Urethral Mucosa Prolapse In a 7-Year-Old Black Girl: Conservative Management-Case Repot
Utoo BT
Published on: 2024-05-31
Abstract
Urethral prolapse is a rare benign condition and majorly occurs in black prepubertal girls. Although, some cases are now being reported in whites and Hispanic girls. It consists of the eversion of the distal urethral mucosa through the outer urethral meatus, leading to vascular obstruction and prolapsed tissue oedema. The aetiology is not very clear but there are associated predisposing factors. A reported case of a urethral prolapse in a 7-year-old girl at a University Teaching Hospital in Nigeria is here presented. She was referred from a private health facility with a presentation of vaginal bleeding and a soft, reddish coloured, donut-shaped vulva swelling. The impression of urethral caruncle or sexual abuse was entertained before referral. She was treated conservatively with oestrogens and antibiotics and discharged after 6 months of follow up care.
Keywords
Prolapse; Urethral caruncle; Pre-Pubertal; Genital swellings; Conservative treatmentIntroduction
Urethral prolapse is said to be rare occurring in 1/3000 cases. A study has reported in-hospital cases ranging from 2.1 to 3.9 per year in the western world [1]. It is described as eversion of the urethral mucosa through the urethral meatus [1,2]. It was first described in 1732 by Solingen [3,4]. Although, previously considered to occur more in Africans, it has been reported in whites and Hispanic girls as well [3]. The aetiology is not clear; however, several risk factors have been documented [1-4]. These include, cough, chronic constipation, perineal trauma, urogenital infections, sexual abuse, malnutrition, oestrogen deficiency, excess urethral mucosa among others [3,4]. Some common differential diagnoses of a urethral prolapse range from a simple urethral caruncle to rhabdomyosarcoma [4]. Also, prolapse of a ureteric cyst, ectopic ureterocele, urethral or vaginal malignancy, and condyloma [4]. The prolapsed urethral mucosa in between the labia minora folds overlying the vaginal orifice usually appears reddish and bleeds easily thereby presenting with vaginal bleeding as a major complaint. And, because it simulates an oedematous traumatized vaginal redundant hymenal folds, it is very often mistaken for sexual abuse [2,3]. The diagnosis is basically clinical and treatment is either conservative or surgical [4-7].
Case Presentation
Miss MT was a 7-year-old primary school pupil who was apparently well until 2 days prior to presentation when she was noticed to have vaginal bleeding. Bleeding was not severe but continued to stain her pants. She was not bleeding from any other orifices. There was no history of trauma to the genitals, no history of fall astride or sexual abuse. There was no associated vaginal discharge or volvo-vaginal itching. She had associated symptom of painful micturition, with no change in urine colour or haematuria. No history of fever. She had no symptoms of cough, chronic constipation or diarrhoea.
She first presented to a private health facility close to her place of residence where she had medical evaluation by the attending physician who reported a swelling around the urethra orifice that was tender to touch and bleeds on contact. The physician made an impression of a bleeding urethra caruncle and thereafter referred to the Benue State University Teaching hospital Makurdi for expert care.
Patient had not been admitted in the hospital before. She had no history of sickle cell disease or any medical condition. Her birth and developmental milestone are said to be essentially normal. She had no known drug allergy. She was the second child in a monogamous family. No similar condition in other siblings. The review of systems was essentially normal.
On examination, she was a young pre-pubertal girl who was not pale, anicteric, acyanosed, not in painful distress and with no pedal oedema. Her chest was clinically clear. Heart sounds were first and second only. Her abdomen was full, moves with respiration, soft, non-tender and no palpable organomegaly.
Vaginal examination showed a normal prepubertal volvo-vaginal findings. There was a round, soft, red coloured, and doughnut like swelling around the urethral orifice with no contact bleeding nor associated discharge as at the time of presentation to the University Teaching Hospital. A paediatric catheter introduced into the urethral revealed clear urine (see figure 1). The hymen was intact.
Figure 1: Urethral prolapse seen before treatment.
An assessment of a urethral mucosa prolapse was made. She was consequently treated with oestrogen cream twice daily and Baneocin (Bacitracin plus Neomycin) 20grams twice daily. She also had paracetamol for analgesic and was encouraged to do sitz bath. She was subsequently given 2 weeks follow up visit. She kept improving steadily and was seen fortnightly until 2 months. She had been on estrogen vaginal cream for 2 months and achieved complete resolution of the mucosa swelling. She was discharged from the clinic after 6 months of follow-up assessment.
Discussion
Urethral mucosa prolapse is a rare case which was initially thought to be only in black girls [7]. It is however reported in some whites and Hispanics [7]. Our patient is black and within the reported age range of 4 to 16 years [1,3,7]. She did not have any associated risk factor but painful urination. Probably a low level of estrogen could be an underlying problem [7]. This condition is not only reported in pre-pubertal girls but also in post-menopausal women [5,6]. Unlike in postmenopausal women, prepubertal girls could be asymptomatic and the urethral prolapse is accidentally discovered, as a round, soft, and plain red-coloured mass, donut-shaped from the vagina measuring 0.5 to several centimetres in diameter and protruding from the distal urethra [5,6]. This was the finding in our patient. All the symptoms that were observed in our patient can readily be ascribed to sexual abuse and this was why the first attending physician made that initial diagnosis. This could cause anxiety to the parents and the relations of the patients until sexual abuse is ruled out and diagnosis is confirmed as in the index case [7-9]. There is need to train health practitioners to be able to identify this condition so that prompt and appropriate treatment could be offered to the patients [10-12]. Treatment is said to be controversial but of two approaches, which are conservative and surgical [7-10]. The conservative approach was adopted in our case. Conservative treatment consists mainly of local estrogen cream application to the area which is aimed at increasing muscle strength [8,9]. However, Valerie et al indicated that only 33% of patients were treated successfully with conservative management which is consistent with the findings of Jerkins et al who found 67% of failure to medical treatment [8]. In Surgical approach, the modalities could be either excision or ligation [9,10]. Some studies have reported that excision technique has a shorter postoperative hospital stay and recovery [8]. Surgical excision is performed by excising the redundant mucosa followed by anastomosis of the urethra to the vestibule [8]. Surgical ligation is performed over a catheter and requires ligation of the prolapsed tissue. Between conservative and surgical approaches to treatment, the later modality is reported to have dramatically reduced recurrence rates compared to the former [8,10]. The patient had treatment with estrogen cream application twice daily and Baneocin (bacitracin plus neomycin) 20grams twice daily. She was also placed on paracetamol tablets for analgesic and advised for twice daily sitz bath [9,10]. She was followed up fortnightly until 2 months and thereafter monthly for 6 months. The prolapse had resolved after the second week of treatment and remained so until 6 months (see figure 2). She was consequently discharged from the clinic.
Figure2: Resolved urethral prolapse after conservative treatment.
Conclusion
Urethral prolapse is a benign and rare condition in prepubertal girls. It is sometimes misdiagnosed because of its rarity and vague presentation. Conservative approach could be useful for treatment in order to prevent complications of anaesthesia and surgery. However, where conservative approach fails surgery should be offered to the patient.
Conflict of Interest-The author declares none.
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