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Common vulvar and vaginal complaints
Published in Joseph S. Sanfilippo, Eduardo Lara-Torre, Veronica Gomez-Lobo, Sanfilippo's Textbook of Pediatric and Adolescent GynecologySecond Edition, 2019
Urethral prolapse is the protrusion of the distal urethra through the external meatus. The tissue appears as a friable, often donut-shaped mass superior to the hymen. Patients report painless, bright red bleeding, especially with wiping.30 The volume of bleeding is minimal and is usually noted on tissue or underwear. The frequency of urethral prolapse as a cause of vaginal bleeding depends on the population studied. It has been reported to be more common in African American girls (as well as postmenopausal Caucasian women), and a Swedish case series of 86 prepubertal vaginal bleeding identified no cases related to urethral prolapse.29 A series of 89 Chinese girls presenting to a single institution with urethral prolapse over 16 years was published in 2017, prompting reconsideration of risk based on race. In contrast to earlier studies, most of these girls had a body mass index of less than the 50th percentile, challenging obesity as a contributing cause.31 Predisposing factors can be those that decrease tissue integrity, such as malnutrition, neuromuscular disorders, steroid use, or the hypoestrogenic state, or those that increase intraabdominal pressure, such as chronic cough or constipation. Diagnosis is made based on vulvar examination. The mass may appear red and friable, but if strangulation of vascular supply has occurred with prolapse, the mass may appear dark, necrotic, and malodorous. Management of urethral prolapse depends on the severity of presentation and is covered in more detail in Chapter 11. Conservative management of nonnecrotic urethral prolapse includes correcting underlying constipation, sitz baths, and topical estrogen cream for 2–6 weeks.30 Recurrent or larger lesions may require surgical resection.
Case 86
Published in Vincent J Palusci, Dena Nazer, Patricia O Brennan, Diagnosis of Non-accidental Injury, 2015
Margaret T. McHugh, Anastasia Feifer, Lori A. Legano
A 4-year-old female had 1 day of bleeding noted in her underpants. Her mother said that when she checked her genitals, the area ‘looked red’. The girl had been afebrile, active and playful, though was recovering from a mild upper respiratory tract infection. She denied any vaginal pain or dysuria. She was a healthy and developmentally normal child, attended school regularly and was toilet trained. She denied any sexual abuse when questioned in the office. Her physical examination is shown in Image 86. What was the diagnosis?What are the next steps in management of this condition?List other causes of bleeding in prepubertal girls.This patient has a urethral prolapse, a relatively rare occurrence in prepubertal girls and mostly affecting patients of African descent.1 The distal urethral mucosa protrudes beyond the urethral meatus, causing bleeding with or without urinary symptoms. Urethral prolapse may be caused by laxity of periurethral ligaments and low levels of oestrogen, and in some it has been shown to be associated with increased intra-abdominal pressure as with episodes of coughing or an asthma exacerbation.2 The appearance of the prolapsed tissue is erythematous or even haemorrhagic and often obscures the anterior vagina (the 12 o’clock position) when the patient is examined supine. A ‘donut-shaped’ urethral opening can often be seen surrounded by prolapsed tissue. In this image, the extruded tissue is erythematous and highly vascular.The patient can be medically treated with topical oestrogen cream and sitz/salt baths to alleviate symptoms of bleeding and discomfort.2 In some cases, this may resolve the prolapse; however, recurrence after a first episode is common and the patient may need surgical correction. Cases with persistence should be referred to a paediatric urologist.1Bleeding in a prepubertal girl can be distressing to patients and caregivers and should be evaluated thoroughly with a careful history. Child sexual abuse is part of the differential, and if there is concern, a verbal patient should be questioned carefully by a qualified interviewer. Physicians must always consider other non-abusive causes of bleeding, such as infections (Salmonella or group A strep), foreign body (especially toilet paper), accidental trauma such as a straddle injury, precocious puberty, including McCune-Albright syndrome or oestrogen secreting tumour, exogenous exposure to oestrogen and autoimmune conditions such as Behçet disease or lichen sclerosus et atrophicus.1
Foreign body granuloma development after calcium hydroxylapatite injection for stress urinary incontinence: A literature review and case report
Published in Arab Journal of Urology, 2023
David A. Csuka, John Ha, Andrew S. Hanna, Jisoo Kim, William Phan, Ahmed S. Ahmed, Gamal M. Ghoniem
The MAUDE adverse events database contains two potentially relevant complication reports. The first patient received three sequential 1.0 mL CaHA injections. Sometime during the next calendar year, the patient was diagnosed with urethral prolapse via periurethral exam, which was assessed by the physician to be of mild severity and not CaHA-related. The urethral prolapse was untreated and resolved shortly. The patient was later diagnosed with caruncle via periurethral exam, which was assessed to be of mild severity and probably not CaHA-related. The caruncle was untreated and resolved shortly [20]. The second patient was unable to urinate without a catheter for 10 days after the CaHA injection, and experienced hematuria with loss of bulking agent particles into the urine due to a urethral tear [21]. Both patients were not formally included as the presence of an FBG requiring surgical intervention was inexplicit.
Urologic view in the management of genitourinary syndrome of menopause
Published in Climacteric, 2023
In additional to the functional changes described previously, there are also anatomic changes unique to the urinary system, at the level of the urethral meatus, that occur in the setting of VVA. The estrogenized vestibule surrounds the urethral meatus and this, in addition to the labia minora and internal fascia, provides a protective component as well as support to the urethral mucosa internally. The two pathologies to be discussed here are urethral prolapse and urethral caruncle. The majority of the literature on urethral prolapse is from the pediatric population and there is very scarce primary literature discussing the etiology and management of urethral prolapse in postmenopausal women. There are series within the pediatric population documenting potential etiologies including loss of tissue support related to decreased hormones as well as constipation and increased intra-abdominal pressures [40,41]. Based on this literature, combined with the prevalence in postmenopausal women and improvement of prolapse with topical estrogen, we presume urethral prolapse is the result of loss of estrogen related to menopause. Urethral prolapse is the complete or partially circumferential external telescoping of the inner lining of the urethra at the level of the urethral meatus. Women may present with bleeding or spotting due to irritation of the unprotected urethral mucosa against undergarments. Patients may also endorse dysuria or dyspareunia. Urethral prolapse does not typically present with urinary obstruction. The condition is otherwise benign and can be managed with topical estrogen cream applied directly onto the exposed urethral mucosa twice weekly, as well as sitz baths [42]. Surgical resection is the most definitive form of management, but there is a risk of urethral stenosis and scarring [43]. Urethral caruncles are another type of urethral pathology associated with VVA. Caruncles are a non-circumferential protrusion of tissue from the urethra. The exact etiology of caruncles is unknown, but there are several theories related to inflammation based on histologic appearances [44]. These lesions present similarly to urethral prolapse with bleeding or spotting, dyspareunia, dysuria and, rarely, obstruction symptoms [44]. They usually occur at the inferior border of the meatus at the 6 o’clock position and have an edematous, vascular appearance. Similar to urethral prolapse, these lesions can be treated with topical estrogen, and if this fails one can consider surgical excision. Although urethral caruncles are benign, it is always prudent to consider urethral carcinoma in your differential diagnosis and refer to a urologist for evaluation and biopsy if there is any question. Unlike caruncles, carcinoma will appear more atypical and may grow, while caruncles generally remain stable in size with a more uniform appearance. In one series of 376 patients, 1.6% of caruncles were found to be carcinoma [45].