[Prolapse of the urethral mucosa in young girls from the Ivory Coast]

Conservative management of urethral prolapse in African girls: a report of 15 cases

Background

Urethral prolapse is a rare disease, mainly occurring in African prepubertal girls. Its etiology remains unclear; however, some risk factors have been reported. The diagnosis is made clinically. The treatment can be conservative or surgical.

Methods

We report our experience in the service of pediatric surgery at Albert Royer National Children’s Hospital Centre. We conducted a retrospective descriptive cross-sectional study, on which considered patients were managed for urethral prolapse in our service from 2014 to 2019.

Results

Our study has included 15 girls whose mean age was 4.08 years (1.17–10). Two risk factors (chronic cough and constipation) were found in 20%. Genital hemorrhage was the main symptom (73.3%), and suspicion of sexual abuse was documented in 13.3%. The clinical finding was classical (donut-shaped vulvar mass) in all patients. All patients underwent conservative management, which was successful in 73.3%. Patients with failed conservative management were treated surgically by resection of the prolapsed mucosa on a Foley catheter. No complication was reported after surgical treatment, and after a 13-month mean follow-up, no recurrence was reported in all patients.

Conclusions

Conservative management is an efficient option for urethral prolapse. It has the advantage of avoiding general anesthesia with its potential complications and restricted availability in sub-Saharan Africa. Surgical management should be reserved for failed conservative management.

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.

Urethral prolapse: contemporary report on a modified ligation over a urethral catheter treatment approach

Background

Most contemporary series on urethral prolapse report either on the use of excisional or conservative treatment approaches.

Objectives

To introduce a modified ligation over a Foley catheter treatment method for urethral prolapse that addresses most of the previously reported complications.

Patients and Methods

Five consecutive patients with urethral prolapse treated between 2003 and 2011, all using the ligation method on an outpatient basis were studied prospectively. Maintaining the inflated balloon of the Foley catheter with timed removal of the catheters among other modifications to the original technique is further described in the article. The main outcome measures were to evaluate for recurrence, post-operative appearance of the urethral orifice and satisfaction of parents. Secondarily the actions of the parents of the patients and those of the receiving physicians were also recorded.

Results

The mean age of the patients was 6 years old (ranging from 3 to 8 years). All parents suspected sexual molestation and in two cases, the suspected perpetrators were verbally threatened of dire consequences of their actions if proven. None of the receiving medical personnel were aware of this condition. Maximum length of catheterization was for 4 days. The post treatment urethral openings appeared normal and there were no complications.

Conclusions

The ligation method with attention to the modifications described further in the article is a simple, safe and cost effective option for the management of urethral prolapse.

Maintaining the inflated balloon of the Foley catheter with timed catheter removal especially adds predictability to this technique.

Lower genital tract lesions requiring surgical intervention in girls: perspective from a developing country

AIM

To determine the spectrum, outcome of treatment and the challenges of managing surgical lesions of lower genital tract in girls in a low-resource setting.

METHOD

Retrospective study of 87 girls aged 13-years and younger, with lower genital tract lesions managed between February 2002 and January 2007 at the University of Nigeria Teaching Hospital, Enugu, southeastern Nigeria. Clinical charts were reviewed to determine the types, management, outcome of treatment and management difficulties.

RESULTS

The median age at presentation was 1 year (range 2 days-13 years). Congenital lesions comprised 67.8% and acquired lesions 32.2%. The lesions included: masculinized external genitalia (24), vestibular fistula from anorectal malformation (23), post-circumcision labial fusion (12), post-circumcision vulval cyst (6), low vaginal malformations (6), labial adhesion (5), cloacal malformation (3), bifid clitoris (3) urethral prolapse (3), and acquired rectovaginal fistula (2). Seventy-eight (89.7%) had operative treatment. Procedure related complications occurred in 19 cases (24.4%) and consisted of surgical wound infection (13 cases), labial adhesion (4 cases) and urinary retention (2 cases). There was no mortality. Overall, 14 (16.1%) abandoned treatment at one stage or another. Challenges encountered in management were inadequate diagnostic facilities, poor multidisciplinary collaboration and poor patient follow up.

CONCLUSION

There is a wide spectrum of lower genital lesion among girls in our setting. Treatment of these lesions may be challenging, but the outcome in most cases is good. High incidence of post-circumcision complications and poor treatment compliance may require more efforts at public enlightenment.

Uro-genital bleeding in pre-menarcheal girls: dilemmas of child abuse

Uro-genital bleeding in pre-menarcheal girls always raises concerns regarding child abuse. There are serious social issues involved; however, before labeling it as sexual abuse, all efforts must be made to rule out an organic pathology. We recently encountered two young girls of Afro-Caribbean origin who presented with vaginal bleeding with concerns from referring physicians about child/sexual abuse. On examination both had a rare condition of urethral prolapse. One of them underwent four-quadrant excision and the other was treated conservatively with urethral catherization.

Vulvar and genital trauma in pediatric and adolescent gynecology

PURPOSE OF REVIEW

This review will look critically at recent research articles that pertain to children and adolescents who present with genital injuries.

RECENT FINDINGS

Many recently published articles have noted that the history as given by the child or adolescent is the most important factor in determining the etiology of genital injuries as abuse or accidental. The history is more important than any documented or lack of documented findings on physical examination. Distinguishing whether the injury was accidental or caused by abuse is of significance to the family and the injured child or adolescent. Genital examinations of victims of documented abuse are often normal. Examinations of pregnant adolescents may appear normal, the only evidence that intercourse has taken place being pregnancy. Documented accidental genital injuries are described; unfortunately such injuries can easily be confused with sexual abuse. Photographic documentation of injuries by colposcopic photography has allowed a new level of peer review, improving the understanding of what are normal and non-specific findings, many of which were considered to be abnormal in the past. The psychological impact of living in a violent, war-torn culture, or surviving a traumatic genital injury are reviewed. New ideas on the management of genital trauma are also reported.

SUMMARY

Increasingly, victims of sexual abuse are found to have normal examinations, and the victim's history becomes the most important determining factor. Peer review has led to a better understanding of the wide variations in the normal genital examination. Psychological support for these victims is important in the management of genital injuries.