Bulking agent induced early urethral prolapse after distal urethrectomy

Foreign body granuloma development after calcium hydroxylapatite injection for stress urinary incontinence: A literature review and case report

Objectives

To present a case of foreign body granuloma (FBG) development after injection of calcium hydroxylapatite as a urethral bulking agent and to review all documented cases of this phenomenon in the literature.

Methods

We analyzed a new case of calcium hydroxylapatite-induced FBG. We also conducted a literature review of the PubMed, Embase, CINAHL, and Web of Science databases through March 2022. Reports were included if they contained stress urinary incontinence patients that developed an FBG after calcium hydroxylapatite injection. The cases were reviewed for presenting symptoms, patient demographics, granuloma details, and surgical treatment.

Results

We screened 250 articles and included six articles between 2006 and 2015 in addition to the present case. The median age of the patients was 65.5 years (range 45-93), and all patients were female. The most common presenting symptoms and the proportion of patients affected were difficulty voiding (4/8), recurrent urinary incontinence (3/8), and dyspareunia (2/8). The median time between the first CaHA injection and discovery of the FBG was 5 months (range 1-50). The median longest dimension of the FBGs was 1.85 cm (range 1.0-3.0). The 8 masses observed were evenly distributed throughout the urethra, with 3 in the bladder neck, 2 in the midurethra, and 3 in the distal urethra. Surgical excision was the predominant management choice, with some variation in technique.

Conclusions

Severe, persistent lower urinary tract symptoms after calcium hydroxylapatite injection may indicate an FBG, which has been successfully managed with surgical excision.

Thrombosed Urethral Prolapse: a case series and review of the literature

Thrombosed urethral prolapse is a rare clinical condition. In this context, we describe our experience and compare our findings with the literature, following presentation of five consecutive cases over 2 years. This will hopefully improve awareness and appropriateness of specialty referrals as a correct diagnosis is rarely established prior to the patient being seen by a urologist. We also wish to highlight a case presentation of thrombosed urethral prolapse outside the bimodal age distribution which has been recorded in the literature.

Level of Evidence: Level 4

Particulate Versus Non-Particulate Bulking Agents In The Treatment Of Stress Urinary Incontinence

Stress urinary incontinence (SUI) has been treated surgically with the midurethral sling but in recent years, this option has come under scrutiny and the risk-benefit balance continues to be reviewed. The low-risk alternative for women with uncomplicated SUI is the bulking agent, which aims to achieve continence through coaptation of the urethra. Two classes of bulking agents can be identified: those made from solid microparticles in an absorbable liquid or gel carrier (particulate agents) and those comprising a homogenous gel (non-particulates) that resists absorption. Polydimethylsiloxane®, carbon-coated zirconium oxide®, calcium hydroxyapatite® and polyacrylate polyalcohol copolymer® are currently marketed particulate agents. With the exception of calcium hydroxyapatite, the particles are non-degradable. Each agent achieves its long-term bulking effect through reactive changes around the persisting particles while the carrier volume is lost. Bulkamid® is a non-particulate agent with the bulking effect resulting from the volume of gel injected. The lasting network of fine fibers formed by the host tissue anchors the gel in situ. Foreign-body granulomas, erosion and migration/material extrusion and loss of bulk have been observed in connection with the particle-based products. Bulkamid may be mechanistically less liable to these events; however, there are minimal data directly comparing the two types of bulking agent. The question of durability is inevitable based on their differing modes of action.

A Case of Strangulated Urethral Prolapse in a Premenopausal Adult Female

Urethral prolapse in a premenopausal adult female is exceedingly rare. This paper describes a case of strangulated urethral prolapse presenting as a urethral mass in an unusual demographic and reviews the literature on etiology and management. Only a few cases have occurred in women of reproductive age. The etiology is likely multifactorial. Treatment with surgical excision provides good results in the majority of cases.

"Vaginal" bleeding in prepubertal age: a rare scaring riddle, a case of the urethral prolapse and review of the literature

The entities responsible for isolated vaginal bleeding are a broad spectrum of diseases. Vaginal bleeding in a prepubertal child is always treated as an alarming symptom both by parents and professionals. Most often, one of the first hypotheses is that a sexual abuse may be occurred and the clinical work up is oriented to explore it and eventually confirm or substantiante another diagnosis. Among the possible differential diagnosis urethral prolapse has to be considered. We report the case of a 6 years-old Caucasian girl referred to our Service for a mild vaginal bleeding and with the suspicion of sexual abuse, excluded after the confirmation of the presence of urethral prolapse. The clinical picture and workup are described and compared with a review of the international literature on the issue.

Urethral bulking agents: techniques and outcomes

Stress urinary incontinence is a common health problem affecting women and interfering with their quality of life. The use of bulking agents for urethral augmentation seems to be a beneficial way of restoring continence in these patients while avoiding the risk of surgical intervention. Many agents are available for injection, but the ideal choice should be durable, nonmigratory, and hypoallergenic, while evoking healing with minimal scarring. We reviewed the literature to provide an update on the best techniques of bulking agent injection, to describe the different available injectable agents, and to give their outcome and possible complications.