Urethral Prolapse: An Overlooked Diagnosis of Urogenital Bleeding in Pre-Menarcheal Girls
Article Outline
A healthy 2-1/2 year-old girl presented to the emergency department with genital bleeding, which began that morning. Her history revealed no trauma, no fever, and no dysuria. The parents were concerned that their child may have been sexually abused. The mother was of African origin, and the father was Caucasian. On physical examination, a 0.5-cm circumferential prolapse of the urethra was revealed (Figure). Bleeding of the protruding burgeon was triggered on application of sterile compresses. Results of a laboratory work-up were normal for both cellular blood count and routine coagulation tests. The child was discharged with treatment by promestriene, a topical estrogen cream, two times daily and sitz baths with camomile. On day 5, bleeding had stopped, and the urethral bourgeon had not progressed. The treatment was continued for 14 days, and the child was seen at week 6 with complete regression of the urethral bourgeon. To date, at 20 months of follow-up, there has been no relapse; however, this girl is being treated for theliarchy possibly related to estrogen treatment.
Figure.
Urethral prolapse.
Urethral prolapse occurs when the urethral mucosa protrudes spontaneously beyond the urethral meatus.1 The condition is most commonly seen in postmenopausal women. In prepubertal girls, the condition is uncommon. The presentation of urethral prolapse is primarily bleeding from the urogenital region, sometimes profusely, and it is rarely accompanied by other symptoms such as pain, dysuria, or urinary retention.2 The prolapse is a circular doughnut-shape protrusion of the mucosa at the urethral meatus between 0.5 cm and 3 cm in diameter. The exact pathophysiological process of this pathology is unknown. Potential causes have been proposed: inadequate periurethral supporting tissue, weakness of the submucosal tissue, increased intra-abdominal pressure (straining), and neuromuscular dysfunction.1 This arises before puberty, after menopause, or both, when estrogen levels are at their lowest. Medical treatment is mainly with sitz baths and local estrogen cream application.1 When the urethral prolapse fails to regress with this treatment, surgical resection of the mucosal edges may be necessary.3
It is important that the attending physician obtain a thorough history and identification on physical examination of a potential organic pathology.4 This requires physician awareness of the alternative diagnoses of urogenital bleeding (Table). There is a racial predilection of this lesion in children of African descent, and it is rarely seen in Caucasian children.2
Table. Principals causes of urogenital bleeding in childhood
| Traumatic | Accidental (foreign body or straddle injury) |
| Non-accidental (ritual excision) | |
| Child sexual abuse | |
| Infectious | Group A Beta-hemolytic streptococcus |
| Shigella species | |
| Enterobiasis (pin worm) | |
| Shistosomiasis | |
| Structural disorders | Condyloma |
| Polyp, cyst | |
| Vaginal/cervical prolapse | |
| Urethral prolapse | |
| Neoplastic/tumor/hematological | Sarcoma botryoides |
| Rhabdomyosarcoma | |
| Arteriovenous malformation | |
| Coagulation disorders | |
| Hormone-mediated | Precocious puberty of diverse origins |
| McCune-Albright syndrome | |
| Estrogen-secreting tumor |
Child abuse is a critical diagnosis to consider in the differential of urogenital bleeding in the pre-menarcheal infant and child.5 Because obtaining a detailed and accurate history in a very young child may be difficult, this diagnosis cannot always be excluded. Consequently, the stress and anxiety inflicted by the suspicion of child abuse are evident, and therefore it is important to avoid misdiagnosis. In most pediatric hospitals, child abuse and neglect teams have been created and are responsible for handling situations of child abuse.6 An extensive and thorough work-up is conducted, including police questioning during several periods with the parents and other adults in contact with the “victim,” separate questioning with the “victim,” and a complete gynecological examination, often under general anesthesia.
This case illustrates the importance of formal training of all resident physicians in the physical examination of the normal genital area in prepubertal infants and children and the physiological variants. This training will improve the recognition of organic pathology in the case of urogenital bleeding. It remains important to consider child abuse in the absence of an organic pathology.
References
- . Diagnosis and treatment of urethral prolapse in children: experience with 34 cases. Urology. 2009;73:1008–1011
- . Urethral prolapse in girls. Pediatr Surg Int. 1995;10:115–117
- . Diagnosis and treatment of urethral prolapse in children. Urology. 1999;54:1082–1084
- . Urethral prolapse: an often misdiagnosed cause of urogenital bleeding in girls. Pediatr Emerg Care. 1995;11:212–214
- . Prolapse of the urethra: confusion of clinical and anatomic characteristics with sexual abuse. Pediatrics. 1991;87:722–725
- . Medical evaluation of suspected child sexual abuse. J Pediatr Adolesc Gynecol. 2004;17:191–197
PII: S0022-3476(10)01044-9
doi:10.1016/j.jpeds.2010.11.050
© 2011 Mosby, Inc. All rights reserved.
