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1. Urethral prolapse = mucosal eversion
Evidence shows that urethral prolapse is a circular eversion of the urethral mucosa through the external meatus, producing the classic “doughnut‑shaped ring” of tissue at the urethral opening.
This is well‑described in case series and reviews, including the 12‑patient adult series by Fornari et al., which emphasises the visible circumferential mucosal protrusion.

Link to this study.

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2. Urethrocele = descent of the urethra into the vagina
A urethrocele is defined as the prolapse of the urethra into the anterior vaginal wall, usually occurring together with a cystocele (hence “cystourethrocele”).
It is considered a form of anterior vaginal wall prolapse, where the urethra shifts position internally rather than everting externally. 

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3. Key anatomical difference
Urethral prolapse: external, visible, mucosal eversion at the urethral opening

Urethrocele: internal descent of the urethra into the vaginal canal, usually part of anterior compartment prolapse

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4. Differences in presentation

Urethrocele:

Pelvic pressure, stress incontinence, difficulty emptying bladder

Often accompanies cystocele

No external mucosal ring

Urethral prolapse:

Visible ring of mucosa (“pink/red donut”)

Bleeding, irritation, pain at urethral opening

More common in prepubertal girls and postmenopausal women

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5. Differences in underlying mechanism
Evidence suggests:

Urethral prolapse is linked to oestrogen deficiency, mucosal fragility, and circumferential detachment of mucosa. 

Urethrocele is associated with pelvic floor support failure, childbirth trauma, fascia weakening, and anterior compartment descent.

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What Can Happen to the Urethra?

When the tissues supporting the urethra become stretched, weakened or altered, the urethra may change position or its normal angle. This can affect the way urine passes through it.

In some women, prolapse may contribute to bladder outlet obstruction or incomplete bladder emptying. In others, changes in urethral support may be associated with stress urinary incontinence, where urine leaks when pressure inside the abdomen rises, during coughing, sneezing, laughing, lifting or exercise.

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The relationship is not always straightforward. For example, a woman may have little or no leakage while the prolapse is pronounced, because the altered position of the urethra can partially obstruct urine flow, in some cases the descent of the bladder can "kink" the urethra, reducing flow or preventing leakage. When the prolapse is supported or reduced (for example with a pessary), the urethra may return towards a more normal position, and previously hidden stress urinary incontinence can become apparent.

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This is one reason why urinary symptoms should be assessed carefully rather than assuming that every woman with a urethrocele will experience leakage.

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Symptoms of a Urethrocele

A urethrocele can cause no symptoms at all and may be discovered during an examination for another reason. When symptoms occur, they may include:

• Urinary leakage

• Stress urinary incontinence can cause leakage of urine when coughing, sneezing, laughing, lifting, running, jumping or exercising. Some women experience urgency or increased urinary frequency instead.

• Difficulty emptying the bladder

 

A change in the position of the urethra, or an associated prolapse, may interfere with normal urine flow. You may notice:

• Difficulty starting the flow of urine

• A weak or interrupted stream

• Needing to change position to empty your bladder

• Feeling that your bladder has not completely emptied

• Needing to pass urine again shortly after going

• Straining to urinate

• Post-void dribbling

These symptoms are worth mentioning to your healthcare professional, because incomplete bladder emptying can often be measured objectively (see Post-void residual measurement, below).

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Recurrent urinary tract infections
The evidence linking pelvic organ prolapse and recurrent UTI is indirect, via incomplete bladder emptying, rather than evidence that a urethrocele itself causes infection. Research has found that women with pelvic organ prolapse can have higher post-void residual urine volumes, and raised residual urine is associated with an increased likelihood of recurrent UTI. NICE therefore recommends measuring post-void residual urine in women with symptoms of voiding dysfunction or recurrent UTI.

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International consensus statements on prolapse and lower urinary tract dysfunction similarly describe UTIs in this context as secondary to impaired bladder emptying and outlet obstruction, reinforcing that management should focus on optimising voiding, reducing residual urine, and addressing co-existing risk factors (such as vaginal atrophy, catheter use or diabetes), rather than attributing infection to the urethrocele alone.

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This means that if you have a urethrocele or other prolapse together with repeated UTIs, it is reasonable to ask: "Is my bladder emptying completely, and has my post-void residual urine been checked?"

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A UTI should not automatically be attributed to prolapse. Urine testing and, when clinically indicated, urine culture are used to establish whether an infection is actually present.

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Urinary frequency and urgency
Some women experience the need to urinate more frequently or suddenly, with urgency that can be difficult to defer. Pelvic organ prolapse and lower urinary tract symptoms commonly occur together, although the relationship is complex and not every urinary symptom is caused by the prolapse.

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Sexual discomfort
Some women experience discomfort or pressure during sexual intercourse. This may relate to changes in vaginal support, associated pelvic floor muscle dysfunction, vaginal dryness, or another pelvic health condition. Pain during sex should be assessed rather than automatically attributed to the urethrocele.

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How Is a Urethrocele Diagnosed?

Diagnosis is usually based on symptoms, medical history and a physical examination. There is no single test required for every woman. Your clinician may assess all three areas of pelvic support, anterior, posterior and apical, because more than one compartment can be affected at the same time.

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For women referred for specialist evaluation of prolapse, NICE recommends that the presence and degree of prolapse be assessed and recorded using the POP-Q (Pelvic Organ Prolapse Quantification) system, together with assessment of the vaginal tissues. Routine imaging is not recommended simply to document a prolapse that can already be identified clinically.

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Tests and assessments that may be considered

1. Pelvic examination
The clinician may examine you lying down and/or standing, and may ask you to cough or bear down. This allows assessment of how the pelvic organs and vaginal walls move when pressure increases.

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2. POP-Q assessment
The Pelvic Organ Prolapse Quantification system provides a standardised way of documenting the location and degree of vaginal wall or apical descent. This can be particularly useful for monitoring whether prolapse has changed over time.

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3. Pelvic floor muscle assessment
Your pelvic floor muscles may be assessed for strength, endurance, ability to contract, ability to relax, recoil time, coordination, and tenderness or overactivity. This matters because pelvic floor dysfunction is not simply a problem of weak muscles, some women have difficulty relaxing or coordinating the muscles correctly.

 

4. Urine testing
If you have urinary symptoms, a urine test may be appropriate to look for evidence of infection, blood or other abnormalities. If UTI symptoms are present, a midstream urine sample for culture may be required, depending on the clinical circumstances. NICE provides specific recommendations for urine testing in women with urinary symptoms.

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5. Post-void residual (PVR) urine measurement
A PVR measurement shows how much urine remains in the bladder after you have urinated. It can be measured using a bladder scanner or, when necessary, catheterisation, and is particularly useful when you have difficulty emptying your bladder, a weak urine stream, urinary retention, recurrent UTIs, or significant pelvic organ prolapse. NICE recommends using a bladder scan in preference to catheterisation where appropriate, as it is less invasive and associated with fewer adverse effects.

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6. Uroflowmetry
A uroflow test measures the rate and pattern of urine flow, and can be useful when there is concern about obstruction, poor bladder emptying, or an abnormal urine stream.

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7. Bladder diary

A bladder diary records when and how often you pass urine, along with urgency, leakage and fluid intake. It can help distinguish different patterns of urinary symptoms and is particularly useful when frequency, urgency or incontinence are part of the picture. NICE recommends bladder diaries as part of the initial assessment of urinary incontinence or overactive bladder.

(Download the Pelvic Angel bladder diary from the resources area.)

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8. Urodynamic testing
Urodynamics is not automatically required for every woman with a urethrocele. It may be considered when the diagnosis is unclear, urinary symptoms are complex, bladder emptying is problematic, or when the results could influence treatment or surgery. Urodynamic testing assesses how the bladder and urethra store and release urine, and may help distinguish conditions such as stress urinary incontinence, detrusor overactivity and voiding dysfunction.

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9. Ultrasound or other imaging
Imaging is not routinely necessary simply to diagnose a prolapse that is clearly visible on examination. It may be considered when the clinical picture is unclear, when there are unusual symptoms, suspected urinary tract abnormalities, significant voiding problems, or another diagnosis to investigate.

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10. Other specialist investigations
Further investigations may occasionally be appropriate , for example, cystoscopy or specialist urological assessment where there is unexplained blood in the urine, persistent urinary symptoms, suspected urethral or bladder pathology, or another indication requiring investigation.

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What Can Help a Urethrocele?

Treatment depends on your symptoms, the degree and location of prolapse, bladder function, pelvic floor function, and what you want to achieve. If a urethrocele is not causing troublesome symptoms, treatment may not be necessary, monitoring and understanding your symptoms may be all that is required.

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For women who do have symptoms, options can include:

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Pelvic floor muscle training
The aim is not simply to "squeeze harder." A properly assessed programme considers whether you can contract, relax and coordinate the pelvic floor muscles effectively. NICE advises considering a supervised programme of pelvic floor muscle training, typically for at least 16 weeks, as a first option for women with stage 1 or 2 prolapse; if the programme helps, it's worth continuing afterwards. The evidence for benefit is less established for more advanced prolapse.

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Pessary support
A vaginal pessary can provide mechanical support for pelvic organ prolapse and may improve symptoms for some women. The right pessary depends on the woman's anatomy, the type and extent of prolapse, symptoms, sexual activity and ability to manage pessary care. A pessary does not permanently reposition the pelvic organs, it provides support while it is in place.

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One particularly important point: supporting a prolapse with a pessary can sometimes unmask stress urinary incontinence that was previously hidden by the prolapse.

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Lifestyle and bowel management
Managing factors that increase pressure on the pelvic floor can help. This may include:

Treating and preventing constipation
Avoiding repeated straining to empty the bowel
Addressing a chronic cough
Reviewing activities involving frequent heavy lifting
Maintaining a healthy weight
Maintaining an appropriate level of physical activity
Addressing other individual factors that may aggravate symptoms

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NICE specifically recommends offering advice on these areas, including weight management, constipation and heavy lifting , as part of prolapse management, on the basis that they all increase intra-abdominal pressure.

 

Surgical treatment
Surgery is not automatically required simply because a urethrocele is present. If symptoms remain troublesome despite conservative management, or there is significant functional impairment, referral to a urogynaecologist or another clinician experienced in female pelvic floor disorders may be appropriate. The decision about surgery should be individualised, taking into account symptoms, anatomical findings, urinary and bowel function, sexual function, previous surgery, future pregnancy plans, and the woman's own priorities.

NICE recommends shared decision-making when discussing prolapse treatment options.

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Questions to Ask Your Healthcare Professional

If you have been told that you have a urethrocele, you may find it helpful to ask:

• "What exactly is prolapsing, the urethra, bladder, or both?"

• "Do I have a cystocele as well as a urethrocele?"

• "What is my POP-Q stage, and which compartments are affected?"

• "Is my bladder emptying completely? What is my post-void residual urine volume?"

• "Could my urinary symptoms be caused by the prolapse, or could there be another cause?"

• "Do I have stress urinary incontinence, urgency, or a combination of urinary problems?"

• "Would a pessary be appropriate for me?"

• "Could supporting the prolapse reveal previously hidden stress incontinence?"

• "Would pelvic floor physiotherapy be appropriate, and can my contraction and relaxation be assessed?"

• "Do I need any further testing, such as uroflowmetry or urodynamics?"

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These questions can help move the conversation beyond simply being told you have a prolapse, and towards understanding how it is affecting your individual bladder and pelvic floor function.

 

A Note About Terminology

The terms used to describe urethral support problems can vary between clinicians and sources.

A urethrocele generally refers to descent or bulging of the urethra associated with loss of anterior vaginal support. A urethral prolapse is different: it refers to eversion of the urethral mucosa through the external urethral opening.

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If you have been told you have a "urethral prolapse," it is worth asking your clinician exactly what anatomical finding they mean.

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Standardised terminology matters because it helps healthcare professionals communicate consistently about pelvic floor disorders. The International Urogynecological Association (IUGA) and International Continence Society (ICS) have developed joint international terminology and classification systems for pelvic organ prolapse and pelvic floor disorders.

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This page reflects the principles set out in the NICE guideline NG123, Urinary incontinence and pelvic organ prolapse in women: management, and the NICE Clinical Knowledge Summary for Urinary Tract Infection (Lower) Women. It is intended for general educational purposes for patients and clinicians and does not replace individual clinical assessment.

Page reviewed and updated August 2026