A rare case of urethral prolapse in a postmenopausal woman.

Green J, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-222182 Description We present the case of a 74-year-old postmenopausal woman presenting with a 5-day history of dysuria, pain, urinary frequency and urethral bleeding. Her previous medical history included hypertension. Obstetric history included one forceps delivery and one normal vaginal delivery. On examination, an irreducible urethral prolapse was noted with bleeding urethral mucosa (figure 1). Patient went to theatre; another attempt was made to reduce the prolapse which was unsuccessful. Cystoscopy was then used to examine the urethra and bladder which revealed evidence of cystitis. With the cystoscope in situ, manual reduction was possible. A 20 French urethral catheter was inserted and the urethral wall was buttressed with suture to maintain reduction. Patient was discharged with topical oestrogen cream and the catheter has since been removed without recurrence of prolapse. Urethral prolapse is a very rare condition with a bimodal age distribution most commonly occurring in prepubertal girls and postmenopausal women. The exact aetiology is unknown; however, several risk factors are postulated including hypermobility of the urethra and vaginal/urethral mucosal atrophy secondary to decreased oestrogen. Differential diagnoses include urethral caruncle, condyloma, prolapsing ureterocoele and rhabdomyosarcoma. A variety of different management approaches have been employed ranging from conservative treatment with topical oestrogen to multiple surgical techniques. The most commonly reported surgical technique involved excising the mucosal prolapse and suturing to the vaginal wall with a catheter in situ. The surgical technique reported in this case has not previously been described and may represent a novel treatment when faced with this rare condition.