Case report. Successful conservative treatment in a symptomatic postmenopausal woman with a urethral prolapse

A 75 years old female presented at the department of Urology with vaginal bleeding, urinary tract symptoms and a protruding mass. Pelvic examination showed a urethral prolapse. There was no recurrence of the urethral prolapse after a combination of manual reduction, a pessary, a transurethral catheter for 10 days and estrogen cream for three months. Literature describes some cases concerning conservative treatment in women with symptomatic urethral prolapse. The best reasonable treatment option for this group of women would be surgical excision. This case report shows a symptomatic urethral prolapse in a post-menopausal woman with good results after non-surgical treatment, a combination of manual reduction, a transurethral catheter and a pessary, with a follow up of eight months.

Trefwoorden Urethraprolaps · Urethrale massa · Conservatieve behandeling · Menopauze Case A 75 years old female presented with vaginal bleeding, urinary tract symptoms and a protruding mass. Obstetric history included two vaginal deliveries. Medical history showed non-small cell lung cancer for which she had a recent bilobectomy and adjuvant chemotherapy. Other than that she uses statins for hypercholesterolemia. Pelvic examination showed an impressive circular purple protruding mass located at the introitus, greater than three centimeters (Figs. 1 and 2).
Before coming to the urologist, she already tried sitz bath three times a day and used estrogen cream at the mass, both of which were not effective. The prolapse was placed into its natural position after manual reduction. With this movement the prolapse was placed behind the external sphincter. After 10 minutes of reduction the protruding mass had completely disappeared.
Four days later the urethral prolapse appeared again. After 20 minutes of manual reduction the prolapse was back in its position. A regular tampon was placed to support the urethra and the trigone. With this tampon in situ, the patient was not able to pass urine, so she removed it by herself after which the prolapse returned. A transurethral catheter was placed, which was only temporarily effective. The catheter showed the circular eversion of the distal urethra (Fig. 3).
At last a successful combination was found: manual reduction, a pessary placed by the gynecologist, 10 days of transurethral catheter and three months of estrogen cream (Figs. 3 and 4). There was no recurrence of the urethral prolapse after removal of the transurethral catheter, the pessary stayed in situ. There was no residue after miction.
After the follow up of eight months, there was still no recurrence of urethral prolapse.

Discussion
Urethral prolapse is a rare condition that involves circular, so both anterior and posterior, eversion of mucous membrane of the distal urethra. The condition is often misdiagnosed as urethral caruncle, which  is a benign outgrowth at the urethral meatus and do not encircle the entire urethra [1]. Urethral prolapse is most seen in young girls and postmenopausal women, and is often presenting itself asymptomatic. When manifestations are present, they would be vaginal bleeding, urine retention, pain, hematuria and/or dysuria. Complications would be thrombosis of the urethral prolapse [1]. Treatment options are conservative or surgical. Conservative treatments can involve sitz baths, estrogen cream and manual reduction.
In literature, several cases are discussed, but there is a lack of large series of randomized controlled trials with great numbers. The majority of cases describe a successful result after surgical treatment, which means resection of the prolapsed mucosa or the fourquadrant excisional technique [1]. A Japanese study describes a higher treatment failure in the non-surgical treatment (81%, 25/31 patients) in comparison to the surgical treatment group. A big limitation of this study is the fact that topical estrogen cream was only available in 20% of the non-surgical cases [2]. Only a few cases describe the results of conservative treatment, with recurrence being the major disadvantage [3].
The aim of this case report is showing a successful result after conservative treatment. We noticed that manual reduction alone was not effective for more than a couple of days. Usually the protruding mass appeared after micturation, therefore the transurethral catheter was placed for 10 days. The addition of placing the pessary, in consultation with the gynecologist, was to counter the prolapse of the anterior and posterior wall. In the eight months of follow up time, no recurrence was seen while the pessary was still in situ.

Declarations
Conflict of interest M.T.A. Vreeburg and J. Wiltink declare that they have no competing interests.

Ethical standards
For this article no studies with human participants or animals were performed by any of the authors. All studies mentioned were in accordance with the ethical stan-dards indicated in each case. For images or other information within the manuscript which identify patients, consent was obtained from them and/or their legal guardians.
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