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ORIGINAL ARTICLE Table of Contents   
Year : 2011  |  Volume : 8  |  Issue : 1  |  Page : 12-14
Urethral mucosal prolapse in young girls: A report of nine cases in Cotonou


Paediatric Surgery service of National Teaching Hospital (CNHU) in Cotonou, Avenue Jean Paul II, 01 BP 386 Cotonou, Benin

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Date of Web Publication6-Apr-2011
 

   Abstract 

Background: Urethral mucosal prolapse is rare. This condition may be confused with tumour or sexual abuse in girls. This study aims at reporting the pathology presentation and therapeutic options of urethral prolapse in girls. Materials and Methods: A retrospective study was undertaken from January 2000 to December 2008. Authors analysed the clinical features and the treatment options. Results: There were nine cases of urethral prolapse. The ages ranged from 2.5 to 10 years (mean age: 5.08 years). The main presentation was vaginal bleeding (five cases). Physical examination revealed a soft, non-tender mass that bleeds on touch (six cases), with a length ranging from 0.75 to 1 cm. Urine culture in four patients revealed urinary infection that yielded Escherichia coli in three cases and the Staphylococcus aureus in one case. Six patients had surgical treatment while three had medical treatment. In those who had surgery, one had acute urine retention and one had recurrence that was treated successfully without operation. All the nine girls are cured. Conclusion: Urethral prolapse is a disease of the prepubertal girls of low socio-economic group. Diagnosis is clinical. The treatment of choice is surgical.

Keywords: Girl, urethral mucosal prolapse

How to cite this article:
Fiogbe M A, Hounnou G M, Koura A, Agossou-Voyeme K A. Urethral mucosal prolapse in young girls: A report of nine cases in Cotonou. Afr J Paediatr Surg 2011;8:12-4

How to cite this URL:
Fiogbe M A, Hounnou G M, Koura A, Agossou-Voyeme K A. Urethral mucosal prolapse in young girls: A report of nine cases in Cotonou. Afr J Paediatr Surg [serial online] 2011 [cited 2014 Sep 17];8:12-4. Available from: http://www.afrjpaedsurg.org/text.asp?2011/8/1/12/78661

   Introduction Top


Urethral mucosal prolapse is rare in young girls. [1] It is a benign disease, seen in most cases as a circular protrusion of the distal urethra through the external meatus. [2] For most cases, medical treatment and follow-up are sufficient, but failure of this or possible complications may necessitate a surgical correction with very few complications. [3]

This study reports nine cases of urethral prolapse, highlighting the pathology and therapeutic options of this condition.


   Materials and Methods Top


It is a retrospective study of cases managed at Paediatric Surgery Service in National Teaching Hospital (CNHU), Cotonou, between January 2000 and December 2008. The age, the aetiology, the socio-economic status of the parents, the clinical aspects, associated signs and the treatment applied were studied.

Regarding clinical aspects, urethral prolapse is most common in black females and presents with what it is often misinterpreted as vaginal bleeding. [4] Redundant urethral mucosa may prolapse through the urethral meatus, encircling the urethral meatus, and with the development of vascular congestion there may be tissue strangulation appearing as a friable polypoid mass. [5] The identification is easy thanks to the catheterisation of the urethral meatus in the centre of the lesion, in contrast to an exteriorised ureterocoele which can be circumscribed. [6] The differential diagnosis includes prolapse of an ureterocoele, para-urethral cyst and sarcoma botryoides. For this reason, complete evaluation of the genitourinary tract is indicated. [4]

The socio-economic status of the parents was classified into three groups: high, middle and low according to the National Institute of Statistics and Economic Analysis (INSAE) of the Republic of the Benin criteria.


   Results Top


There were nine cases of urethral prolapse. Patients' age ranged from 2.5 to 10 years (mean age: 5.08 years).

Common presenting complaints included vaginal mass in two cases, vaginal bleeding in five, and painful micturation with burning sensation and perineal pain in two patients. Seven children were initially seen by the gynaecologists who diagnosed them as cases of sexual abuse and referred them to paediatric surgeon for further treatment. Seven patients (80%) belonged to low socio-economic group.

Physical sign was essentially that of a ring of congested, oedematous, non-tender tissue protruding from the urethral opening that bled on contact in six cases [Figure 1], with a length ranging from 0.75 to 1 cm. The identification is easy thanks to the catheterization of the urethral meatus in the center of the lesion [Figure 2]. None of the patients had any associated anomalies or particular syndrome.
Figure 1: Post-operative aspects of vulvar

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The microscopic examination of urine revealed urinary infection in four patients, showing  Escherichia More Details coli in three cases and Staphylococcus aureus in one.
Figure 2: Physical examination showing urethral mucosa prolapsed

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Initial treatment consisted of parental reassurance that urethral prolapse was a benign urological pathology and not sexual abuse. Three of the nine patients had non-surgical treatment. The non-surgical treatment consisted of the regulation of a vulvar toilet with application of povidone iodine and prophylactic antibiotic (which is readjusted according to the sensitivity result) and oral or suppository anti-inflammatory drugs.

The remaining six patients had surgical treatment under a general anaesthesia. After a rigorous asepsis of the operative field, with a Foley's urethra catheter Ch 6-10 in place, a circumferential resection of the prolapsed urethral mucosa followed by immediate muco-mucous suture was achieved [Figure 3].
Figure 3: Urethral meatus catheterisation

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Post-operatively, the urethral Foley catheter was left inside for 4-8 days, after which it was removed. One patient had acute urinary retention when the catheter was removed at 72 hours after intervention, which necessitated recatheterisation. Hospitalisation after surgical management ranged from 5 to 10 days (mean hospitalisation duration was 7 days). One patient had a recurrence 20 months after surgery, and was treated successfully without operation. All the nine patients are cured and are presently symptom free.


   Discussion Top


Urethral prolapse is a pathological situation which occurs when the urethral mucosa evaginates beyond urethral meatus, resulting in vascular congestion and oedema of the prolapsed tissue. [7],[8] The cause of this lesion is uncertain, but it has been linked to the hypoestrogenic state. [5] We do not have any clues to explain the development of this condition in our cohort. A racial predisposition to develop this pathology has been suggested in Black African girls. [3],[9],[10],[11]

Urethral prolapse in children is a disease of the prepubertal girls; Akpo et al. [12] also share this view. This condition occurred in girls commonly under 10 years; usually the patients' age ranged from 4 to 7 years. [2],[3] The 5.08 years mean age in our study is in agreement with the 4.9 years reported by Anveden-Hertzberg et al.[13]

Urethral prolapse is a rare cause of consultation, probably due to under reporting of cases. [10] The main presenting symptom is vaginal bleeding, [9],[11],[12],[14] as in our experience given in this report. In contrast to the reports by other authors, [15] none of our patients presented with acute urine retention. Diagnosis was achieved by physical examination that revealed a soft mass tissue that bleeds on touch. The mass could be mistaken for a malignant tumour or for injuries related to sexual abuse, [7],[8],[10] which may make the very anxious parents to consult the gynaecologists at first instance. Urethral prolapse can be definitively diagnosed without laboratory or radiographic evaluation by demonstrating that the oedematous tissue surrounds the meatus circumferentially. Trotman et al, [14] identified 31% of patients having associated urinary infection and 97% belonged to low socio-economic group. In our study, seven patients (80%) belonged to low socio-economic group.

Initial treatment consists of parental reassurance, observation and warm soaks. [7] Most often, the prolapse responds to these conservative measures, including sitz baths and oestrogen cream application. If the prolapsed mucosa becomes necrotic, excision with approximation of the mucosal edges may be necessary. [5]

The catheter could be removed at 48 hours and leads to reduced hospitalization according to Belman et al. [4] But in spite of the simplicity of the procedure which could be done in outpatient basis, we suggest according to our environment that it is necessary that patient stay in hospital for 24 hours after the removal of the catheter, in order to monitor a possible acute urinary retention.

In Cotonou, we routinely undertake surgical repair because the long-term follow-up of the children is erratic and unreliable as in other reports. [16] The surgical method gives us satisfactory results with one recurrence. In the three cases that had conservative treatment, this option was not predetermined, but during the work up time we noticed a reduction of the oedema of prolapsed tissue only under sitz baths and anti-inflammatory treatment. This observation prompted us not to proceed with the surgical option. Generally, the surgical repair produced excellent results in our experience as in that of other authors, [10],[11],[12] but in contrast, Trotman et al, [15] after their study concluded that treatment should be medical rather than surgical. Anveden et al, [13] obtained five recurrences among eight cases treated non-operatively; they suggested medical treatment to be appropriate for asymptomatic girls with a mild degree of urethral prolapse. [13],[14] Falandry [10] demonstrated that the treatment of choice for urethral prolapse is surgical resection which is simple, safe, and effective in Cotonou.

In conclusion, urethral prolapse is a disease of prepubertal girls, occurring mainly in the low socio-economic group. The diagnosis is clinical. The treatment could either be medical or surgical, but our experience and that of others indicate that the treatment of choice is surgical which is simple and without complications.


   Acknowledgement Top


The authors thank the parents whose children participated to this survey.

 
   References Top

1.Mollard P. Precise of urology of the child: the female urethra. Paris: Masson; 1984. p. 387.   Back to cited text no. 1
    
2.Akani CI, Pepple DK, Ugboma HA. Urethral prolapse: A retrospective analysis of hospitalized cases in Port Harcourt. Niger J Med 2005;14:396-9.  Back to cited text no. 2
    
3.Pouya M, Van Cangh PJ, Wese FX, Opsomer RJ, Saleh M. [Mucous prolapse of the urethra]. Acta Urol Belg 1995;63:23-9.  Back to cited text no. 3
    
4.Belman AB, King LR. Urethra. In: Kelalis PP, King LR, editors. Clinical Pediatric Urology. Vol 1. Philadelphia: Saunders Company WB; 1976. p. 576-99.  Back to cited text no. 4
    
5.Katz AL. Benign gynecologic disorders. In: Mattei P, editor. Surgical directives: Pediatric surgery. Philadelphia: Lippincott William and Wilkins; 2003. p. 765-70.  Back to cited text no. 5
    
6.Cendron J. Tumours of the urinary tract. In: Cendron J, Schulman C, editors. Urologie Pédiatrique. Paris: Flammarion; 1985. p. 352-55.  Back to cited text no. 6
    
7.Shurtleff BT, Barone JG. Urethral prolapse: Four quadrant excisionnal technique. J Pediatr Adolesc Gynecol 2002;15:209-11.  Back to cited text no. 7
    
8.Shavit I, Solt I. Urethral prolapse misdiagnosed as vaginal bleeding in a premenarchal girl. Eur J Pediatr 2008;167:597-8.   Back to cited text no. 8
    
9.Lopez C, Bochereau G, Eymeri JC. Urethral mucosal prolapse in girls: Apropos of 24 cases. Chir Pédiatr 1990;31:169-72.   Back to cited text no. 9
    
10.Falandry L. [Prolapse of the urethra in black girls: Personal experience in 11 cases. Med Trop (Mars) 1994;54:152-6.  Back to cited text no. 10
    
11.Valerie E, Gilchrist BF, Frischer J, Scriven R, Klotz DH, Ramenofsky ML. Diagnosis and treatment of urethral prolapsed in children. Urology 1999;54:1082-4.  Back to cited text no. 11
    
12.Akpo EC, Aguessy-Ahyi B, Padonou N, Odoulami H, Kiniffo HV, Goudote E. Urethral mucosal prolapse in children at the National Hospital and University Center of Cotonou: Apropos of 13 cases. J Urol 1983;89:351-3.  Back to cited text no. 12
    
13.Anveden-Hertzberg L, Gauderer MW, Elder JS. Urethral prolapse: An often misdiagnosed cause of urogenital bleeding in girls. Pediatr Emerg Care 1995;11:212-4.  Back to cited text no. 13
    
14.Kisanga RE, Aboud MM. Urethral mucosa prolapse in young girls. Cent Afr J Med 1996;42:31-3.  Back to cited text no. 14
    
15.Trotman MD, Brewster EM. Prolapse of urethral mucosa in prepupertal West Indian girls. Br J Urol 1993;72:503-5.  Back to cited text no. 15
    
16.Gaudens DA, Moh-Ello N, Fiogbe M, Bandre E, Ossoh BM, Yaokreh JB, et al. Labial fusion in the paediatric surgery department of Yopougon University hospital (Côte d'Ivoire): 108 cases. Santé 2008;18:35-8.  Back to cited text no. 16
    

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Correspondence Address:
M A Fiogbe
02 BP 8229 Cotonou
Benin
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DOI: 10.4103/0189-6725.78661

PMID: 21478579

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    Figures

  [Figure 1], [Figure 2], [Figure 3]

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    Materials and Me...
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