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Clinical Summary

Urethral prolapse is a condition that only occurs in females, usually in school-aged children. Patients will present with painless bleeding and, on exam, will have what appears as swelling, but is actually the prolapsed portion of the urethra. Urethral prolapse is commonly mistaken for vaginal injury. The etiology is unknown, but estrogen deficiency is thought to be a contributing factor. Other risk factors include increased intra-abdominal pressure that results from coughing or constipation and anatomic defects. Urethral prolapse is more common in African American girls.

Lichen sclerosus et atrophicus (LSA) is found often in older women but occasionally in prepubertal girls. Findings include thin hypopigmented (as white or yellow plaques) and easily friable skin in the genital and anal areas that can bleed even without trauma; itching and pain can also occur. The hemorrhagic form of LSA includes subepithelial hemorrhagic lesions to the affected skin, which can be mistaken for trauma.

FIGURE 15.112

Urethral Prolapse. A round donut-shaped mass consistent with urethral prolapse is seen in this school-aged child. (Photo contributor: Cincinnati Children’s Hospital Medical Center.)

FIGURE 15.113

Lichen Sclerosus. This image shows both the hypopigmentation (white plaque area) and the multiple hemorrhagic areas characteristic of lichen sclerosus. (Photo contributor: Kathi L. Makoroff, MD.)

Management and Disposition

Medical treatment of urethral prolapse includes sitz bath and topical estrogen cream. A referral to urology should also be made, as well as reviewing with the family indications for emergent return including increased pain or bleeding, which are signs of strangulation. Surgical repair may be needed when conservative treatment fails or when the prolapse is necrotic.

FIGURE 15.114

Lichen Sclerosus. This close-up image shows the hypopigmentation (white plaque area) and the differentiation between it and the surrounding normal skin. (Photo contributor: Cincinnati Children’s Hospital Medical Center.)

FIGURE 15.115

Lichen Sclerosus. Hemorrhagic lichen sclerosus atrophicus. The perineum surrounding the vagina and anus is hypopigmented in an hourglass configuration. The hemorrhagic lesions are not traumatic in etiology. (Photo contributor: Cincinnati Children’s Hospital Medical Center.)

Treatment of LSA consists of high-potency corticosteroids and referral to dermatology or pediatric gynecology.

Pearls

  1. Urethral prolapse often presents with painless bleeding in school-aged girls.

  2. The hemorrhagic form of LSA can be mistaken for trauma; surrounding hypopigmented skin is the clue to the diagnosis.

  3. Estrogen cream (Premarin) can be prescribed and applied gently over the adhesions twice daily for 2 to 4 weeks. Recurrence is common.

  4. Labial adhesions may be mistaken for scars, and dehiscence from labial separation during the medical examination ...

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