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An 8-year-old Caucasian girl was referred with perineal bleeding of sudden onset during micturition. There was no history of trauma, fever or dysuria, but she had a history of constipation. Family history was unremarkable. Physical examination showed a prepubertal girl with a red ‘doughnut’-shaped lesion surrounding the urethral meatus (figure 1). Laboratory findings, including platelet count and coagulation, were normal. A vaginoscopy, performed using sedation, was negative. Swabs tested negative for sexually transmitted pathogens. A diagnosis of urethral prolapse (UP) was made on clinical appearance. Treatment with topical oestrogen cream was started and constipation treated with oral polyethylene glycol. On day 10, the bleeding stopped, and at week 5 there was a moderate regression of the UP. However, occasional mild bleeding persisted at 10 months, so she was referred to a urologist (figure 2).
UP is an eversion of the distal urethral mucosa through the external meatus. It is most commonly seen in postmenopausal women and is uncommon in prepubertal girls.1 UP is rare in Caucasian children and more common in patients of African descent.1 ,2 It may be asymptomatic or present with bleeding, spotting or urinary symptoms.2 The exact pathophysiological process of UP is unknown. Increased intra-abdominal pressure with straining, inadequate periurethral supporting tissue, neuromuscular dysfunction and a relative oestrogen deficiency are possible predisposing factors.2
Differential diagnoses include ureterocele, polyps, tumours and non-accidental injury.2 ,3 Management options include conservative treatments such as tepid water baths and topical oestrogens. Surgery is indicated if bleeding, dysuria or pain persist.4 ,5
Vaginoscopy in this case was possibly unnecessary, as there were no signs of trauma to the perineal area or other concerning signs or history of abuse.
In the presence of typical UP, invasive diagnostic procedures should not be considered as first-line investigations and they should be reserved for cases of diagnostic uncertainty.
Contributors AL, FS, EB, AT and AV: Conception or design of the work, data collection, data analysis and interpretation. AL: Drafting the article. EB and AV: Critical revision of the article and final approval of the version to be published.
Competing interests None.
Patient consent Parental/guardian consent obtained.
Provenance and peer review Not commissioned; externally peer reviewed.