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Description
A 48-year-old woman presented with acute urinary retention for 1 day and severe periurethral pain for last 3 days. She also revealed a history of occasional blood spotting of undergarments, dysuria and a protruding mass from the urethra for the last 3 months. Her medical/surgical and personal histories were unremarkable. Her obstetric history revealed presence of three normal vaginal deliveries and menopause at the age of 45 years. Local examination revealed presence of irreducible dusky red oedematous tender donut-shaped swelling measuring 2×2 cm around the urethral orifice suggestive of strangulated urethral prolapse (figure 1). A gentle attempt at reduction of the prolapsed mass was done under sedation which was successful following which a Foley catheter was placed. Cystourethroscopy revealed excess urethral mucosa with normal bladder mucosa. Ultrasonography of the abdomen was suggestive of normal bladder parameters with bilateral normal upper tracts. After proper counselling and consent, the patient was taken for surgery under general anaesthesia. The prolapsed urethral mucosa was circumferentially excised around the Foley catheter, and the healthy urethral mucosal margin was sutured to the vestibule using absorbable suture. The histopathological examination (HPE) revealed ulcerated oedematous urethral tissue lined with transitional cells with lymphocytic infiltration and congested vessels. She was advised for local application of oestrogen cream. The patient is voiding well at the 3-month follow-up, and local examination revealed no prolapse (figure 2).
Clinical image showing strangulated dusky red oedematous donut-shaped urethral prolapse around urethral orifice.
Postoperative clinical image showing resolution of the urethral prolapse.
Urethral prolapse is a rare clinical entity, and strangulated urethral prolapse is an even rarer urological emergency. It occurs due to circular protrusion of urethral mucosa through the urethral meatus with bimodal age distribution, mostly seen in either prepubertal girls or postmenopausal women.1 The exact aetiology is still unknown; however, lack of oestrogen and poor pelvic support have been implicated as major predisposing factors, especially in postmenopausal women. As the size of the protruding mass increases, the vascularity is compromised due to extrinsic compression at urethral meatus leading to strangulation which results in venous congestion, thrombosis and necrosis of the prolapsed urethral tissue. Patients with strangulated urethral prolapse mostly present with vaginal bleeding with periurethral mass and/or voiding symptoms like dysuria, frequency and so on.1 2 In extreme cases, it may present with acute urinary retention. The circumferential excision of prolapsed urethral mucosa and buttressing of remaining urethral wall to vestibule margin followed by long-term oestrogen cream application are considered as a standard treatment.3
Learning points
Strangulated urethral prolapse is an extremely rare urological emergency.
Rarely urethral mucosal prolapse may strangulate at meatus opening and may present with acute urinary retention.
Surgical excision and long-term oestrogen cream application are considered as a standard treatment.
Footnotes
Contributors GG: concept, design, supervision, processing, writing manuscript and critical analysis. AS: concept, design, supervision, processing, writing manuscript and critical analysis. BPS: supervision, processing, writing manuscript and critical analysis. SP: concept, supervision, writing manuscript and critical analysis.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.