Background

Urethral prolapse manifests as the protrusion of the urethra. During such an occurrence, the vicinity surrounding the urethral opening may exhibit characteristics resembling a slight pink, red, or purple ring. The presence of a palpable lump around the urethral entrance, pain, bleeding, and difficulty peeing are typical symptoms. Congenital disabilities, persistent straining, elevated abdominal pressure, and connective tissue abnormalities are examples of contributing factors. Depending on the patient’s specific circumstances and the severity of their symptoms, treatment choices range from conservative measures like topical estrogen therapy to surgical operations.  

Epidemiology

Urethral prolapse is a rare condition that exhibits a bimodal age pattern. In pediatric cases, it predominantly affects prepubescent girls, typically manifesting around the age of 4 on average. Conversely, in adults, urethral prolapse primarily afflicts postmenopausal women. 

Anatomy

Pathophysiology

Weakness in the pelvic floor muscles: The rectum, uterus, and bladder are supported by the pelvic floor muscles. Prolapse may result from these muscles’ inability to maintain the urethra sufficiently when they are weak. 

Changes in hormone levels can impact the elasticity and strength of urethral tissues. For instance, during menopause, the decline in estrogen levels may contribute to weakening urethral tissues, increasing the likelihood of prolapse. Additionally, persistent strain on the pelvic floor muscles and urethra, caused by activities such as heavy lifting, childbirth, and bowel movements, can also elevate the risk of prolapse. 

Some women are born with structural abnormalities in their pelvic floor muscles or urethra, which can potentially heighten their susceptibility to prolapse later in life. 

Etiology

Chronic Straining: 

Activities that involve repetitive straining, like heavy lifting, chronic coughing, or constipation, can put immense pressure on the pelvic floor and urethra. 

Over time, this strain can weaken the pelvic floor muscles and contribute to prolapse. 

Congenital Abnormalities: 

In some cases, individuals may be born with structural abnormalities in the urethra or pelvic floor muscles, predisposing them to prolapse. 

Weakened Pelvic Floor Muscles: 

The pelvic floor muscles act as this hammock, providing vital support for the bladder, uterus, and rectum. 

When these muscles weaken due to factors like childbirth, aging, or chronic straining, they lose their ability to support the urethra, increasing their vulnerability to prolapse adequately. 

Genetics

Prognostic Factors

When treated appropriately, urethral prolapse has a typically favourable prognosis. But it’s crucial that people with this illness receive routine follow-up care so that symptoms or complications don’t reappear, and therapy can be modified as necessary. Maintaining a healthy lifestyle can also assist to enhance results and lower the chance of recurrence. This includes regular exercise and taking good care of the pelvic floor. 

Clinical History

• Age group 

Urethral prolapse is a condition that typically affects prepubertal girls and postmenopausal women. While it can occur at any age, it is most seen in these age groups. In prepubertal girls, urethral prolapse often presents between different age, while in postmenopausal women, it tends to occur in those over the age of 50.  

Associated Comorbidity or Activity: 

Comorbidities: 

Urinary Tract Infections: Urethral prolapse can predispose individuals to recurrent UTIs due to urinary stasis and irritation caused by the prolapsed urethral mucosa. 

Hematuria: Both visible blood in the urine and microscopic hematuria can result from trauma to the prolapsed urethral tissue. 

Voiding Dysfunction: Some patients may experience voiding difficulties, including urinary retention or incomplete bladder emptying, secondary to urethral obstruction or irritation. 

Pain and Discomfort: Urethral prolapse can cause discomfort, pain, or a sensation of pressure in the genital area, affecting daily activities and quality of life. 

Impact on Activities: 

Sexual Function: Urethral prolapse may affect sexual function and intimacy due to discomfort or pain during sexual intercourse. 

Psychological Impact: Chronic symptoms and discomfort associated with urethral prolapse can lead to psychological distress, including anxiety, depression, and decreased self-esteem. 

Limitations in Physical Activities: Severe cases of urethral prolapse may limit physical activities or participation in sports due to discomfort or fear of exacerbating symptoms. 

• Acuity of Presentation: 

Onset and Duration: 

Acute Onset: Urethral prolapse can present acutely with sudden onset symptoms such as pain, bleeding, or urinary retention, particularly following activities that increase intra-abdominal pressure, such as straining during bowel movements or heavy lifting. 

Chronic Presentation: In some cases, urethral prolapse may present chronically with gradual onset symptoms, such as urinary frequency, urgency, or discomfort during urination, which may progressively worsen over time. 

Severity of Symptoms: 

Mild Presentation: Patients with mild urethral prolapse may present with minimal symptoms, such as urinary frequency, mild discomfort, or visible protrusion of urethral tissue during voiding or straining. 

Severe Presentation: Severe cases of urethral prolapse can present with more pronounced symptoms, including severe pain, significant bleeding, urinary retention, or complete obstruction of the urethra, necessitating urgent medical attention. 

Associated Symptoms: 

Urinary Symptoms: Common associated symptoms include urinary frequency, urgency, dysuria, urinary incontinence, and hematuria, which, according on the degree of urethral prolapse and related problems, might differ in severity. 

Genital Discomfort: Patients may experience discomfort, pain, or a sensation of pressure in the genital area, particularly during urination or sexual activity, which can significantly impact quality of life. 

Bleeding: Urethral prolapse may cause bleeding from the protruding urethral mucosa, resulting in visible blood in the urine or spotting on undergarments. 

Physical Examination

Visible Protrusion: On physical examination, urethral prolapse may manifest as a visible reddish or purplish mass protruding through the external urethral meatus, which becomes more prominent during straining or Valsalva maneuver. 

Tenderness: Palpation of the protruding urethral tissue may elicit tenderness or discomfort in some patients, particularly if the prolapse is associated with inflammation or trauma. 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Urethritis: 

Urethritis is inflammation of the urethra, commonly caused by infectious agents such as bacteria like gonorrhea and chlamydia or non-infectious causes like trauma or chemical irritation. 

Symptoms may include dysuria, urinary urgency, urethral discharge, and urinary frequency. 

Unlike urethral prolapse, urethritis typically presents with inflammation and discharge from the urethral opening without visible tissue protrusion. 

UTI: 

Urinary tract infections, or UTIs, are typically a bacterial infection. 

Symptoms may include dysuria, urinary frequency, urgency, hematuria, and suprapubic pain. 

While UTI symptoms can overlap with those of urethral prolapse, the presence of visible tissue protrusion distinguishes prolapse from UTI. 

Urethral Stricture: 

Urethral stricture refers to narrowing of the urethral lumen, often due to scarring from inflammation, trauma, or previous procedures. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Conservative Management: 

Topical Estrogen Therapy: Topical estrogen cream applied to the prolapsed urethral tissue may help improve tissue integrity and reduce inflammation, particularly in postmenopausal women or pediatric patients. 

Sitz Baths: Warm sitz baths can provide symptomatic relief by reducing discomfort and inflammation associated with urethral prolapse. Regular sitz baths may also promote tissue healing and reduce the risk of infection. 

Pelvic Floor Exercises: Pelvic floor may help strengthen pelvic floor muscles and improve urethral support, potentially reducing symptoms of prolapse and urinary incontinence. 

Surgical Intervention: 

Urethral Prolapse Repair: Surgical repair of urethral prolapse may be indicated for symptomatic or severe cases that do not respond to conservative measures. Surgical techniques may include excision of prolapsed tissue, urethral repositioning, and reconstruction of the urethral meatus to restore anatomical integrity and improve symptoms. 

Transvaginal or Transurethral Approach: Urethral prolapse repair can be performed through a transvaginal or transurethral approach, depending on the extent of prolapse and patient factors. Transvaginal techniques involve accessing the prolapsed tissue through the vaginal canal, while transurethral approaches involve accessing the urethra directly through the urethral meatus. 

Multidisciplinary Approach: 

Collaborative Care: A multidisciplinary approach involving urologists, gynecologists, pelvic floor specialists, and pediatricians may be necessary for the comprehensive evaluation and management of urethral prolapse, particularly in complex cases or pediatric patients. 

Patient Education and Support: Patient education regarding the condition, treatment options, and postoperative care is essential for informed decision-making and optimal outcomes. Supportive care, including counseling and resources for coping with symptoms and recovery, can also improve patient satisfaction and adherence to treatment recommendations. 

Long-term Follow-up: 

Monitoring and Surveillance: Long-term follow-up is essential to monitor for recurrence of urethral prolapse, resolution of symptoms, and potential complications following surgical intervention. Regular urological examinations and pelvic floor assessments may be recommended to assess urethral function and overall pelvic health. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

lifestyle-modifications-in-treating-urethral-prolapse-specialty-urology

Bathroom Accessibility: 

Ensure easy access to bathrooms to accommodate frequent urination or discomfort associated with urethral prolapse. 

Hygiene Products: 

Provide access to hygiene products such as unscented wipes or gentle cleansers to maintain cleanliness and prevent irritation of the genital area. 

Use soft, non-abrasive toilet paper to minimize friction and discomfort during wiping. 

Comfortable Seating: 

Use cushioned or ergonomic seating options to provide comfort and support, particularly for individuals experiencing discomfort or pain associated with urethral prolapse. 

Appropriate Clothing: 

Encourage wearing loose-fitting, breathable clothing to minimize irritation and friction in the genital area. 

Avoid tight clothing or undergarments that may exacerbate symptoms or restrict movement. 

Pelvic Floor Support: 

Provide ergonomic chairs or seating with built-in pelvic floor support to promote proper posture and pelvic alignment, which can help alleviate symptoms of urethral prolapse. 

Stress Reduction: 

Create a calming and stress-free environment to minimize anxiety and tension, which can exacerbate symptoms of urethral prolapse. 

Provide access to relaxation techniques such as meditation, deep breathing exercises, or aromatherapy to promote relaxation and reduce stress levels. 

Temperature Control: 

Maintain a comfortable room temperature to prevent excessive sweating or discomfort, particularly in individuals experiencing symptoms such as genital irritation or inflammation associated with urethral prolapse. 

Privacy and Dignity: 

Ensure privacy and dignity in personal care routines and medical examinations to promote a sense of autonomy and respect for individuals with urethral prolapse. 

Education and Support: 

Provide urethral prolapse patients and their caretakers educational materials and support systems to foster knowledge, coping mechanisms, and self-determination in handling the problem in their surroundings. 

Effectiveness of topical estrogen cream in treating urethral prolapse

Premarin:

Premarin is topical estrogen cream that helps by promoting tissue health and elasticity in the vaginal and urethral area, potentially reducing symptoms like discomfort or bleeding associated with urethral prolapse. 

Use of petroleum jelly in treating urethral prolapse

Vaseline:

To relieve sensitivity or soreness, use vaseline. 

role-of-surgery-in-treating-urethral-prolapse

Surgery is a treatment option for urethral prolapse, particularly in cases where conservative measures fail to alleviate symptoms or when the prolapse is severe. The goal of surgery is to restore anatomical integrity, alleviate symptoms, and improve quality of life. 

Urethral Prolapse Repair: 

Urethral prolapse repair involves surgical excision of the prolapsed urethral mucosa and reconstruction of the urethral meatus to restore anatomical integrity. 

The procedure may be performed through a transvaginal or transurethral approach, depending on the extent of prolapse and patient factors. 

During surgery, the prolapsed tissue is carefully excised, and the edges of the urethral mucosa are reapproximated to create a new urethral meatus with adequate support. 

Urethral plication: 

Correction of urethral prolapse and restoration of normal urethral anatomy. 

Reduction of symptoms such as urinary frequency, urgency, and discomfort. 

Improvement in urinary continence, particularly in cases of associated stress urinary incontinence. 

Minimal invasiveness compared to more extensive surgical procedures. 

role-of-management-in-treating-urethral-prolapse

Assessment and Diagnosis: 

History and Physical Examination: This phase involves taking a detailed medical history, including symptoms related to urethral prolapse, and performing a thorough physical examination, including pelvic examination. 

Diagnostic Tests: Urine analysis, urethroscopy, and imaging examinations are examples of other tests that can be performed. 

Conservative Management: 

Topical Estrogen Therapy: Topical estrogen cream may be prescribed to improve tissue integrity and reduce inflammation, particularly in postmenopausal women or pediatric patients. 

Lifestyle Modifications: Encouraging lifestyle modifications such as maintaining a healthy weight, avoiding activities that increase intra-abdominal pressure, and practicing pelvic floor exercises can help manage symptoms and prevent recurrence. 

Surgical Intervention: 

Surgical Options: Surgical options for urethral prolapse include urethral plication, urethral prolapse repair, or sling procedures, which aim to reduce the prolapsed tissue, restore anatomical integrity, and improve symptoms. 

Postoperative Care: Following surgery, patients will require a period of postoperative recovery, including pain management, wound care, and activity restrictions. Close monitoring and follow-up with the surgical team are essential to assess outcomes and address any complications. 

Rehabilitation and Follow-Up: 

Recovery and Rehabilitation: Patients undergo rehabilitation to optimize recovery, including gradually increasing physical activity and pelvic floor exercises as tolerated. 

Long-Term Follow-Up: Long-term follow-up appointments with healthcare providers are necessary to monitor for recurrence of prolapse, assess urinary function, and address any ongoing symptoms or complications. 

Patient Education: Providing ongoing education and support to patients regarding self-care strategies, symptom management, and the importance of adherence to follow-up appointments is crucial for long-term success. 

 Psychosocial Support: 

Counseling: Patients may benefit from counseling or support groups to address any psychological distress, anxiety, or concerns related to their condition and treatment. 

Supportive Care: Offering emotional support, encouragement, and resources improves patient satisfaction and general well-being by helping them deal with the psychological and physical difficulties of having urethral prolapse. 

Medication

Future Trends

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References

Urethral Prolapse: A Case Series and Literature Review | The Journal of Obstetrics and Gynecology of India (springer.com)