Urethral Prolapse Treatment & Management

Medical therapy for urethral prolapse includes local hygiene with sitz baths and topical antibiotic, steroid, or estrogen creams.

The effectiveness of medical therapy is debated in the literature. Some authors report that local application of an antibacterial ointment allows symptoms of the prolapsed mucosa to resolve. In one series, the prolapsed urethra persisted at a 3-year follow-up, even though the symptoms disappeared.^[3] In another series, treatment of urethral prolapse with topical estrogen cream resulted in complete involution in 3-6 weeks, without recurrence.^[4]

Current recommended medical therapy for prepubertal girls includes treatment with sitz baths and topical antibiotics and estrogen cream. The usual regimen consists of the application of estrogen cream to the prolapsed urethra 2-3 times daily for 2 weeks, in combination with sitz baths. The use of antibiotics is optional, depending on the patient's clinical presentation.

For women with mild forms of urethral prolapse, the recommended therapy consists of oral conjugated estrogen or topical estrogen cream applied to the prolapsed urethra 2-3 times daily for 2 weeks, in combination with sitz baths. Prescribe antibiotics if infection is present.

Failure of medical therapy or the presence of strangulated urethral prolapse mandates surgical excision.

Conservative therapy is not recommended when significant thrombosis, necrosis, or bleeding of the prolapsed urethra is present.

If medical therapy does not rapidly reduce the prolapse, surgery is the treatment of choice. In one reported series, a comparison of treatment modalities (nonoperative vs excision) indicated that patients undergoing early local excision of the prolapse had the lowest complication rates and the earliest convalescence.^{[5, 6]}

Procedures used to treat urethral prolapse include the following:

• Keefe vaginal/urethral plication
• Emmet handkerchief-through-buttonhole
• Surgical reduction maintained with mattress sutures
• Manual reduction
• Incision
• Cautery excision
• Local excision
• Suture ligation
• Cautery, fulguration, and cryosurgery to destroy or incise prolapsed tissue

The procedures described by Emmet and Keefe are difficult to perform in the small vagina of a child.

Simple manual reduction and urethral catheterization for 1-2 days have been effective in minor cases of urethral prolapse; however, recurrence rates are high.

Tying a ligature around the prolapsed mucosa over an indwelling urethral catheter causes the tissue to slough in a few days.

Some of these procedures have significant morbidity, resulting in urethral strictures and meatal stenosis. They are also associated with partial recurrences, infection, and prolonged recovery. These procedures are not commonly performed today.

Some authors feel that a prolapsed urethra is the result of inadequate attachment of the urethra to the pubis. As such, the herniated urethra should be reduced and the bladder and urethra attached to the posterior surface of the pubis and rectus abdominis muscles. However, the Hepburn procedure (ie, suprapubic vesicourethropexy) is too extensive of an operation for this simple lesion and is no longer recommended.

The preferred method of removing the prolapsed urethra is excision of the everted mucosa with suturing of the incision and short-term catheterization. Several modifications of this procedure are discussed below. Of these procedures, complete circumferential excision and closure of the incision appears to be the most effective treatment and is associated with minimal complications.

According to Haverkorn et al, obesity does not appear to be a risk factor for additional complications after surgery. Although cure rates are lower, obese women have significant improvements in quality of life after surgery for stress urinary incontinence.^[7]

Eradicate any coexisting urinary tract infection with appropriate antibiotics. Discuss the potential benefits and risks when obtaining informed consent from the patient or parents.

Complications unique to surgical excision include urethral stenosis, urinary incontinence, and recurrence of prolapse.

In most cases, the operation can be performed in an outpatient setting.

Administer general anesthetic. Place the patient in a dorsolithotomy position, and sterilely prepare and drape the vaginal area. Place a Foley catheter. Excise the prolapsed urethra in one of the following ways:

• Lowe and colleagues described a technique in which a meatotomy is performed to release the constricting meatal ring. The prolapsed mucosa is then manually reduced. Follow this by placing several absorbable mattress sutures through the mucosa and urethra and tying them to the periurethral vestibule.^[8]
• The Kelly-Burnham technique involves excising the prolapsed mucosa over an indwelling Foley catheter. Close the incision by approximating the normal urethral mucosa to the introital mucosa with interrupted absorbable sutures. Take care to not pull down any more urethra than is already prolapsed because shortening the urethra may lead to urinary incontinence.
• A modification of the Kelly-Burnham technique involves placing absorbable stitches in 4 quadrants of the prolapsed mucosa (see image below). Incise each quadrant between the holding sutures up to the mucocutaneous junction. Excise the prolapsed urethra in quadrants, followed by immediate approximation of the mucocutaneous junction with absorbable sutures. Urethral prolapse. Intraoperatively, the prolapsed mucosa is excised in quadrants, and the 2 layers of smooth muscle are apposed together.

All of these operations serve 2 functions. They remove the nonviable tissue and restore the 2 muscle layers of the urethra to their normal state of apposition.

After surgery, leave the urethral catheter in place for 48-72 hours to allow continuous bladder drainage (see image below). Diverting the urine via a Foley catheter prevents irritation and stinging of the urethral mucosa during voiding. Catheterization is unnecessary in children.

Discharge the patient home on oral antibiotics and supplemental narcotics.

The patient needs to return in 2-3 days for catheter removal. Schedule a follow-up visit for 4-5 weeks later to evaluate the patient's voiding status and to examine the incision site. Following surgical excision of urethral prolapse in postmenopausal women, long-term topical estrogen therapy is recommended.

Postoperative complications are unusual, but the following have been reported:

• Urethral stenosis
• Urinary incontinence (extremely rare)
• Acute urinary retention
• Vaginal bleeding
• Recurrence of prolapse
• Bleeding from the suture line (early complication)
• Meatal stricture (delayed complication of surgery)
• Late recurrences (uncommon)

Although ureteral injury is possible during surgical correction of a severely prolapsed urethra, it has not been reported.

Use of topical estrogen therapy in postmenopausal women with urethral prolapse usually suffices as a primary intervention, provided that the therapy is used long-term. For acute interventions that may be warranted based on bleeding and pain, excising the prolapsed mucosa and oversewing of the edges provides the most definitive therapy with the fewest recurrences. Oversewing the mucosal edge restores the coaptation of the longitudinal and circular-oblique muscle layers to prevent any future recurrence.

Optimal management of urethral prolapse consists of initials trials of medical therapy, followed by minimally invasive procedures for refractory conditions. Reported advantages of conservative therapy versus surgery and vice-versa are generally based on personal preference rather than objective randomized prospective studies.

Offering medical therapy, at least initially, to children and adults with minimal symptoms is prudent. Medical therapy is also appropriate for patients with a high risk of complications with general anesthesia. Careful follow-up is important.

All other patients, including those in whom medical therapy has failed, are good candidates for surgical excision of the prolapsed urethra. Complete excision with oversewing of the mucosa appears to have the highest success rate with the lowest prevalence of recurrences.