Overview
What is urethral prolapse?
Urethral prolapse is a rare condition in which the inner lining of the urethra, the hole you pee from, protrudes through the external urethral opening.1 If you imagine the urethra as a tube, it is as if the tube starts to turn inside out and sag outside its opening.
Significance of the condition
Although an extremely rare condition, urethral prolapse is most commonly observed in pre-pubescent people assigned female at birth (PAFAB) with a suggested occurrence of one in 3000.2 Therefore, it is a condition of interest as to how we can inform and prevent these occurrences. The purpose of this article is to explain what urethral prolapse is and provide an overview of the urogenital tracts, some of the common risk factors, symptoms and treatments.
Urogenital anatomy
PAFAB more commonly encounter urethral prolapse than people assigned male at birth (PAMAB), therefore we will focus on the PAFAB anatomy of the urethral and genital tracts.
The female urogenital tract contains all the organs necessary for reproduction and the production of urine.3 However urethral prolapse only focuses on the organs that produce urine- the urethra. The urethral opening lies just above the vaginal opening but below the clitoris. When prolapsed, the opening appears as a small, reddish or pink mass, often perceivable as a small pink doughnut.
How does prolapse differ from other urological conditions?
Urethral prolapse is frequently misdiagnosed as a simple urethral caruncle, but can also range to more serious diagnoses, thus it is important to discern the differences between these conditions.4
Urethral caruncle is a non-cancerous growth on the skin surrounding the outside of the urethra. However, these masses differ due to the extent to which they protrude out of the urethral opening. A caruncle only sticks out on one edge, but a prolapse causes protrusion from all sides of the external urethra.5
Causes of urethral prolapse
Common risk factors
There are a number of risk factors contributing to the increased likelihood of urethral prolapse, such as:
- History of heavy or severe coughing
- Lifting heavy objects
- Constipation
- Recurrent urinary tract infections (UTIs)
- Trauma to the urethral tract
- Obesity
These risk factors all contribute to an increased pressure in the stomach (abdomen) which increases the risk of the urethral prolapse.6
Age, ethnicity and hormonal influence
Whilst the aforementioned risk factors do increase the risk of urethral prolapse, they are more so mechanical risk factors rather than genetic ones. The influence of age, ethnicity and hormonal influence also greatly impact the risk of urethral prolapse. For instance, being:
- Female
- Pre-pubescent
- Post-menopausal
- Of African American or Hispanic ethnicity
Both pre-pubescent and post-menopausal females have a low hormone balance of oestrogen.15 This is the hormone that regulates the growth and development of the female reproductive system. Additionally, it aids the connection of muscles and connective tissues.9 Therefore when there is insufficient oestrogen, the proposed idea is that the muscles surrounding the urethra are unable to connect as firmly, therefore the inner lining is allowed to move out of place and protrude.1
Childbirth and pregnancy
Childbirth and pregnancy are also important risk factors for urethral prolapse, as when the abdominal pressure is increased, the muscles surrounding your pelvis start to weaken.10 Moreover, following the same fate as low oestrogen, the muscle fails to support the urethra, thus allowing it to project outwards.
Recognising signs and symptoms
The signs and symptoms tend to vary amongst children and adults, so we can take a look at each separately.
Children with urethral prolapse may not present with any symptoms. However, there are some key signs to look out for such as blood spots on their underwear, complaints of tenderness following wiping themselves after using the toilet, pain ‘down below’ and even whilst peeing.6
In adults, these signs can also present, but it may be easier to examine what is going on by looking out for a noticeable ring of red or pink tissue that may be sensitive or swollen.
Making a diagnosis
If you go to your doctor, they will ask for your consent to do an internal pelvic exam. This consists of a below-the-waist examination, where the doctor will examine for any lumps in your pelvic area.11
Further tests may involve a urine test to investigate for any infective causes, or inserting a small tube into your bladder to look for any other causes.11
Treatment options
Conservative
Treatment methods for urethral prolapse can vary depending on the severity of the presentation. There are two main categories of treatment options: conservative or surgical.
Conservative treatment essentially avoids the use of invasive methods such as surgery.11 Lastly, surgical treatment options provide more invasive methods of treatment to remove the problem.
The majority of patients are directed to the non-surgical or conservative treatment path, whereby the use of oestrogen creams and sitz baths are promoted. When using oestrogen creams in children, a healthcare provider will monitor their usage to prevent the delay of developmental changes such as breast budding or growth of pubic hair.14
Additionally, if risk factors such as a UTI were present before the appearance of urethral prolapse, then antibiotics may also be provided. However, as this is a rare occurrence, these are not often prescribed.12
Surgical
If the urethral prolapse is severe or has caused an obstruction further up in the urethral tract, then your healthcare provider may propose surgery. The most common surgical intervention would be to pull together weakened or damaged tissue through a small cut in the vagina. However, if you have a health condition that prevents this, the incision would be made through the abdomen, but this is extremely uncommon.13
It is important to bear in mind that there is no clear first-line treatment for urethral prolapse, therefore it is best to seek medical attention so that your healthcare provider can define its cause and discuss what treatment works for you.
Surgical complications
With every procedure, it is important to remember that there are some main complications, such as infection, pain and possibly some bleeding afterwards.15 But there are also more specific complications directly related to the procedure. Invasive procedures often have to bypass nearer structures; therefore, complications may arise here.
The bladder is the biggest structure to be aware of, so if you have continued issues with bladder emptying or leakage then contact your healthcare provider.15 There are more particular complications, however, your doctor will inform you of these prior to the surgery and allow you to choose whether you would like to continue with the procedure.
Prevention and risk reduction
If you have had successful treatment for urethral prolapse, unfortunately, there is always a possibility that it might come back. Lifestyle changes are a feasible way of reducing your risk of recurrent prolapse, these work by reducing the pressure in your abdomen and strengthening your pelvic muscles. Here are some of these methods that you can try out at home:
- Avoid heavy lifting
- Practice doing Kegel exercise
- Maintain a healthy weight
- Prevent or treat constipation11
FAQs
Do all urethral prolapse need treatment?
No, if you have a urethral prolapse, but no symptoms and it is not bothering you, then you may not need medical treatment.11 However, if you are concerned, then you can simply contact your local healthcare professional.
Do males get urethral prolapse?
Yes, males can get urethral prolapse, however it is extremely rare.
Summary
Urethral prolapse is a condition where the inner lining of the urethra falls out of place. It is an uncommon condition and usually not severe, however it can cause irritation or pain in the pelvic area. Treatment options can involve a mixture of prevention methods and lifestyle changes such as Kegels exercise, as well as medical and surgical interventions depending on the severity of the prolapse. If you have any questions or apprehensions, we recommend reaching out to your healthcare provider. Together, you can explore the treatment options that are tailored to your needs.
- Healey, Kevin D., et al. ‘Successful Surgical Management of Urethral Prolapse in a Postmenopausal Female’. Cureus, vol. 15, no. 5, p. e38818. PubMed Central, https://doi.org/10.7759/cureus.38818. Accessed 29 Sept. 2023.
- Holbrook, Charlotte, and Devesh Misra. ‘Surgical Management of Urethral Prolapse in Girls: 13 Years’ Experience’. BJU International, vol. 110, no. 1, July 2012, pp. 132–34. PubMed, https://doi.org/10.1111/j.1464-410X.2011.10752.x.
- ‘Female Reproductive System (Urogenital System) Information | myVMC’. HealthEngine Blog, 21 Mar. 2006, https://healthinfo.healthengine.com.au/female-reproductive-system-female-urogenital-system.
- Urethral Prolapse: Practice Essentials, History of the Procedure, Problem. Aug. 2023. eMedicine, https://emedicine.medscape.com/article/443165-overview#:~:text=Upon%20examination%2C%20round%2C%20often%20doughnut,simple%20urethral%20caruncle%20to%20rhabdomyosarcoma.
- Meutia, Alfa Putri, et al. ‘Giant Urethral Caruncle Resembling Urethral Prolapse Causing Outflow Obstruction’. Urology Case Reports, vol. 39, July 2021, p. 101783. PubMed Central, https://doi.org/10.1016/j.eucr.2021.101783.
- Philadelphia, The Children’s Hospital of. Urethral Prolapse. 28 Apr. 2014, https://www.chop.edu/conditions-diseases/urethral-prolapse.
- Mayala, Armand Mayala Ma, et al. ‘Diagnosis and Management of a Urethral Prolapse in a 6-Year-Old Girl: A Case Report’. The Pan African Medical Journal, vol. 39, Aug. 2021, p. 284. PubMed Central, https://doi.org/10.11604/pamj.2021.39.284.30954.
- Chidi-Ogbolu, Nkechinyere, and Keith Baar. ‘Effect of Estrogen on Musculoskeletal Performance and Injury Risk’. Frontiers in Physiology, vol. 9, Jan. 2019, p. 1834. PubMed Central, https://doi.org/10.3389/fphys.2018.01834.
- Urethrocele: Care Instructions. https://myhealth.alberta.ca:443/Health/aftercareinformation/pages/conditions.aspx?hwid=tw12330. Accessed 29 Sept. 2023.
- ‘Pelvic Organ Prolapse’. Nhs.Uk, 20 Oct. 2017, https://www.nhs.uk/conditions/pelvic-organ-prolapse/.
- Lee, Becca. Conservative vs. Surgical Treatment: Pros and Cons. https://www.ewmotiontherapy.com/blog/conservative-vs-surgical-pros-cons. Accessed 29 Sept. 2023.
- Fornari, Alexandre, et al. ‘Urethral Prolapse: A Case Series and Literature Review’. Journal of Obstetrics and Gynaecology of India, vol. 70, no. 2, Apr. 2020, pp. 158–62. PubMed Central, https://doi.org/10.1007/s13224-019-01288-2.
- ‘Repair Of Bladder Prolapse (Cystocele) Or Urethra Prolapse (Urethrocele) | NYP’. NewYork-Presbyterian, https://www.nyp.org/healthlibrary/surgical-details/repair-of-bladder-prolapse-cystocele-or-urethra-prolapse-urethrocele. Accessed 29 Sept. 2023.
- ‘Urethral Prolapse: Causes, Symptoms, Diagnosis & Treatment’. Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/24177-urethral-prolapse. Accessed 29 Sept. 2023.
- ‘Possible Complications of Prolapse Surgery’. Dr Marcus Carey, https://drmarcuscarey.com/prolapse/possible-complications-of-prolapse-surgery/. Accessed 29 Sept. 2023.