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

A case report of urethral prolapse in young girls: Clinical manifestations and surgical management

BACKGROUND AND IMPORTANCE

Urethral Prolapse (UP), first described by Solinger in 1732, is a rare condition characterized by the circular protrusion of the distal urethral mucosa through the external meatus, forming a hemorrhagic, sensitive vulvar mass. This condition is most commonly observed in prepubertal black females. This case report details the clinical manifestations and surgical management of UP in three young girls.

CASES PRESENTATION

Three girls, aged 4, 5, and 6 years, were admitted with symptoms of vaginal blood spotting. Physical examinations revealed moderate bleeding and a red ring of congested, edematous tissue prolapsing through the urethral meatus. Diagnostic procedures confirmed UP, and surgical management was undertaken. The surgical approach involved the complete excision of the prolapsed tissue and mucosal-to-mucosal anastomosis under general anaesthesia. Postoperative follow-up over a mean period of 11 years showed no recurrence or urethral stricture.

CLINICAL DISCUSSION

UP is a rare benign condition primarily affecting the female urethra, with several hypothesized etiologies, including weak pelvic floor structures and increased intraabdominal pressure. The typical presentation includes vaginal bleeding and a doughnut-shaped mass around the urethral meatus. Conservative management may be considered for mild cases, but surgical excision is recommended for severe cases, offering a safe and effective solution with low recurrence rates.

CONCLUSIONS

UP in children, although rare, should be considered in cases of unexplained vaginal bleeding. Diagnosis is primarily clinical, and surgical resection provides a definitive and cost-effective treatment.

Urethral Prolapse Case Report: Surgical and Social Considerations in Senegal

We present three cases of urethral prolapse in prepubertal females in Senegal who presented with vulvar bleeding. Careful gynecologic and urologic physical exams were performed and revealed urethral origin and prolapse. Conservative versus surgical approaches were taken in different patients, but ultimately, each patient received a urethral meatoplasty. Surgical excision of these masses yielded a full recovery in the patients. A careful review of the literature was then undertaken and showed that surgical excision or ligation of the prolapse is preferable to more conservative treatment. The case series article discusses the rare occurrence of urethral prolapse, as well as the epidemiology and prognostic and therapeutic implications of urethral prolapse in prepubertal females. Introduction. Urethral prolapse is a rare condition occurring mostly in young black females. It can be worrying to the parents as it often causes vulvar bleeding. Case Presentation. We present three cases of urethral prolapse in prepubertal females who presented with vulvar bleeding. Physical exams were performed and revealed urethral origin and prolapse. Each patient underwent a urethral meatoplasty and subsequently experienced a full recovery after respective follow-up of 2 years, 1 year, and 1 year. Conclusion. Urethral prolapse is a rare condition which can be managed successfully by surgery. Plain Language Summary. This case report on pediatric urethral prolapse showcases the different presentations and modalities of treatment, as the literature does not show that a specific treatment is always undertaken. In some countries, there are strong social considerations and they demonstrate difficulty separating sexual abuse from genitourinary pathologies, which are important to address in the treatment of these conditions.

Conservative approach for the treatment of urethral prolapse in children: case report and literature review of 278 pediatric cases

Background

Urethral prolapse (UP) is a rare, benign condition that often goes misdiagnosed and mistreated. It consists of the eversion of the distal urethral mucosa through the outer urethral meatus, leading to vascular obstruction and prolapsed tissue edema, which aggravates the prolapse. Although many review articles were reported on this condition, none of them focused on the conservative approach nor targeted the pediatric population. In this paper, we present successful medical management of UP in a 13-month-old Caucasian female and perform an extensive review of the literature to include articles that reported a conservative approach in patients under 18-years-old. We also suggested a practical algorithm for both diagnosis and management of this condition.

Case presentation

A 13-month-old Caucasian white female was presented with a urinary tract infection and vaginal bleeding. Genital examination showed a hyperemic donut-shaped mass covering the urinary meatus, of 0.7 cm diameter, with an actively bleeding open center. After confirming the diagnosis of UP with catheterization, a conservative approach was decided; antibiotics associated with topical corticosteroids including betamethasone 1% cream. The first-week outcome showed regression of the prolapsed tissue and the examination after four months showed normal vaginal mucosa with no evidence of relapse.

Conclusions

20 studies were retained after PubMed search with a total of 278 female patients aged between 1 month and 15 years old. The main reasons for referral were vaginal bleeding and mass, urinary symptoms followed by sexual abuse. Non-surgical treatment was tried for 162 patients. 53 of them were successfully managed, while 92 reported unsuccessful outcomes. The conservative approach was successful in 19% of all patients and raised to 32.7% in the portion of children selected for the initial conservative approach. Even though this review showed good results with medical treatment in children with UP, additional comparative studies are required to evaluate the effectiveness of conservative treatment in comparison with surgical interventions. In addition, Long-term follow-up is required as recurrence was reported up to 2 years following conservative treatment.

Rare (uro-)genital pathologies in young girls mimicking sexual abuse

Examinations of young children for suspicions of sexual abuse are challenging for the involved medical specialists because the consequences of the interpretation of the findings can be severe and dramatic. A broad knowledge of differential diagnoses including rare pathologies like urethral prolapse and failure of the midline fusion of the perineum, known as perineal groove, is essential in order to avoid unnecessary diagnostics and treatment, prejudgment, and to reduce patient family’s anxiety. We report two independent cases of girls aged 7 months and 5 years suffering from these rare pathologies, one presenting with painless lower genital tract bleeding, the other showing a lesion of the perineum as random finding during a neuropediatrician’s consultation. In both cases, the pathologies were initially misdiagnosed as injuries due to sexual assault, and judicial investigation procedures were initiated. In this paper, the characteristic symptoms and morphology of urethral prolapse and perineal groove are presented to enhance the awareness of these pathologies among forensic experts and help to establish the correct diagnosis.

The clinical legal medicine: a need for quality of care and patient's safety. A single center five-year experience

INTRODUCTION

Clinical legal medicine is a branch of legal medicine that takes place in a clinical setting approaching the patient's bedside and using a particular attention not only for conceptual or normative references but also for every possible medical and social aspect.

MATERIAL AND METHODS

The requests of medico-legal opinions received by the Department of Legal Medicine of a large university hospital were retrospectively collected over a 5-years period. The analysis focused on the recurrence rate of the requests and the most common medico-legal issues to be solved in a clinical context, differentiating between adult and minor patients.

RESULTS

The collected medico-legal advices amounted to 448. The most clearly involved clinical area was Medicine (54%) followed by Gynecology and Obstetrics (15.6%), Pediatrics and Surgery (10.7%). The requests concerning patient's self-determination in therapeutics choices, including refusal of proposed treatments, covered almost one-half of total casuistry. The designation of support administrator represented also a relevant issue (20.5%). In case of minors, the queries related to reporting crimes were three times higher than in adults, while the appointment of a support administrator was never requested.

CONCLUSION

Clinical legal medicine, through medico-legal advices, plays a primary role in contributing to the safeguarding of health and to the decision-making process of clinicians.

Diagnosis and treatment of urethral prolapse in children: 16 years' experience with 89 Chinese girls

Objective

To review our experience and results in the diagnosis and treatment of urethral prolapse (UP) in Chinese girls.

Patients and methods

We conducted a retrospective chart review of 89 consecutive girls (aged <16 years) with UP and without other complications, who received treatment for UP from January 1999 to January 2015 (a study period of 16 years) at the Children’s Hospital of Chongqing Medical University, China. Data analysed included: age, symptoms, clinical findings, predisposing factors, management, and outcomes.

Results

The presenting symptoms in the 89 girls were: mass (54 girls), bleeding (34), and dysuria/straining at micturition (one). In all, 14 patients received conservative treatment as their symptoms were mild, and 75 were successfully treated by excision of the prolapsed urethral mucosa or ligation over a Foley catheter, as their symptoms were severe and recurred too frequently to be managed conservatively. The mean postoperative length of stay for ligation was 7.76 days and for excision was 4.57 days. Ligation over a Foley catheter had a longer hospital stay.

Conclusions

UP is a rare condition occurring in prepubertal girls, evidenced by a urethral mass and bleeding. Increased physician awareness and early recognition of UP avoids unnecessary examinations and patient anxiety.

Genital trauma and vaginal bleeding: is it a lapse of time issue? A case report of a prepubertal girl and review of the literature

Child victims of sexual abuse may present with physical findings whose interpretation requires the most exhaustive evaluation and an accurate collection of a detailed history. Genital bleeding is usually considered as an acute sign, related to a trauma that occurred shortly before its appearance. We report a case of a 34-month-old child who was referred to the emergency room with a significant vaginal hemorrhage, originating from a wide laceration of the posterior fourchette, and a negative history for accidental trauma. The characteristics of the lesion, compared to the temporal evolution of the healing process, and the witnesses' depositions led us to assume that the time elapsed between the abusive event and the physical examination was longer in respect to what had appeared at the first sight. The judicial reconstruction of the events confirmed our assumption, allowing the charge of the right abuse perpetrator. As the literature regarding this eventuality is very poor, we report this case to stress the importance for physicians to consider that an active bleeding may be the manifestation of a trauma that occurred very long before.