Prolapse Urethrocele – Causes, Symptoms, Treatment

A Prolapse Urethrocele is of the female urethra into the vagina. The weakening of the tissues that hold the urethra in place may cause it to protrude into the vagina. Urethroceles often occur with cystoceles (involving the urinary bladder as well as the urethra). In this case, the term used is cystourethrocele.

The urethra is the tube that takes urine from the bladder to the outside of the body. It is part of the group of organs that make up the female pelvic area. These organs are held in place by strong pelvic floor muscles. As these muscles weaken, due to menopause, pregnancy, and aging (among other factors), each organ is at risk of prolapsing and dropping down into the pelvic cavity. If this happens to the urethra, it’s called a urethrocele prolapse. During a urethrocele, the urethra widens and begins to curve downwards and press into the vaginal wall. This usually results in further pelvic organ prolapses, causing a noticeable and often painful bulge.

A urethrocele prolapse can be disruptive, embarrassing, and inconvenient, but it is treatable.

As with most medical problems, it’s important not to put off treatment. Allowing your prolapse to go untreated for a long period of time leads to weakened pelvic muscles and damage to associated nerves – increasing the risk of recurrence. So avoid unnecessary delays and speak to your doctor if you have any concerns.

Stages of Urethrocele Prolapse

As with most female pelvic organ prolapses, a urethrocele prolapse can occur in varying degrees of severity:

• Stage 1 – The urethra begins to press down against the upper wall of the vagina and protrudes into it only to a slight degree. Symptoms can be mild or even unnoticeable.
• Stage 2 – The urethra has prolapsed, or dropped down, far enough into the vagina that it reaches the opening of the vagina but is not visible. Symptoms will be moderately uncomfortable or inconvenient.
• Stage 3 – The urethra has prolapsed down far enough that it protrudes outside of the vaginal opening. Symptoms will be severe, and the urethra will be visible from the outside of the body.

Symptoms of  Urethrocele Prolapse

In the early stages of a urethrocele prolapse you may have no symptoms at all and it, therefore, may only be diagnosed during a routine examination, such as a smear test. But it is also possible to experience any or all of the following symptoms severely:

• a feeling of pressure inside the vagina, especially when sitting down
• a dragging feeling inside the vagina, and/or feeling that something is going to fall out
• noticeable red tissue protruding from the vagina
• discomfort or pain during sex
• persistent or frequent urinary tract infections (cystitis)
• urinary stress incontinence – the inability to hold in urine when you cough, sneeze, laugh, exercise or lift heavy objects
• urinary incontinence – a complete inability to hold in urine
• a frequent need to urinate
• an urgent need to urinate
• difficulty passing urine and completely emptying your bladder

With the number of different prolapse conditions and their close proximity to each other in the body, it can be difficult to know which symptoms point to which condition. Visiting your doctor to get a diagnosis is important and can help you decide which course of treatment is best for you.

Some symptoms are similar to those experienced with a urinary tract infection (cystitis), which can often occur at the same time as a urethrocele prolapse.

Causes of Urethrocele Prolapse

Each one of these factors increases your risk of experiencing a urethrocele, or other type or pelvic organ prolapse, as they all result in weakened pelvic floor muscles:

• Pregnancy – This is in part due to the extra weight that the baby adds to the pelvic area, which can weaken the pelvic floor muscles. It is also thought to be caused by pregnancy hormones allowing vaginal tissues to stretch beyond their rebound limits. Multiple pregnancies will further increase your risk.
• Childbirth – Again, around 50% of women who give birth vaginally will experience some level of prolapse. A large baby or a difficult birth where you’ve had to push a lot or forceps were used may increase your risk. More than one birth also increases your risk of experiencing a vaginal prolapse.
• Menopause – The change in hormones you experience during this time of your life, particularly the drop in estrogen, can cause your pelvic floor muscles to weaken. Effects can be worsened by the general loss of muscle tone associated with aging.
• Hysterectomy – A hysterectomy is the complete removal of the uterus and cervix. This surgery removes some of the strength of the pelvic area as the uterus is no longer there as support.
• Bodyweight – Being overweight or obese can increase your chances of suffering a pelvic organ prolapse due to the weight on your pelvic area.
• Constipation – Continued straining to pass a stool will put extra pressure on the pelvic floor and could cause it to weaken.
• Persistent coughing – Constant heavy coughing can add pressure to the pelvic floor. If you smoke and have a persistent smoker’s cough or if you have a lung condition that results in a cough, such as asthma or bronchitis, then you could be at a higher risk.
• Heavy lifting – Repetitive heavy lifting, and lifting incorrectly, increases the pressure put on the pelvic floor.
• Strenuous activity – Heavy, high impact exercises such as running or plyometric training (jump training) can cause the pelvic floor muscles to weaken.
• Previous pelvic surgeries – A previous vaginal prolapse surgery can weaken the pelvic floor muscles, and is likely to be part of the cause of any future pelvic organ prolapses.
• Pelvic conditions – Heavy fibroids or a tumor somewhere in your pelvis can add weight to the area and weaken the pelvic floor muscles.

Diagnosis of Prolapse Urethrocele

Medical history

A health care professional may ask about your

• symptoms, such as bulges or lumps in the vagina, pelvic pressure or heaviness, and urinary incontinence
• pregnancy and childbirth history
• current and past medical problems, including surgeries
• family history
• over-the-counter and prescription medicines
• bowel habits

History

Rectoceles have a broad range of symptoms. Some patients may present as asymptomatic while others may demonstrate a significant impact on the quality of life, including the following symptoms[rx]:

• Pelvic pain/pressure
• Posterior vaginal bulge
• Obstructive defecation
• Incomplete defecation
• Constipation
• Dyspareunia
• Erosions and bleeding of mucosa if there is tissue exposure to the outside environment

Physical Exam

A thorough examination will include a vaginal exam, rectal exam, abdominal exam, and focused neurological exam.

The focused neurological exam consists of levator ani muscle tone and contraction strength.

The vaginal exam can be evaluated using the Baden-Walker or POP-Q exam. The Baden-Walker system utilizes one measurement. The distance of the most distal portion of the prolapse from the hymen while the patient is completing the Valsalva maneuver.[rx]

Evaluation

• A pelvic exam – You may be examined while lying down and possibly while standing up. During the exam, your doctor looks for a tissue bulge in your vagina that indicates pelvic organ prolapse. You’ll likely be asked to bear down as if during a bowel movement to see how much that affects the degree of prolapse. To check the strength of your pelvic floor muscles, you’ll be asked to contact them, as if you’re trying to stop the stream of urine.
• Filling out a questionnaire – You may fill out a form that helps your doctor assess your medical history, the degree of your prolapse, and how much it affects your quality of life. This information also helps guide treatment decisions.
• Bladder and urine tests – If you have significant prolapse, you might be tested to see how well and completely your bladder empties. Your doctor might also run a test on a urine sample to look for signs of a bladder infection if it seems that you’re retaining more urine in your bladder than is normal after urinating.
• Urodynamics – Measures the bladder’s ability to hold and release urine.
• Cystoscopy (cystourethroscopy) – A long tube-like instrument is passed through the urethra to examine the bladder and urinary tract for malformations, blockages, tumors, or stone
• A special test – that can be done to confirm a rectocele is defecography. The patient will have a contrast medium instilled in the vagina, bladder, and rectum. Using a special commode, the patient will be instructed to defecate while the X-ray is taken. This test can be useful to determine the size of the rectocele, larger than 2 cm is considered abnormal.[rx]
• Urodynamic studies – can be helpful in patients with rectocele and complex voiding issues. If a patient is receiving surgery, it may be useful to determine if the patient has urinary incontinence with the prolapse reduced. If there is incontinence with reduction with prolapse, it may be helpful to include a procedure to prevent urinary incontinence in the plan.[rx]
• Pelvic floor strength test – During the pelvic examination, the doctor tests the strength of the pelvic floor, the sphincter muscles, and muscles and ligaments that support the vaginal walls, uterus, rectum, urethra, and bladder. Irregularities in this test can help diagnose vaginal prolapse and determine if kegel exercises would be helpful to the patient.
• Bladder function test – Otherwise known as urodynamics, bladder function tests determine the ability of the bladder to store and eliminate urine. This is measured in two ways. Uroflowmetry measures the volume and force of the urine stream. Cystometrogram is a procedure that fills the bladder with water via a catheter. Measurements of the volume are noted when the patient indicates the urgency of urination.

Another useful diagnostic tool for surgical planning is dynamic MRI (DMRI) which provides visualization of the rectocele and movements of the pelvic floor.[rx] DMRI is a valuable adjunct test when a patient’s symptoms are more significant than the physical examination findings suggest. Its use for preoperative planning has made it more widespread.[rx]

Treatments for Urethrocele Prolapse

If you’ve suffered a urethrocele prolapse, speak to your doctor about what treatments may work for you. There are numerous different urethrocele prolapse treatments that work and depend on your personal circumstances. Targeted pelvic floor muscle exercises are a popular choice for seeing a quick and effective improvement in mild to moderate prolapses.

Surgery is considered as an option only when symptoms are severe and cannot be treated through other means, as there is a risk of further damage in the case of complications. Non-surgical treatments are also preferred when future children are desired, which can reduce the success of previous surgical procedures:

• Kegel exercises – Performing daily pelvic floor exercises could be all you need to keep your urethrocele prolapse under control. Using an electronic pelvic toner such as the Kegel8 Ultra 20 Pelvic Toner will make them more beneficial.
• Lifestyle changes – Maintain a healthy weight and avoid constipation, heavy lifting and prolonged coughing.
• Wearing a vaginal pessary – A vaginal pessary will support even severe pelvic organ prolapses. It’s a small, usually silicone, device that is placed inside the vagina to help support the vaginal wall and prevent other pelvic organs from collapsing further into it. Different shapes and sizes of vaginal pessaries suit different shapes and sizes of women. Your doctor can help you find the right one and help you change the pessary every four to six months. This is commonly the favored treatment for those unable to undergo surgery due to medical conditions or those wishing to have children in the future.
• Maintain your weight – Making sure you stick to a healthy weight will put less pressure on your pelvic floor muscles, giving you more chance of keeping them strong. The National Institute for Heath and Care Excellence (NICE) recommends keeping your BMI under 30.
• Avoiding constipation – Eating a high fiber diet of fruits, vegetables, and wholegrain cereals will help your bowels stay regular, as will drinking plenty of water.
• Lift heavyweights (and children) safely – Lifting correctly will make all the difference to not only your back, but your pelvic area too. The National Health Service (NHS) suggest holding the load close to your waist and avoid bending your back.
• Avoid too much high impact exercise – High impact exercises are great for overall health. But if you’re worried about a prolapse, then gentler, lower impact exercise like swimming will be better.
• Treat that cough – Persistent heavy coughing can cause a weakening in the pelvic floor muscles that may not become apparent straight away. Get medical help for a cough that lasts longer than a week.
• Good posture – Make sure you have good posture, especially when seated – walk tall and sit tall with no slouching and adopt the BBC, Bum to the Back of the Chair, method.
• Estrogen cream – Oestrogen cream should be applied 2-3 times a day for a course of two weeks, directly to the prolapsed urethra. This treatment is not recommended if bleeding is occurring. In postmenopausal women, you may be prescribed a long term course of treatment following a urethrocele surgery.
• Antibiotics – The use of topical antibiotics is prescribed for complex situations and those where the infection is present. This treatment is not recommended if bleeding is occurring.
• Sitz bath – These hot saltwater baths can be purchased relativity cheaply. Used once or twice a day, they can reduce the discomfort for mild urethrocele prolapses.

In the circumstance of non-surgical treatments not fully relieving your symptoms and they remain severe, you may be advised to have a surgical intervention for your urethrocele prolapse. The surgery may be completed in conjunction with others, to repair all prolapses you are experiencing at once:

• Surgery – Surgery is usually the last resort and is used for women with severe urethral prolapses. The aim of the surgery is to remove tissue that is no longer functional and restore strength in the urethra. During surgery, usually through the vagina, but sometimes through the abdomen, your surgeon will lift the urethra back into place and remove part of the mucosa (mucous membrane) that covers the urethra. They will usually also add a few deep dissolvable surgical stitches to the vaginal wall to help strengthen it. It is important to note that surgery is unable to repair the pelvic floor muscles. You will need to perform pelvic floor exercises after your recovery to prevent the prolapse from returning.

How Long Does It Take to Recover from a Urethrocele Prolapse Surgery?

Most urethrocele surgeries are completed under general anesthetic and you will be able to leave the hospital the same day, with a catheter fitted. In the following two or three days, you will attend a post-operative appointment to remove the catheter, and can normally expect to be back to your usual self within four to six weeks.

Your doctor will book an appointment with you four or five weeks after the surgery. At this appointment, you may be prescribed antibiotics to treat any associated urinary tract infections. In some cases, the repair of a pelvic organ prolapse can uncover other related underlying conditions such as damage to the bladder or bowel. Your doctor will discuss whether these require further treatment following your recovery.

Following the recovery from a pelvic organ surgery, you may notice different or fewer sensations during sex. This can be improved by building pelvic floor / Kegel exercises, into your routine. A physiotherapist will be able to advise on the best pelvic floor exercises for you. There is also a small risk of urinary incontinence following surgery if the urethra was shortened.

What Is the Difference Between a Urethrocele and a Cystocele Prolapse?

A urethrocele is a prolapse of the urethra only. If the pelvic floor muscles weaken and allow the bladder to prolapse, then this is separately called a cystocele. Often, both a urethrocele and a cystocele occur at the same time and the prolapse is then called a cystourethrocele.

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