Urethrocele

Urethrocele

A urethrocele is a type of pelvic organ prolapse where the female urethra bulges or herniates into the vaginal wall due to loss of support from the pelvic floor. It often occurs together with a cystocele (bladder prolapse) and the highest prevalence is seen in women with history of vaginal delivery, pelvic floor weakness or repeated straining. 

Urethrocele Meaning

Urethrocele is when the urethra abnormally descends into the vaginal canal due to our underlying vaginal tissues that normally support the urethra weakening. This causes difficulty in urinary flow and deficiency in urinary control.

Urethrocele symptoms

A urethrocele produces symptoms the urge to urinate frequently and the feeling of pelvic pressure as the urethra loses its normal support and protrudes into the vaginal wall. 

Typical Signs and Symptoms

Pressure in the vagina or feeling of vaginal heaviness

• Sense that something is “dropping down” inside the vagina.

Urinary incontinence 

• Urine leakage 

Trouble starting urination

• True or false hesitations Delay or hesitation before the flow of urine starts.

Sluggish or diminished urine output

• The flow can be decreased or discontinuous.

Frequent urination

• Having to urinate more frequently than normal. 

Urgency

• Strong desire to pass urine 

Feeling of incomplete emptying

• Feeling that the bladder has not been completely emptied after urination. 

Recurrent urinary tract infections 

• Due to bladder emptying

Visible/Physical Symptoms

Protrusion in the vaginal wall

• A soft bulge can be touched and seen from inside the vagina. 

Pain during sexual activity

• Loosening of the vagina or vaginal pressure can lead to dyspareunia.

Less Common Symptoms 

• Pelvic/back discomfort
• Problems with tampon insertion
• Vaginal dryness (particularly in postmenopausal women) 

Urethrocele treatment

The treatment varies on the level of prolapse, symptoms, age of the patients and pregnancy intentions in the future. There are options ranging from non-operative management to operative repair.

Non-Surgical Treatments

Pelvic Floor Exercises

• Makes the muscles holding the urethra strong.
• Urgent in mild urethrocele and stress urinary incontinence.
• Better performed with the help of a pelvic floor therapist.

Vaginal Pessary

• A silicone plug that is incorporated into the vagina to sustain the urethra.

Useful in women who:

• Want to avoid surgery
• Are elderly
• Unable to be anesthetized due to medical reasons.
• Newly acquired postpartum prolapse.
• Provides a quick solution to pressure and urinary leakage.

Estrogens for topical use (Post-Menopausal Women)

• It increases the strength and elasticity of vaginal tissue.
• It helps relieve symptoms and increases pelvic floor therapy effectiveness.

Lifestyle Modifications 

• Weight reduction
• Avoid heavy lifting
• Treat chronic cough
• Solve constipation (do not strain)

Medical Treatment

• (Not a cure, but supportive therapies)
• Anticholinergics (if urgency or overactive bladder symptoms present). 
• Prophylaxis of UTI in women with recurrent infections.

Surgical Treatments

• Is recommended for moderate to severe urethrocele, or when symptoms interfere with daily life.

Anterior Colporrhaphy 

• Pulling of pubocervical fascia (supportive tissue under urethra).
• The majority of surgery of urethrocele.

Urethral Sling Procedures

• Indications In case of urethrocele with stress urinary incontinence (SUI).

Types include:

• Mid-urethral sling
• Pubovaginal sling
• These steps will give extra assistance to avoid urine leakage.
• Urethropexy
• Surgical suspension in order to reposition and support the urethra.
• Not much used nowadays but can work in few cases.

Urethrocele surgery

The surgery of urethrocele is carried out to restore the urethra to provide support, correct the prolapse, and alleviate the symptoms that include urinary leakage, frequent urination, and vaginal pressure. It is prescribed typically with prolapse of moderate to severe intensity or when the conservative methods have not been effective.

Surgery types of Urethrocele

Anterior Colporrhaphy (Vaginal Wall Repair -Most Common)

• It is the conventional surgery of urethrocele.

What is done?

• The surgeon cuts the anterior wall.
• The elongated or ruptured pubocervical fascia is pulled and healed.
• The urethra becomes normally supported and positioned.
• Absorbable stitches are used to close vaginal wall.

Best for:

• Vaginal-wall laxity urethrocele.
• Prolapse grade 1 to 2

Mid urethral Sling Surgery (TVT/TOT)

• Performed for urethrocele with stress urinary incontinence (SUI). 

What is done?

• A sling (mesh tape) is positioned under the mid-urethra.
• It works like a sling or hammock to stop urine leaking when you cough, laugh or pick things up. 

Types:

• Tension free Vaginal Tape – retropubic.
• Transobturator Tape - placed via the groin. 

Best for:

• Stress urinary incontinence + urethrocele.

Pubovaginal Sling (Self Tissue or Fascia)

• Applied at the case of inability to utilize synthetic mesh or in difficult situations.

What is done?

• A piece of your own tissue from the abdominal fascia or donor tissue is placed under the urethra. 
• Provides long-term support.

Urethropexy (Urethral Suspension ).

• Less commonly used today.

What is done?

• A urethra is fixed and elevated with the help of sutures to supporting ligaments or bone.
• Restores urethral position.

Surgery Procedure

• Anaesthesia: Spinal or general
• Route: Vaginal (most common) or laparoscopic for suspension procedures
• Duration: 30 to 60 minutes
• Length of stay in hospital: Day case or 1 day discharge day after surgery. 
• No external vaginal surgical scar.

Post-Urethrocele Recovery

First Week

• Mild pain and swelling
• Light bleeding or discharge
• Able to walk same day
• Avoid strenuous activity

4–6 Weeks

• No heavy lifting
• No sexual intercourse
• Do not strain or constipate.
• Slow progress in activity.

After 6 Weeks

• Majority of the patients resume normal lifestyle.
• Pelvic floor exercises can be re-introduced.

Success Rate

• Success of anterior colporrhaphy 80-90%.
• 85-95 percent success with sling at middle of the urethra (in case of incontinence)
• The long-term vaginal support and improvement of the urinary symptoms.

Urethrocele diagnosis

A urethrocele diagnosis is a mixture of physical examination, urinalyses and at times imaging to determine the extent of the prolapse and exclude other urinary issues.

Primary Diagnostic Method: Pelvic Examination

• This is the primary and the most significant method.

In the examination, the physician will:

• Examine the anterior vaginal wall in terms of bulging.
• Ask to cough or bear down to look at prolapse.
• Determine if the urethra descends into the vagina.
• Check for coexisting prolapse (cystocele, rectocele). 

This defines grade/severity:

• Grade 1: Mild urethral descent
• Grade 2: Urethra opening is at vaginal opening
• Grade 3: Urethra is protruded outside of the vaginal opening

Post-Void residual (PVR) urine test

• Amount of urine in the bladder after urination. 
• Identifies the difficulties of emptying the bladder due to urethrocele.

Done via:

• Ultrasound, or
• Catheter measurement.

Uroflowmetry

• Monitors urine flow rate and pattern.
• Useful in patients with weak stream, hesitancy or intermittent flow.
• Flattened flow curve indicates that it is affected by urethral obstruction or prolapse.

Urinalysis & Urine Culture

It is used to detect:

• UTIs
• Inflammation
• Changes attributable to urine stasis from urethrocele.

Pelvic Ultrasound

Not routinely required but may be utilised to:

• Assess the bladder and urethra
• Exclude other pelvic organ diseases
• Evaluate associated cystocele
• Transperineal ultrasound is effective in dynamically evaluation.

Cystourethroscopy (If Required)

A tiny camera is placed to see:

• Urethra
• Bladder
• Support of the vaginal wall

Used for:

• Ongoing urinary complaints
• Suspected strictures
• Blood in urine
• Get ready for surgery

Urodynamic Testing (Certain Cases)

Significant if:

• You have mixed urinary incontinence
• Symptoms are at variance with examination findings
• Considering surgery, but the diagnosis is unclear

Checks:

• Pressure within your bladder
• Function of your urethra
• Leakage patterns

Best hospital for urethrocele treatment India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Urethrocele is when the urethra drops through the vaginal wall due to a loss of support in the pelvic floor, causing urinary symptoms such as incontinence, weak stream, urgency, and pelvic pressure. Early diagnosis by pelvic examination and urinary investigations enables timely intervention. Mild symptoms generally improve with pelvic floor exercises, pessary and lifestyle changes, moderate to severe prolapse can require surgical correction such as anterior colporrhaphy or sling procedures. With treatment, most patients get excellent relief from their symptoms and improved quality of life.

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FAQ

1. Does urethrocele is harmful?

• Mild forms are harmless but can be uncomfortable. Severe cases may result in urinary retention, recurrent UTI's, and further prolapse.

2. Can urethrocele be treated without surgery?

• Yes. For mild prolapse: a combination of Kegel exercises, use of a pessary, topical estrogen, and lifestyle modifications can be very effective

3. When is surgery required?

• Surgery should be considered when the symptoms are moderate to severe, or when conservative management has no effect on the urinary symptoms or the prolapse.

4. What operations correct urethrocele?

• Common choices are anterior colporrhaphy, mid-urethral sling procedure (if stress incontinence is present) and urethropexy. 

5. Is the operation safe?

• Yes. Urethrocele surgery is highly successful (80–95%) and complications are rare in the hands of skilled surgeons.

6. Can an urethrocele return after treatment?

• Repetition may occur in 10-20% of cases over period of time, more so if strain on pelvic floor continues.