Urethral prolapse is a pathological condition characterized by the exit of a fold of the mucous membrane from the opening of the urethra. Symptoms of pathology are disorders of urination (difficulty or, conversely, incontinence), the presence of a visible formation protruding from the urethra, rarely – hematuria. Diagnosis is made on the basis of general examination data, additionally urethrocystoscopy is used, the study of the anamnesis of life. In the course of treatment, catheterization and surgical techniques are used, auxiliary therapy includes hormonal and antimicrobial agents.
Meaning
Urethral prolapse, or urethral mucosal prolapse, is almost exclusively a female disease caused by a number of anatomical features of the genitourinary system. There are two age peaks of this condition – the prepubescent period (up to 14-15 years) and the menopausal age (45-55 years). About 80% of all cases of pathology are registered in girls and women of these age groups. This is due to the hormonal characteristics of the female body in these periods of life and the influence of endocrine indicators on the functioning of the genitourinary system. Exact statistics regarding urethral prolapse are unknown.
Causes
The immediate cause of urethral prolapse is the omission (ptosis) of the bladder against the background of increased looseness of the amniotic fatty tissue and the submucosal layer of the urethra. Such disorders occur when the hormonal background changes caused by the processes of puberty, pregnancy or menopause. Anatomical features of the genitourinary system in women – increased width and reduced length of the urethra compared to the male urethra – also contribute to the development of prolapse. There are a number of predisposing factors, the presence of which significantly increases the risk of pathology:
- Injuries of the urethra. Traumatization of the urethra can reduce the adhesion of the mucous layer to the underlying tissues and facilitate the process of exiting in the form of a fold to the outside. Injuries can be inflicted as a result of medical manipulations (cystoscopy, catheterization), concretion (with urolithiasis), very rarely – during sexual intercourse.
- Multiple births. The repeated process of childbirth contributes to the development of pathology through several mechanisms at once. Pregnancy changes the hormonal background that affects the state of the genitourinary system, the birth of a child can injure the urethra and significantly increases intra-abdominal pressure, which also contributes to loss.
- Chronic constipation. It is statistically determined that approximately 40% of women with this condition have a history of episodes of prolonged constipation. The occurrence of urethral prolapse is caused by overflow of the large intestine and a sudden change in intra-abdominal pressure during attempts to defecate.
- Heavy physical activity. In the presence of certain predisposing factors (looseness of the submucosal layer), it is possible that the mucous membrane of the urethra may fall out under the influence of physical exertion. They increase intra-abdominal pressure, “pushing out” tissues in weakened areas.
- Chronic inflammatory processes. Urethritis and cystitis are accompanied by tissue edema, their infiltration by immunocompetent cells and therefore weaken the connection of the mucous layer with the underlying membranes. Tissues acquire pathological mobility, which in certain conditions can lead to loss.
Pathogenesis
The pathological condition is based on a number of factors that lead to a weakening of the connection of the mucosa with the submucosal plate of the urethra. In most cases, the cause is a violation of the hormonal background – a lack or sharp changes in the level of estrogen, which is observed in adolescents and during menopause. Hormones have a complex effect on the processes of blood circulation and the functioning of the female genitourinary system, fluctuations in their number lead to an increase in the mobility of the urethral mucosa. Increased intra-abdominal pressure (as a result of physical exertion), pelvic injuries, congenital weakness of the ligamentous apparatus also contribute to the exit of the mucosa from the lumen of the urethra.
In the process of falling out, the end sections of the mucosa form a fold, which actually comes out. An atypical position, combined with the pressure exerted by the edges of the hole, disrupts the blood supply processes in the tissues. Venous stagnation is formed, due to which the fold acquires a bluish hue and swells, which further complicates blood circulation. This is accompanied by soreness, irritation of the nerve endings of the urethra, and causes frequent urge to urinate. In some situations, swelling of a fragment of the urethra leads to a difficult outflow of urine and reflux of fluid back into the bladder. The risk of infection of the urethra, bladder, kidney pelvis increases.
Classification
There are several clinical varieties of urethral prolapse, which differ in the pathanatomic picture and the age of the pathology. The need to identify individual types of the disease is due to different approaches to treatment, different prognostic prospects and other circumstances. In this regard, two parallel classification systems have been developed in modern urology, which divide all cases of this condition into several forms. According to the clinical picture , there are two main types of pathology:
- Segmental prolapse. The mucosal fold is represented only by a segment or one side of the urethra. It proceeds with less pronounced manifestations – moderate or absent soreness, there are no violations of urine outflow. In some cases, this type of condition can spontaneously heal.
- Circular prolapse. The entire circumference of the urethral mucosa is exposed to prolapse. It is considered a form of pathology with a more serious course. It may be accompanied by severe pain and severe edema with impaired urine outflow. It is often a concomitant sign of such pathology as bladder prolapse.
Another classification of urethral prolapse was developed taking into account the age of patients, more precisely, the age characteristics of their genitourinary system. The type of complex of therapeutic measures depends on the type of pathology, the choice of a conservative or surgical method of eliminating the condition, recommendations for preventing relapse. Also, different (according to this classification system) types of pathology have different etiology, which leaves its mark on the prognosis of the disease. According to this scheme , the following types of loss are distinguished:
- Prepubescent form. Occurs in girls under 15 years of age, the main causes of development are congenital features of the genitourinary organs, hormonal instability during puberty. It responds well to conservative treatment, there is a risk of relapse during pregnancy.
- Postmenopausal form. It is registered mainly in women over 40-50 years old, due to a sharp decrease in the functioning of the ovaries and a drop in estrogen levels. It is eliminated with varying success by conservative methods, surgical correction is often required.
- Paradoxical form. It can develop at any age under the influence of various factors – pregnancy, physical exertion, injuries, operations on the organs of the genitourinary system. Treatment methods are determined by the severity of pathology and the presence of concomitant diseases.
Symptoms
The severity of manifestations in urethral prolapse may vary, depending on the type of pathology (segmental or circular prolapse), the volume of tissues released into the external environment and a number of other factors. Most women note the feeling of a foreign object in the area of the urethra outlet, which is replaced by a feeling of soreness and burning. When feeling and examining the genitals in the area of the opening of the urethra, a dense pink or cyanotic formation is found, painful when touched. Edematous phenomena can also spread to the genitals – the labia minora and the frenulum of the clitoris increase, their redness is observed, unpleasant sensations occur when walking.
Disorders of urination with urethral prolapse are quite diverse. Complaints of frequent and painful urges to empty the bladder (imperative or imperative urges) are often noted. A number of women may experience urinary incontinence, which is expressed in the release of small amounts of fluid during sleep or the inability to delay urination when the urge to it. In severe cases, mucosal edema can lead to a violation of the outflow of urine and its acute delay (ischuria), an admixture of blood is found in the urine. Sometimes bloody discharge from the urethra (urethrorrhagia) can be noted without urination – with palpation of the genitals, in the form of stains on underwear or hygiene products.
Complications
The most common complication of urethral prolapse is the development of inflammatory diseases of the urinary tract – urethritis and cystitis, which can be complicated by other, more serious pathologies (pyelonephritis). Infection occurs due to circulatory disorders in the genitourinary system and urodynamic disorders that contribute to the penetration of pathogens. Severe and frequent bleeding from the pinched area of the shell, which can cause anemia, is rarely observed. Prolapse sometimes becomes a manifestation of more serious internal pathological processes (for example, ptosis or omission of the bladder), therefore, in the presence of such a condition, a complete examination of the genitourinary system is necessary.
Diagnostics
In urological and gynecological practice, determining the urethral prolapse is usually not particularly difficult due to the severity of symptoms and the specificity of the clinical picture. The diagnosis and treatment of the condition is handled by a urologist or gynecologist, sometimes in cooperation with surgeons and endocrinologists. The diagnosis is based on a number of factors – the picture of gynecological examination and endoscopic examinations, the study of age and anatomical features of the patient, laboratory tests. Most often , the urethral prolapse is determined by the following algorithm:
- Survey and general inspection. The specialist analyzes complaints (soreness in the genital area, urination disorders), finds out their duration, conditions of occurrence. When examined in the area of the opening of the urethra, an elastic dense swelling of the mucous membrane is determined, often edematous and bluish in color, the swelling also extends to the area of the labia minora. Sometimes spotting is possible, which increases when touched or pressed.
- Endoscopic examinations. Urethrocystoscopy allows you to determine the localization of the lesion (in case of prolapse – the terminal parts of the urethra) and the safety of the patency of the urethra. As an alternative to urinary retention, therapeutic and diagnostic catheterization is used.
- Laboratory tests. A general urinalysis can detect macrohematuria caused (by microscopic examination) by the presence of unchanged red blood cells. Changes in the blood are not detected, with the addition of urinary tract infection, nonspecific signs of inflammation are possible, with chronic urethrorrhagia – anemia. A blood test for the level of female sex hormones sometimes confirms a decrease in estrogen, which indirectly indicates the possibility of prolapse.
In many cases, an examination and questioning of the patient is enough to make a diagnosis, other methods of determining the condition are mainly aimed at identifying its causes and possible complications, conducting differential diagnosis. The latter is carried out with neoplastic processes in the urethra (papillomas, tumors), bladder prolapse and prolapse of the urethra (PMK). PMK differs from urethral prolapse by exiting through the opening of all layers of the urethra, which leads to more severe circulatory disorders, pronounced symptoms and often requires surgical treatment.
Treatment
Therapeutic measures for prolapse are quite diverse, including both conservative methods of local and general nature, and surgical interventions. The choice of treatment regimen depends on the causes of the disease, its severity, the presence or absence of concomitant pathologies and other circumstances. An important role is played by auxiliary therapy aimed at preventing infectious complications, reducing the risk of recurrence of this condition. In general, the treatment of hair loss includes the following techniques:
- Conservative events. They suggest the use of warm sedentary baths with herbal extracts and some medications, the purpose of which is to reduce the severity of edematous phenomena. Such therapy can be used both in isolation (in mild uncomplicated cases of prolapse) and as a preparatory stage for other methods.
- Installation of a catheter. Catheterization of the bladder is used not only to facilitate the outflow of urine or reduce urodynamic disorders, but also as a method of “correcting” the fallen fold and fixing the mucosa. Catheterization for 10-12 days has proved effective in this condition, is an alternative to surgical intervention.
- Surgical treatment. In severe and recurrent cases of prolapse, severe bleeding from the urethra, surgical intervention is indicated. Depending on the situation, it can be reduced to strengthening the urethra (sling urethropexy TVT, TVT-O), tightening of the mucous membrane (plication) or excision of the tissue area that has gone beyond the urethra (resection of the mucosa). Sometimes the operation can be complex – for example, it can be performed simultaneously with the elimination of bladder ptosis.
Auxiliary therapy in the presence of urethral prolapse includes the use of antibacterial agents (for the treatment and prevention of infectious complications), general winter activities, gymnastics to strengthen the muscular fixation of the organs of the genitourinary system. If the cause of the pathology is hormonal disorders (estrogen deficiency), then drugs are prescribed under the supervision of an endocrinologist to eliminate them. Local use of estrogen-containing agents in the form of vaginal suppositories and ointments shows good results.
Prognosis and prevention
The prognosis of loss of the urethral mucosa is usually favorable, this condition rarely leads to serious and life-threatening complications. With timely treatment, prolapse is eliminated quickly enough, does not have time to lead to problems such as difficulty in urine outflow or anemia due to chronic bleeding from the urethra. Prepubertal forms of pathology are the basis for more careful monitoring of the state of the genitourinary system during pregnancy, since during this period there is a high risk of relapse. Prevention of prolapse is reduced to general therapeutic recommendations – timely treatment of urinary tract infections, body weight control, exclusion of excessive physical exertion, active lifestyle.