ABSTRACT
This 4-year-old African girl presented to the emergency department. Her parents said she had vaginal bleeding. She was otherwise healthy and there was no history of injury. On examination, she was apyrexial. General examination was normal. In the genital examination, the doctor saw a small amount of blood staining in her pants and thought the vulva looked ‘odd’ (Image 64). He could not identify exactly where the bleeding was coming from. A more senior doctor examined the girl and the genital findings are shown in the image. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig64.jpg"/>
What are the clinical signs shown?
What are the diagnosis and differential diagnosis?
How should the condition be managed?
146The illustration shows a red, doughnut-shaped swelling around the urethra covering the urethral meatus.
The diagnosis, made clinically from the examination, is urethral prolapse. This benign condition is most common in prepubertal African-American girls and white post-menopausal women, although a series of urethral prolapse have been described in white girls. 1 The mucosa can become infected or ulcerated or necrotic. It usually presents with vulval bleeding (often minor) or blood on the undergarments, and sometimes with dysuria. It is thought to occur from weakening of the connections between the mucous and submucous membranes or from poor attachment between longitudinal and circular-oblique smooth muscle layers of the urethra. It is often associated with an acute episode of raised intra-abdominal pressure, such as coughing with asthma or vigorous physical activity and appears to be more common in overweight girls. It has also been associated with trauma and neurogenic abnormalities and constipation can exacerbate the condition through straining. Sexual abuse has also been reported before the urethral prolapse and must be considered in the differential diagnosis. 2 Differential diagnoses include bladder prolapse, ureterocoele prolapse, ectopic ureter, periurethral cyst, polyps and tumours such as rhabdomyosarcomas.
Some centres initially try conservative management of urethral prolapse such as antibiotic and/or oestrogen cream, sitz baths and even bedrest. However, many of those which respond later relapse, some centres go straight to surgical management, particularly excision of the prolapsed mucosa round a Foley catheter and suturing the excised edges. Complications are rare, but urethral stenosis and recurrence can occur.
