Urethral prolapse

Urethral Caruncle

Urethral prolapse is where the end of the urethra protrudes from the exit point inside the vulva (meatus). It is an uncommon condition that seems to (interestingly) mostly affect girls of African descent prior to puberty (under age 10) and postmenopausal Caucasian women. There is a more advanced and rarer version called a strangulated urethral prolapse.

Because of its uncommonality, urethral prolapse misdiagnosis rates are high.

Symptoms of a urethral prolapse

  • No symptoms may be present, particularly in young girls
  • Adult women are usually symptomatic
  • Vaginal bleeding or spotting in underwear or diaper/nappy
  • Protrusion from urethral opening upon examination
  • Problems urinating – increased frequency, pain, burning, waking up to urinate during the night
  • Urinary tract infections

Treatments for urethral prolapse

Historically, treatment was usually surgical, however new treatments include topical oestrogen cream or other topical ointments. Strangulated urethral prolapse usually requires surgery. The surgery varies depending on the individual and the surgeon, and has a very good success rate. Old-fashioned surgical procedures are not performed anymore, as better versions have been developed.

  • Surgery includes realigning the two layers of smooth muscle that make the urethra, or removing the protruding end.
  • Oestrogen cream is usually applied as well, and a catheter may be used for a short time as it heals.
  • Sitz baths
  • Topical antibiotics
  • Steroid creams
  • In children, oestrogen cream is applied to the prolapsed urethra 2-3 times per day for two weeks along with sitz baths.
  • In women, oral conjugated oestrogen may be given for mild prolapse, or topical oestrogen cream applied 2-3 times per day for 2 weeks, with sitz baths.
  • Failure of this treatment results in the consideration of surgery, however in severe cases, surgery may be recommended immediately if tissue is severely damaged.

There are some rare complications to surgery.

Note: women who have had oestrogen-dependent breast cancers won’t be prescribed oestrogen creams, however please see the atrophic vaginitis article for women on post-breast cancer hormone-blocking therapies for some solutions.

Note: this condition is different from urethral caruncle, which is where about a quarter of the urethral tissue protrudes from the body.

Who gets urethral prolapse

  • Girls under 10, with average onset age 4 years or after menopause, though it can affect any woman.
  • Frequently prescribed hormone therapy (oestrogen) postmenopause has reduced the incidence of urethral prolapse in postmenopausal women.
  • Both these groups have little or no oestrogen in their blood. Oestrogen is known to exert an influence on skin integrity, meaning the lack of oestrogen can affect tissues in a negative way, allowing easier damage and irregularities.
  • The distribution of age is very marked. An interesting point is a pair of identical twins both got urethral prolapse, suggesting a hereditary influence
  • Strangulated urethral prolapse is more common in adults than children.
  • This condition generally does not affect men.

Causes of urethral prolapse

The cause is as yet unknown, however there are some theories. General pelvic weakness contributes.

Congenital birth defects – defects we are born with – may include weak pelvic floor muscles, which are the structures that support everything in our pelvis. This can result in pelvic attachments not being fully formed or properly functioning, and this can allow the urethra to move around more than it normally should. Check anatomical abnormalities in children

The causes of this could vary, and suggestions have been made regarding neuromuscular disorders, poor urethral positioning, and deficiencies in the elasticity of the tissue.

An acquired defect is one that happens after or during birth, including sexual abuse, masturbation, malnutrition and debility.

There is some discussion that there is a weak attachment between smooth muscle layers of the urethra that predisposes someone to urethral prolapse after perhaps a lot of coughing or constipation – intra-abdominal pressure.

How urethral prolapse works

There are two layers of smooth muscle that make up the urethra – the inner and outer layers. In a healthy urethra, these two layers are firmly adhered together. If the two layers separate for some reason (see above), one of the layers can slide out the opening, since it is no longer attached to the other.

If it is not treated, the resultant swelling can cut off the blood supply to the protruding piece of urethra, causing the tissue to die.

Anatomy of the urethra

The urethra is about 4cm long in an adult woman, and runs from the neck of the bladder to the external meatus, which is the area between the labia, above the vaginal opening and below the clitoris. The urethra is made up of mucosal tissue, with secretory glands lining the walls to provide lubrication. These periurethral glands are actually the Skene glands, which empty out of two small ducts on either side of the meatus.

The tissue surrounding the urethra (mucosa and submucosa) offer some level of bladder control via the mucosal seal. All the mucosa in the urethral tissue is very sensitive to oestrogen, so the loss of oestrogen can result in the tissue becoming weak and atrophying, loosening the mucosal seal and allowing incontinence.

Contraction and relaxation of one of the smooth muscle layers allows the urethra to allow the shortening and widening that allows urination.