema and venous obstruction enlarge the ring of tissue and can progress to thrombosis or necrosis if severe.[1][10][11]

Constipation deserves specific attention. It is common, treatable, and may drive recurrence if not addressed.[1][8]

Clinical Presentation​

Prepubertal Girls​

Common presentations include:

  • Genital, "vaginal," or perineal bleeding
  • Parent-noted vulvar or urethral mass
  • Dysuria or straining with voiding
  • Perineal discomfort or pain
  • Spotting on underwear
  • Less commonly, discharge or urinary retention[1][2][8][9]

The key exam finding is a circumferential, friable ring of tissue around the urethral meatus. The meatus remains visible in the center.

Postmenopausal Women​

Adults may present with bleeding, urethral pain, dysuria, urgency, frequency, nocturia, hematuria, dyspareunia, urinary retention, or a visible mass. Urethral prolapse may coexist with uterovaginal prolapse or genitourinary syndrome of menopause.[7][12][13]

Complicated Prolapse​

Concerning features include:

  • Marked pain
  • Acute urinary retention
  • Thrombosis
  • Black, dusky, or necrotic tissue
  • Heavy or recurrent bleeding
  • Uncertain diagnosis
  • Firm or irregular mass in an adult

These findings push management toward urgent reduction or excision rather than prolonged observation.

Diagnostic Evaluation​

Diagnosis is usually clinical. The characteristic finding is circumferential prolapsed urethral mucosa with the urethral meatus in the center.[1][3]

Examination Technique​

In children:

  • Use a calm, trauma-informed approach.
  • Frog-leg or knee-chest position can improve visualization.
  • Apply gentle lateral and downward labial traction.
  • Identify the urethral meatus at the center of the prolapsed ring.
  • Avoid repeated painful manipulation unless needed.

A small catheter can be passed through the central opening if confirmation is needed, but this is not required in a classic presentation.

When to Escalate​

Imaging is usually unnecessary. Consider examination under anesthesia, cystourethroscopy, vaginoscopy, biopsy, ultrasound, or specialist referral when:

  • The child cannot tolerate an adequate exam.
  • The diagnosis is uncertain.
  • The lesion is focal rather than circumferential.
  • There is concern for trauma, foreign body, tumor, or sexual abuse.
  • The tissue appears necrotic or thrombosed.
  • Adult lesion is firm, irregular, ulcerated, or suspicious.

Transperineal ultrasound can show a vascular periurethral mass and assess tissue viability, but it is an adjunct rather than the diagnostic standard.[11]

Differential Diagnosis​

Prepubertal Girls​

DiagnosisDistinguishing feature
Urethral prolapseCircumferential doughnut around central meatus
Sexual abuse / genital traumaHistory, hymenal or vulvar injuries, noncircumferential trauma pattern
Sarcoma botryoidesGrape-like vaginal mass arising from the vagina
VulvovaginitisDischarge, erythema, irritation without circumferential meatal mass
Vaginal foreign bodyFoul discharge, bleeding, recurrent symptoms
Precocious pubertyEstrogenized mucosa, breast/pubic hair development
Perineal grooveCongenital wet midline perineal sulcus
Urethral caruncleFocal lesion, not circumferential

Urethral prolapse is a classic mimic of sexual abuse in prepubertal girls with bleeding. Recognition of the doughnut sign can prevent unnecessary distress while still allowing appropriate safeguarding evaluation when history or injuries warrant it.[14][15][16][17]

Postmenopausal Women​

DiagnosisDistinguishing feature
Urethral caruncleFocal posterior meatal lesion
Urethral carcinomaFirm, irregular, ulcerated, indurated, or bleeding mass
Urethral diverticulumAnterior vaginal wall / periurethral mass, often not meatal
Skene gland cyst / abscessParaurethral lateral mass
Pelvic organ prolapseVaginal wall or uterovaginal descent rather than meatal mucosal eversion

Management​

Conservative Treatment​

Conservative therapy is appropriate for mild, uncomplicated prolapse without vascular compromise.

Typical measures include:

  • Sitz baths or warm soaks
  • Topical estrogen cream
  • Local hygiene
  • Topical barrier or antibiotic ointment when irritated
  • Constipation treatment
  • Cough or respiratory symptom treatment when contributory
  • Close follow-up[1][2][8]

Conservative treatment is most attractive in children with mild symptoms, small prolapse, and no thrombosis, necrosis, urinary retention, or heavy bleeding. It may also be reasonable in frail adults when symptoms are minor and the lesion is clearly benign.

Manual Reduction​

Manual reduction under anesthesia is an option for symptomatic pediatric prolapse when the tissue is viable but too swollen or painful for office reduction. Holbrook and Misra reported that reduction under general anesthesia could be curative or reduce the prolapse enough for conservative therapy to work, avoiding excision in many girls.[1]

Surgical Excision​

Surgery is indicated for:

  • Failed conservative therapy
  • Recurrent or significant bleeding
  • Severe pain
  • Acute urinary retention
  • Thrombosis or necrosis
  • Diagnostic uncertainty
  • Adult suspicious lesion
  • Patient preference after counseling[3][9][12][18]

The standard operation is circumferential excision of the prolapsed mucosa with reapproximation of urethral mucosa to vestibular/vaginal epithelium over a catheter.

Four-Quadrant Excision​

The four-quadrant technique reduces the risk of mucosal retraction:

  1. Place a Foley catheter through the urethra.
  2. Place stay sutures in quadrants of the prolapsed mucosa.
  3. Excise one quadrant at a time.
  4. Reapproximate urethral mucosa to the vestibular epithelium with interrupted absorbable sutures.
  5. Repeat circumferentially.
  6. Leave a short-term catheter based on age, edema, and surgeon preference.[3][18]

Ligation over a catheter has been described historically but is generally avoided because of pain, infection, recurrence, and tissue sloughing concerns.[8]

Outcomes and Complications​

Most patients do well with appropriate therapy. Conservative management can resolve mild pediatric cases; excision is highly effective for symptomatic, recurrent, or complicated prolapse.[1][2][9][12]

Potential complications include:

  • Recurrence
  • Temporary bleeding
  • Temporary urinary retention
  • Pain
  • Infection
  • Meatal stenosis
  • Rare stress incontinence or urethral scarring

In the pediatric setting, surgical excision is effective but not always necessary. In symptomatic adult patients, excision provides definitive tissue diagnosis and durable resolution when conservative measures fail or malignancy is a concern.[1][12]

Special Considerations​

Prepubertal Girls​

Always inspect the urethral meatus carefully in a prepubertal girl with genital bleeding. The urethral source may be missed if bleeding is assumed to be vaginal. Address constipation and cough, reassure families when the diagnosis is clear, and involve pediatric urology/gynecology when the exam is uncertain or the presentation is severe.[14][16][17]

Postmenopausal Women​

In adults, hypoestrogenism, caruncle, malignancy, and concomitant pelvic organ prolapse often overlap in the differential. Topical estrogen may help tissue quality, but persistent, bleeding, irregular, or symptomatic lesions often warrant excision and pathology.[4][5][12]

Premenopausal Adults​

Urethral prolapse in healthy premenopausal adults is rare. Reported triggers include Valsalva or heavy lifting. Because it is unusual, confirm the diagnosis carefully and exclude mass, trauma, and urethral diverticulum.[19]

Follow-Up and Prognosis​

Follow-up should confirm:

  • Resolution of bleeding, pain, and mass effect
  • Normal voiding
  • No urinary retention
  • No meatal stenosis
  • Constipation or cough addressed
  • Pathology reviewed when excision performed

Prognosis is excellent. Recurrence is uncommon when predisposing factors are managed and excision is complete. Meatal stenosis is rare but should be considered if postoperative stream becomes narrow, spraying, painful, or obstructive.

See Also​

References​

1. Holbrook C, Misra D. "Surgical management of urethral prolapse in girls: 13 years' experience." BJU International. 2012;110(1):132-134. doi:10.1111/j.1464-410X.2011.10752.x

2. Richardson DA, Hajj SN, Herbst AL. "Medical treatment of urethral prolapse in children." Obstetrics and Gynecology. 1982;59(1):69-74.

3. Shurtleff BT, Barone JG. "Urethral prolapse: four quadrant excisional technique." Journal of Pediatric and Adolescent Gynecology. 2002;15(4):209-211. doi:10.1016/S1083-3188(02)00157-2

4. Zuo SW, Napoe GS. "Evaluation and management of urethral and periurethral masses in women." Current Opinion in Obstetrics & Gynecology. 2023;35(6):517-524. doi:10.1097/GCO.0000000000000914

5. Verma V, Pradhan A. "Management of urethral caruncle: a systematic review of the current literature." European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2020;248:5-8. doi:10.1016/j.ejogrb.2020.03.001

6. Conces MR, Williamson SR, Montironi R, et al. "Urethral caruncle: clinicopathologic features of 41 cases." Human Pathology. 2012;43(9):1400-1404. doi:10.1016/j.humpath.2011.10.015

7. Carley ME, Klingele CJ, Boldt KL, Gebhart JB. "Concomitant urethral and uterovaginal prolapse in a postmenopausal woman. A case report." The Journal of Reproductive Medicine. 2002;47(11):939-942.

8. Fernandes ET, Dekermacher S, Sabadin MA, Vaz F. "Urethral prolapse in children." Urology. 1993;41(3):240-242. doi:10.1016/0090-4295(93)90565-R

9. Hillyer S, Mooppan U, Kim H, Gulmi F. "Diagnosis and treatment of urethral prolapse in children: experience with 34 cases." Urology. 2009;73(5):1008-1011. doi:10.1016/j.urology.2008.10.063

10. Lowe FC, Hill GS, Jeffs RD, Brendler CB. "Urethral prolapse in children: insights into etiology and management." The Journal of Urology. 1986;135(1):100-103. doi:10.1016/S0022-5347(17)45530-3

11. Yang JM, Huang WC. "Transperineal sonographic findings in a woman with urethral mucosa prolapse." Journal of Clinical Ultrasound. 2004;32(5):261-263. doi:10.1002/jcu.20026

12. Hall ME, Oyesanya T, Cameron AP. "Results of surgical excision of urethral prolapse in symptomatic patients." Neurourology and Urodynamics. 2017;36(8):2049-2055. doi:10.1002/nau.23232

13. Noya-Mourullo A, Herrero-Polo M, Heredero-Zorzo O, Garcia-Gomez F. "Four vertex technique for correcting urethral prolapse: technique description and cohort study." Frontiers in Surgery. 2023;10:1149729. doi:10.3389/fsurg.2023.1149729

14. McCaskill A, Inabinet CF, Tomlin K, Burgis J. "Prepubertal genital bleeding: examination and differential diagnosis in pediatric female patients." The Journal of Emergency Medicine. 2018;55(4):e97-e100. doi:10.1016/j.jemermed.2018.07.011

15. Aprile A, Ranzato C, Rizzotto MR, et al. "'Vaginal' bleeding in prepubertal age: a rare scaring riddle, a case of the urethral prolapse and review of the literature." Forensic Science International. 2011;210(1-3):e16-e20. doi:10.1016/j.forsciint.2011.04.017

16. Schaul M, Schwark T. "Rare (uro-)genital pathologies in young girls mimicking sexual abuse." International Journal of Legal Medicine. 2022;136(2):623-627. doi:10.1007/s00414-021-02621-z

17. Shavit I, Solt I. "Urethral prolapse misdiagnosed as vaginal bleeding in a premenarchal girl." European Journal of Pediatrics. 2008;167(5):597-598. doi:10.1007/s00431-007-0523-y

18. Hill AJ, Siff L, Vasavada SP, Paraiso MFR. "Surgical excision of urethral prolapse." International Urogynecology Journal. 2016;27(10):1601-1603. doi:10.1007/s00192-016-3021-9

19. Schreiner L, Nygaard CC, Anschau F. "Urethral prolapse in premenopausal, healthy adult woman." International Urogynecology Journal. 2013;24(2):353-354. doi:10.1007/s00192-012-1820-1