Medical Care
Treatment of urethral prolapse ranges from conservative therapy (eg, applications of antibiotic ointments, estrogen creams, sitz baths, herbal remedies, oral antibiotics) to various surgical techniques.
Although some medical professionals have advocated conservative measures, the author feels that these measures should be used in the milder cases of urethral prolapse or when general anesthesia is contraindicated because the results of medical treatment are less predictable than those of surgery. However, no prospective data have compared cost analysis of conservative treatment versus surgical intervention. [22] Certainly, when the urethral mucosa appears gangrenous or necrotic, conservative measures are not appropriate.
Treatment of the other urethral anomalies discussed in this article is mostly operative.
Urinary tract infections (UTIs) are managed with conventional treatment. For pyelonephritis, conventional treatment typically includes an intravenously administered second-generation cephalosporin (eg, cefotaxime) and antibiotics adjusted later, according to sensitivities.
Surgical Care
Treatment of urethral duplications is individualized. In most instances, the ventral urethra is the functional one. Two thirds of patients require surgery. A decision as to which urethra to preserve (usually the ventral) must be made. Hypospadias and epispadias are treated with standard techniques (see Hypospadias, Exstrophy and Epispadias). Unknowing excision of the functional urethra may result in urinary retention or incontinence.
Managing anterior urethral valves (AUVs) is a subject of controversy. Although Rushton et al recommended cutaneous vesicostomy in the neonate, followed by endoscopic valve ablation when the child is older, [23] others have suggested two-stage urethroplasty, with the first stage to be performed in the neonatal period.
Treatment of megalourethra follows the principles of surgery for hypospadias.
Endoscopic resection is the treatment of choice for urethral polyps. Conversely, endoscopic marsupialization is used to correct urethral diverticula, sinus of Guérin anomalies, and Cowper duct cysts. [24]
Urethral prolapse is managed best with a modification of the Kelly-Burnam operation in which prolapsed mucosa is excised and the mucocutaneous junction is reapproximated with absorbable sutures. [25] Ligation of the prolapsed mucosa over a Foley catheter is discouraged because of a higher rate of complications (eg, infection, recurrence, and prolonged need for analgesics).
Perioperative antibiotics are used in all open and endoscopic procedures for the treatment of urethral anomalies and urethral prolapse.
Complications
In general, treatments are safe and effective, and complications are infrequent. The following can complicate the operative repair of urethral anomalies and urethral prolapse:
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Bleeding
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Infection
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Urinary retention
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Incontinence
Consultations
Consult a pediatric urologist for children in whom urethral anomalies or urethral prolapse are suggested.
Consult a pediatric nephrologist when associated obstructive uropathy is present (particularly in patients with AUVs).
Long-Term Monitoring
After any operation, a follow-up visit should be scheduled to evaluate surgical outcome.
In patients without obstructive uropathy, progress can be monitored by focusing on the symptomatology.
When significant obstruction is present, follow-up care should include serial renal ultrasonography (US) and at least one voiding cystourethrography (VCUG) or retrograde urethrography (RUG) to document anatomic relief of the obstruction and monitoring of the upper urinary tract.
