In some tropical communities prolapse of the mucosa of the urethra is common in young girls between the age 6 months and 8 years. It usually causes no symptoms, but a child may have slight dysuria, or her mother may notice blood on her clothes. While most of her urethra remains in its normal place, its mucosa is gradually extruded at the external orifice to form a deep red or bluish tubular mass, which swells and becomes oedematous, and occasionally even gangrenous. You cannot replace her prolapsed urethral mucosa, so you have to excise it. Be careful to distinguish it from a schistosomal granuloma, or a venereal wart.
Fig. 20-3 PROLAPSE OF THE URETHRA. A, passing a suture through the prolapsed urethra. B, cutting the suture so as to make two separate sutures at either side. C, inserting further sutures as needed. After ''Bonney's Gynaecological Surgery', Figs. 92 to 94, Bailli[gr]ere Tindall, with kind permission.
PROLAPSE OF THE URETHRA is not as easy to treat as it looks, so refer the patient if you can.
Under ketamine, use a small sound to find her meatus in the prolapsed mass of tissue. Pass a catheter, withdraw it, and then replace this by fine artery forceps. Open the points slightly to distend her urethra. With the forceps as a guide, transfix it from side to side and then from front to back with strands of 3/0 catgut. Use a knife or scissors, or, better, diathermy, to cut off the mucosa distal to the point at which the sutures cross the lumen. Pull the strands of catgut down as two loops, cut them, and then tie each of the four pieces, so as to join the edge of her urethral mucosa to her skin. What little bleeding there is is usually controlled by the sutures.
Insert a Foley catheter for at least 24 hours. As soon as her bladder function is normal, she can go home. Warn her that her vulva will be sore for at least a week.