the bladder through the mass can be performed to demonstrate the anatomic relationships safely and rapidly Urinalysis may show red blood cells and urine cultures are routinely sterile, though these tests may not be clinically indicated if the child otherwise looks well Urethral polyps, prolapsed ureterocele, sarcoma botryoides, and urethral carcinoma may be included in the differential diagnosis, but they are rare in children and lack the characteristically annular appearance of a urethral prolapse FIGURE 92.6 A : Urethral prolapse in a 6-year-old girl with “vaginal” bleeding The vaginal orifice cannot be seen B : The smooth doughnut shape and central lumen are characteristic features of a urethral prolapse, which if large or swollen, often conceals the vagina below it Management For the symptomatic patient with a small segment of prolapsed mucosa that is not necrotic, warm moist compresses or sitz baths, combined with a 2-week course of topical estrogen cream, may be prescribed Most patients treated in this way have improved within 10 to 14 days and remained normal thereafter, thus avoiding surgery Patients with dark-red or necrotic mucosa should be treated surgically within several days by reduction of the prolapse and/or excision of necrotic tissue After the diagnosis is confirmed by cystoscopy, the prolapse is excised and the cut edges are sutured together It is also important for the practitioner to address any precipitant related to the prolapse such as chronic constipation or other Valsalva-related intra-abdominal strain Manual separation of adhesions should be avoided Contraceptive Devices Background