Urethrocele – Causes, Symptoms, Treatment

A ureterocele is defined as cystic dilatation of terminal ureter with associated tissue defect in the urinary bladder, bladder neck, or even extending into the posterior urethra. It is usually associated with variable degrees of bladder muscle defect and renal? parenchymal abnormality.

A urethrocele is the prolapse 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.^[rx][rx] Urethroceles often occur with cystoceles (involving the urinary bladder as well as the urethra).^[rx] In this case, the term used is cystourethrocele.^[rx][rx]

A ureterocele is a congenital? abnormality with cystic dilatation of the lower part of the ureter, often associated with other anomalies like a stenotic ureteric orifice or a duplicated system along with other clinical sequelae. They could lead to various effects with regard to obstruction, reflux, continence, and renal? function [^rx]. Ureteroceles may be intravesical (orthotopic) or extravesical (ectopic) [^rx].

Types

Urethral prolapse is classified by the severity of the protrusion:

• The first-degree prolapse means the urethra is mildly pushing against the vaginal walls or slightly dropped toward the urethral opening.
• Second-degree prolapse typically means the urethra extends to the vaginal or urethral opening, or the vaginal walls have collapsed somewhat.
• Third-degree prolapse means the organs bulge outside of the vaginal or urethral opening.

What Are the Stages of a 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.

Causes of Urethrocele

Urethroceles can often result as a result of damage to the supporting structures of the pelvic floor. Urethroceles can form after treatment for gynecological cancers.^[rx] Urethroceles are often caused by childbirth, the movement of the baby through the vagina causing damage to the surrounding tissues.^[rx] When they occur in women who have never had children, they may be the result of a congenital? weakness? in the tissues of the pelvic floor.^[rx]

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 smokers 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 exercise 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 tumour somewhere in your pelvis can add weight to the area and weaken the pelvic floor muscles.

Symptoms of Urethrocele

There are often no symptoms associated with a urethrocele.^[rx] When present, symptoms include stress incontinence, increased urinary frequency, and urinary retention (difficulty in emptying the bladder).^[rx][rx] Pain? during sexual intercourse may also occur.^[rx]

• vaginal or vulvar irritation
• a feeling of fullness or pressure in the pelvic and vaginal area
• aching discomfort in the pelvic area
• urinary problems, such as stress incontinence, being unable to empty the bladder, and frequent urination
• painful sex
• organs bulging out of the vaginal or urethral opening

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

Diagnosis? of Urethrocele

• Voiding-cystourethrography (VCUG) – We performed VCUG in 14 patients and VUR was diagnosed in 4 (33%). One patient had Grade 1 and three patients had Grade 2 VUR. VCUG revealed ureterocele in four patients, and one patient was misdiagnosed as ‘bladder diverticulum. Four patients showed normal images in VCUG.
• Ultrasonography (US) – Ureterocele was defined by the US as showing a cystic ulcer?. সহজ বাংলা: শরীরের অস্বাভাবিক দাগ, ক্ষত বা ফোলা অংশ।" data-rx-term="lesion" data-rx-definition="A lesion is an abnormal area of tissue such as a spot, wound, patch, lump, or ulcer. সহজ বাংলা: শরীরের অস্বাভাবিক দাগ, ক্ষত বা ফোলা অংশ।">lesion? in the urinary bladder in 13 out of 17 patients. Dilated distal ureters were revealed by the US in 2 patients. Duplex systems were diagnosed in 5, and dilated urinary systems with varying degrees were detected in 15 patients. Ureterocele was incorrectly diagnosed with the US as ‘bladder diverticulum’ in one patient.
• Intravenous urography (IVU) – IVU showed ureterocele in 8 of the 12 patients. Duplex systems were found in 5 patients. Nine patients had dilated urinary systems. Remarkable upper pole dysfunction was shown in one patient by this method. The patient was treated by endoscopic incision.
• Ureterocele-urinary system interaction – In general, 15 out of 19 patients were ascertained as having varying degrees of dilated urinary systems-either unilateral or bilateral-depending on the radiological diagnostic methods.
• Dimercaptosuccinic acid scintigraphy (DMSA) – Ipsilaterally localized? renal? scarring and non-functioning upper pole images were taken in 7 of the 13 patients.
• Computed tomography – and MAG ₃ scintigraphy were used in one of our patients for diagnosis?: Differential diagnosis is a list of possible conditions that may explain symptoms. সহজ বাংলা: একই লক্ষণের সম্ভাব্য রোগের তালিকা।" data-rx-term="differential diagnosis" data-rx-definition="Differential diagnosis is a list of possible conditions that may explain symptoms. সহজ বাংলা: একই লক্ষণের সম্ভাব্য রোগের তালিকা।">differential diagnosis? of hydronephrotic mass and obstruction.
• Cystoscopy – was used for complementary diagnostic reasons in patients who underwent open surgery and for all patients who were endoscopically treated.

Treatment of Urethrocele

Nonsurgical treatment

• Pessaries – These silicone devices sit in the vaginal canal and help maintain its structure. Pessaries come in many sizes and shapes. Your doctor will place it in your vaginal canal. It’s an easy, noninvasive option, so doctors often recommend trying a pessary before other treatments.
• Topical hormones – Estrogen creams can supply some of the missing hormones to the weakened tissues to help bolster their strength.
• Pelvic floor exercises – Pelvic floor exercises, also called Kegel exercises, help you tone the organs in your pelvis. Imagine you’re trying to hold an object in place with your vaginal canal, and tightly contract for 1 to 2 seconds. Then relax for 10 seconds. Repeat this 10 times, and do this several times a day.
• Kegel exercises – These are also known as pelvic floor exercises. You can do them quickly and easily, at any time of day as no one will know you’re doing them. They help to strengthen the pelvic floor muscles. You can make them even more effective by using a Kegel8 Ultra 20 Pelvic Toner.
• 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.
• 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.
• Lifestyle changes – Maintain a healthy weight and avoid constipation?, heavy lifting, and prolonged coughing. Obesity can weaken muscles, so losing weight is a good way to help reduce pressure. Likewise, treating any underlying medical conditions that might be impacting your pelvic floor muscles will help eliminate stress. Try to avoid lifting heavy objects too. The tendon?. সহজ বাংলা: মাংসপেশি/টেনডনে টান।" data-rx-term="strain" data-rx-definition="A strain is injury to a muscle or tendon. সহজ বাংলা: মাংসপেশি/টেনডনে টান।">strain? can cause organs to prolapse.
• 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.
• 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 Can I Prevent a Urethrocele?

No matter how old (or young) you are, it’s never too early or too late to take your pelvic floor muscles into account. Keeping them strong means you’re less likely to experience a pelvic organ prolapse of any kind:

• Kegel exercises – These are also known as pelvic floor exercises. You can do them quickly and easily, at any time of day as no one will know you’re doing them. They help to strengthen the pelvic floor muscles. You can make them even more effective by using a Kegel8 Ultra 20 Pelvic Toner.
• 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.

Even if you’re young, of a healthy weight, and have no plans to have a baby any time soon, these steps are still worth taking as preventative measures.

References