Urethral prolapse consists of the eversion and circumferential protrusion of the urethral mucosa through the external meatus. The aetiology can be congenital or acquired, and it can appear at any age. Clinical manifestations vary depending on age and the diagnosis is clinical. Initial treatment is usually conservative, and surgical resection is recommended when complications appear. 
The aim of this study is to know the factors associated with urethral bleeding as the first symptoms in urethral prolapse.

Retrospective observational study including 17 women who have undergone surgery for urethral prolapse in a university hospital between 2000 and 2021. 
Inclusion criteria: female adult patients (18 years or older). 
Variables: Age at surgery, body mass index (BMI), concomitant disorders and drug treatment, toxic habits, medical and surgical background, gynaeco-obstetric history; health status defined by the American Society of Anaesthesiologists (ASA) Physical Status Classification System, reason for consultation (vaginal bulge sensation, bulge sensation + bleeding, haematuria, urethrorrage), time between diagnosis and surgery, functional results (SF-36 quality of life questionnaire).
Descriptive statistics and multivariant analysis (logistic regression) were done.

Mean age was 70.41 year (SD 6.92, range 57 – 81). Mean BMI was 23.67 kg/m2 (SD 2.28, range 20.81 – 29.38). Mean time between diagnosis and surgical treatment was 231.58 days (SD 277.11, range 1 – 961). Urinary incontinence and cystocele were present at diagnosis in 5.88% and 35.29% of patients respectively. Mean number of deliveries was 2.26 (SD 1.10, range 0-4), 58.82% were eutocic. 
Main complain at first consultation: “vaginal bulge sensation” and “urethrorrhagia” were the most common, both in 29.41% of patients; “bulge sensation + bleeding” in 17.65%; “lower urinary tract symptoms” and “haematuria” both in 11.76%. 
A multivariant analysis with logistic regression was undergone to analyse if there was an association between the recorded variables and the probability to present with haemorrhage (including “urethrorrhagia”, “bulge sensation + bleeding” and “haematuria”) as the reason for consultation: a positive correlation was found between haemorrhage and the presence of cystocele (5.33, p=0.012) and greater age (1.60, p=0.007) at diagnosis; on the contrary, a negative correlation was obtained with both the time between diagnosis and treatment (0.989, p=0.033) and the presence of urinary incontinence ( 0.071, p=0.005).

Lower urinary tract symptoms and bulge sensation are usually described as the main complain for consultation in patients with urethral prolapse; however, in our sample, with a mean age of 70 years, haematuria/urethrorrhagia were present in most patients. Reasons for this finding, compared with prepuberal girls, can be the use of anticoagulant/antiplatelet drug treatment and vaginal intercourse, which may facilitate bleeding.

Urethral prolapse with haemorrhage promotes surgical excision. This haemorrhage is associated with the presence of cystocele (with a 5-fold risk of bleeding), a greater time between diagnosis and surgical treatment and the presence of urinary incontinence.