Chronic copper poisoning presenting as pink disease.

held by loose connective tissue makes it mobile and, in children, the mucous membrane may have developed more strongly than the muscularis mucosae. They concluded that two factors might operate: first, a congenital weakness of tissue with an unduly wide urethra and, secondly, an acquired factor such as debility or inflammation. Other theories frequently mentioned are redundancy of the urethral mucosa, stress from cough or straining at stool, straddle injury, foreign body, or a true urethral hernia. Keefe (1917) favoured a neuromuscular cause, whereby the constrictor muscle is too weak to oppose a strong detrusor. Many different methods of treatment have been used. Conservative treatment with replacement of the prolapsed mucosa, followed by continuous pressure, has been advocated but the tendency to relapse is high. A variation of this method is to insert a large catheter after replacing the mass. Catheter drainage is instituted for two to three weeks but relapses still occur after this procedure. Perhaps the most commonly used surgical treatment is to pass a catheter without making any attempt to reduce the mass. The redundant mucosa is then ligated at the base, over the catheter, and allowed to separate. Alternatively, it may be amputated with diathermy. Peters (1962) favoured fulguration at the 'four points of the compass' to induce submucosal fibrosis. Hepburn (1927) used an ingenious method whereby the prolapse was reduced by pulling it up the urethra by a suprapubic approach and stitching the bladder neck to the pubic bone. However, this method has only been considered for elderly patients, and the other surgical measures seem to have given good results with infrequent relapses. Conservative treatment with the local application of steroid and an antibiotic has shown promise in two of the cases, but the time is too short and the number too few to draw any conclusions.