Andrew Siegel MD 9/15/2018
Image above from Howard Kelly, Operative Urology, 1906, public domain
Urethral prolapse is a circumferential eversion (when the inside turns out) of the innermost lining of the urethra (urinary channel) through the urethral opening. It is similar to pulling your lower lip down and your upper lip up, exposing the moist inner surface of the lip that is normally not exposed, except that it occurs in 360-degree fashion and involves the urethral opening. It is a uncommon condition that is often misdiagnosed, but is seen fairly commonly by urologists like myself who have expertise in female urology.
It occurs in two distinct populations, prepubescent women, most commonly of African-American background, and post-menopausal Caucasian women. It typically causes a gradually enlarging mass near the urethral opening and vaginal or urinary bleeding. On examination, a hemorrhagic, donut-shaped vaginal mass is seen surrounding the urethra. It can give rise to painful urination and abnormal urinary patterns. At times the inner tissue that is turned outwards can result in swelling and choking off of its blood supply, resulting in tissue death of the prolapsed tissue from strangulation. This appears as a dark purple or black rosebud configuration.
Image above: strangulated urethral prolapse, Case Rep Urol. 2016; 2016: 1802623.
One theory as to the cause of urethral prolapse is separation or lack of cohesion of the two muscle layers of the urethra and an alternative theory is the post-menopausal lack of estrogen that gives rise to lax pelvic muscles, tissue atrophy, and poor urethral support.
Conservative management involves the local application of topical estrogen. Topical antibiotics can be used if an infection is present and warm baths are used for symptomatic relief. Efforts are made to “reduce” the prolapse, manipulating it so that the inside lining is pushed back in.
If symptoms do not improve or resolve, if the patient cannot urinate because of the prolapse or if there is tissue death, surgery is indicated. Reparative surgery involves circumferential excision of the prolapsed tissue with suturing of the urethral lining to the vagina, a highly effective outpatient procedure that I typically need to do only a handful of times per year.
Wishing you the best of health,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.
Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:
MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health
THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health
PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food
These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.
Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx
New video on female pelvic floor exercises: Learn about your pelvic floor
Our Greatest Wealth Is Health 