History: A 6 ½ year old girl of Chinese parentage presented to the emergency department with a 3 day history of “per-vaginal” bleeding. She was previously well, being born at term and having had normal developmental milestones. She had no pain or itchiness. There was no dysuria, haematuria, incontinence, abdominal pain, fever or constipation. She had no constitutional symptoms. Bowel and urinary habits were normal. She denied any foul play or insertion of any foreign objects. She was in primary one when she was not in school she was taken care of fully by her mother.

Physical Examination: She was prepubertal with no secondary sexual characteristics. There was no abdominal or pelvic mass palpable. There was a doughnut shaped mass seen at the introitus. There was no active bleeding seen. Pelvic ultrasound was normal. It was unclear where the mass was coming from and she had an examination done under anaesthesia. The doughnut shaped mass seen at the urethra. There was blood staining on her underwear but there was no active bleeding. The vagina was seen and it was normal. There were no obvious signs of trauma.

Management: The diagnosis of urethral prolapse was made. She was started on topical oestrogen cream to be applied on the mass. She was also advised to use a salt bath daily for 10 minutes. She was seen again two weeks and 5 weeks later, at the Paediatric and Adolescent Gynaecology Clinic. She had no more bleeding and the mass had reduced significantly and almost disappeared. 

Discussion: Urethral prolapse is an uncommon cause for prepubertal “vaginal bleeding”. It has been reported to occur mainly in girls of African origin. It commonly occurs in prepubertal girls aged between 4 and 7. The mucosa of the urethra everts through the urethral opening and becomes oedematous and friable. The commonest symptom is “vaginal” bleeding. There are usually no urinary symptoms or pain. Management is usually conservative as in this case and usually resolves after 4-6 weeks. Surgical excision of the urethral mucosa has been described in cases where conservative management failed.