S. Salim, A. Taylor & C. Carter. Female paraphimosis? Management of a large female urethral caruncle, trialling manual reduction. 2014. Journal of Obstetrics and Gynaecology; Early Online: 1–2

Dear Sir,

I am writing this letter with reference to the publication ‘Female paraphimosis? Management of a large female urethral caruncle, trialling manual reduction cited as Journal of Obstetrics and Gynaecology, 2014; Early Online: 1–2 by S. Salim et al. We read this article with great interest and found it to be clinically relevant. We henceforth congratulate the authors for their diligent research. However, there are some closely associated issues which should have been taken into account properly.

1. Urethral prolapses are similar in appearance to urethral caruncles but are circumferential, whilst urethral caruncles tend to be ‘Focal’ (Sajadi and Kim 2011). The photograph shown in the article is having circumferential mucosal prolapse with ‘doughnut sign’, that is classical appearance of urethral prolapse rather than urethral caruncle (Hillyer et al. 2009).

2. The conservative management is similar for both urethral prolapse and caruncle including Sitz bath, local application of oestrogen cream and anti-inflammatory ointment. However, the author's claim of ‘using manual reduction in management of urethral prolapse is previously unreported’ is controversial. In their study, Holbrook C and Misra D have emphatically mentioned manual reduction as an alternative to a surgical procedure in cases of symptomatic prolapse or with evidence of vascular compromise and thus avoiding its potential complications (Holbrook and Misra 2012). They found prolapse reduction beneficial as complete reduction was achieved in 3/7 patients, with no recurrence. The remaining four patients with partial reduction had improvement in symptoms, allowing conservative therapy to continue and resulting in almost complete resolution of prolapse at follow-ups. Manual reduction can be repeated in cases of recurrence, reserving surgery for patients who frequently recur or has severe prolapse not responding at all to reduction (Holbrook and Misra 2012).

3. Following manual reduction of prolapsed urethral mucosa, Foley's catheterisation for 1–2 days support continuous bladder drainage and may avoid irritation and stinging of the oedematous urethral mucosa during voiding. However, the decision of its placement should be judicious, because indwelling urethral catheterisation (IUC) is one of the most significant risk factor for developing nosocomial urinary tract infections, especially in elderly patients (Brosnahan et al. 2004).

Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.