Urethral Caruncle

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Background

Urethral caruncles are benign, distal urethral lesions that are most commonly found in postmenopausal women, although a case of urethral caruncle has also been described in a male.[1] Urethral caruncles resemble various urethral lesions, including carcinoma. The differential diagnoses of urethral caruncle include urethral diverticulum, urethral prolapse, urethral carcinoma, and periurethral gland abscesses.

Most urethral caruncles can be treated conservatively with warm sitz baths and vaginal estrogen replacement. Surgical intervention may be indicated for patients with larger symptomatic lesions and for those with uncertain diagnoses. Induration, failure to respond to conservative therapy, atypical appearance, or growth over time may be indications for excisional biopsy.

Problem

Urethral caruncles, which often originate from the posterior lip of the urethra, may be described as fleshy outgrowths of distal urethral mucosa. They are usually small but can grow to 1 cm or more in diameter.

Epidemiology

Frequency

Urethral caruncles are common in elderly postmenopausal women but are rare in premenopausal or perimenopausal women. Urethral prolapse is similar in appearance, but is circumferential while caruncles are focal. Urethral prolapse may occur in prepubescent or postmenopausal females, whereas caruncles are seen almost exclusively in the latter.

Etiology

Urethral caruncles may develop from several simultaneous processes, as discussed in the Pathophysiology section.

Pathophysiology

The first step in the development of a urethral caruncle is likely distal urethral prolapse caused by urogenital atrophy due to estrogen deficiency. Chronic irritation, where the urethral mucosa is exposed, contributes to the growth, hemorrhage, and necrosis of the lesion.

Cases of urethral melanoma,[2] tuberculosis,[3, 4] intestinal ectopia, lymphoma,[5, 6] and urethral leiomyoma[7] masquerading as urethral caruncle have been reported; however, reports of these associations are rare. Intraepithelial squamous cell carcinoma arising within a urethral caruncle has been reported in 2 patients.[8] Additionally, urethral caruncles have been reported to occur rarely in the premenopausal patient and may enlarge during pregnancy. Urethral polyps are the pediatric equivalent of urethral caruncles and manifest in a similar fashion.

Presentation

Most urethral caruncles are asymptomatic and are incidentally noted on pelvic examination; however, some may be painful and others may be associated with dysuria. Many individuals with a urethral caruncle present with bleeding or, more commonly, with the patient noticing blood on undergarments. Urethral caruncles are unlikely to explain voiding or storage symptoms in women. In fact, a comparison of lower urinary tract symptoms and urodynamic factors in incontinent women with and without caruncles found no differences.[9]

On examination, they most often appear clinically as a pink or reddish exophytic lesion at the urethral meatus; in rare cases, they are purple or black secondary to thrombosis. Some caruncular lesions may resemble urethral carcinoma.

Indications

Conservative therapy (ie, warm sitz baths, topical estrogen creams, topical anti-inflammatory drugs) is appropriate in most patients. Surgical intervention should be reserved for patients with larger symptomatic lesions, for those in whom conservative therapy fails to elicit a response, and for those with uncertain diagnoses.

Relevant Anatomy

The female urethra is a 4- to 5-cm tubular structure. It is normally lined by nonkeratinized stratified squamous epithelium distally and transitional epithelium proximally. Outer layers have a complex network of smooth muscle fibers and vascular structures.

Contraindications

Surgical therapy should be reserved for women with larger symptomatic lesions and for women with uncertain diagnoses.

Laboratory Studies

Obtain a urinalysis to rule out urinary tract infection when pain, discomfort, or dysuria is present or when an operative intervention is planned.

Diagnostic Procedures

A urethral caruncle is obvious on physical examination, and biopsy is unnecessary in the vast majority of cases.

Cystoscopy can be performed, either in the office or at the time of excision, to rule out more serious pathologies or when the origin of hematuria is uncertain. Cystoscopy is not necessary when the diagnosis is obvious, hematuria is absent, and no intervention is planned.

Histologic Findings

Microscopically, a urethral caruncle resembles a bed of granulation tissue covered by either squamous or transitional epithelium. Infolding of epithelium may create papillary architecture. Inflammatory infiltration is common (see image below).


View Image

This image shows marked vascular engorgement and a polymorphous inflammatory infiltrate in the stroma. Surface epithelium is benign. Courtesy of G.T. ....

A pathology series of 41 patients demonstrated mixed hyperplastic urothelial or squamous lining.[10] The stroma demonstrated fibrosis, edema, and/or inflammation. Immunohistochemistry for immunoglobulin G (IgG) and IgG4 has been shown in a subset of patients, suggesting a possible autoimmune factor in some patients.[11] This finding warrants further study.

Medical Therapy

Most urethral caruncles can be treated conservatively with warm sitz baths and vaginal estrogen replacement. Topical anti-inflammatory drugs may also be useful. Unfortunately, data on the efficacy of conservative management are lacking in the literature.

Surgical Therapy

Reserve surgical intervention for patients with larger symptomatic lesions and for those with uncertain diagnoses. Induration, failure to respond to conservative therapy, atypical appearance, or growth over time may be indications for excisional biopsy. Tumors are found in approximately 2% of urethral caruncles.

Preoperative Details

Standard vaginal preparation and preoperative antibiotics are recommended.

Intraoperative Details

Excision is usually an outpatient operation and involves the following steps:

Postoperative Details

A Foley catheter may be left in place for 1-2 days to allow for appropriate healing of the urethral mucosa.

Follow-up

If the lesion is benign, no special follow-up is required.

Complications

If the epithelium is not everted adequately with the stay-stitch, meatal retraction and stenosis may occur.

Outcome and Prognosis

The prognosis is excellent if pathology confirms urethral caruncle as the diagnosis.

Future and Controversies

Urethral caruncle management is straightforward. As the etiology of these lesions is better elucidated, improvements in medical therapies may obviate surgery.

Author

Kamran P Sajadi, MD, Assistant Professor, Urology, Oregon Health & Science University

Disclosure: Nothing to disclose.

Coauthor(s)

Ann Y Becker, MD, Assistant Professor, Section of Urology, Medical College of Georgia

Disclosure: Nothing to disclose.

Scott Rutchik, MD, Assistant Professor, Department of Surgery, Division of Urology, University of Connecticut School of Medicine

Disclosure: Nothing to disclose.

Specialty Editors

Allen Donald Seftel, MD, Professor of Urology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School; Head, Division of Urology, Director, Urology Residency Training Program, Cooper University Hospital

Disclosure: lilly Consulting fee Consulting; abbott Consulting fee Consulting; auxilium Consulting fee Consulting; actient Consulting fee Consulting; journal of urology Honoraria Board membership; endo Consulting fee Consulting

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark Jeffrey Noble, MD, Consulting Staff, Urologic Institute, Cleveland Clinic Foundation

Disclosure: Nothing to disclose.

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Associate Chair for Clinical Operations, Director, Division of Endourology and Stone Disease, Department of Urology, University of Michigan Medical School

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Disclosure: Lilly Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Actavis Honoraria Speaking and teaching; Auxilium Honoraria Speaking and teaching

References

  1. Karthikeyan K, Kaviarasan PK, Thappa DM. Urethral caruncle in a male: a case report. J Eur Acad Dermatol Venereol. Jan 2002;16(1):72-3. [View Abstract]
  2. Nakamoto T, Inoue Y, Ueki T, Niimi N, Iwasaki Y. Primary amelanotic malignant melanoma of the female urethra. Int J Urol. Feb 2007;14(2):153-5. [View Abstract]
  3. Indudhara R, Vaidyanathan S, Radotra BD. Urethral tuberculosis. Urol Int. 1992;48(4):436-8. [View Abstract]
  4. Singh I, Hemal AK. Primary urethral tuberculosis masquerading as a urethral caruncle: a diagnostic curiosity!. Int Urol Nephrol. 2002;34(1):101-3. [View Abstract]
  5. Khatib RA, Khalil AM, Tawil AN, Shamseddine AI, Kaspar HG, Suidan FJ. Non-Hodgkin's lymphoma presenting as a urethral caruncle. Gynecol Oncol. Sep 1993;50(3):389-93. [View Abstract]
  6. Young RH, Oliva E, Garcia JA, Bhan AK, Clement PB. Urethral caruncle with atypical stromal cells simulating lymphoma or sarcoma--a distinctive pseudoneoplastic lesion of females. A report of six cases. Am J Surg Pathol. Oct 1996;20(10):1190-5. [View Abstract]
  7. Saroha V, Dhingra KK, Gupta P, Khurana N. Urethral leiomyoma mimicking a caruncle. Taiwan J Obstet Gynecol. Dec 2010;49(4):523-4. [View Abstract]
  8. Kaneko G, Nishimoto K, Ogata K, Uchida A. A case of intraepithelial squamous cell carcinoma arising from urethral caruncle. Can Urol Assoc J. Feb 2011;5(1):E14-6. [View Abstract]
  9. Ozkurkcugil C, Ozkan L, Tarcan T. The effect of asymptomatic urethral caruncle on micturition in women with urinary incontinence. Korean J Urol. Apr 2010;51(4):257-9. [View Abstract]
  10. Conces MR, Williamson SR, Montironi R, Lopez-Beltran A, Scarpelli M, Cheng L. Urethral caruncle: clinicopathologic features of 41 cases. Hum Pathol. Sep 2012;43(9):1400-4. [View Abstract]
  11. Williamson SR, Scarpelli M, Lopez-Beltran A, Montironi R, Conces MR, Cheng L. Urethral caruncle: a lesion related to IgG4-associated sclerosing disease?. J Clin Pathol. Nov 30 2012;[View Abstract]
  12. Park DS, Cho TW. Simple solution for urethral caruncle. J Urol. Nov 2004;172(5 Pt 1):1884-5. [View Abstract]
  13. Martin FM, Rowland RG. Urologic malignancies in pregnancy. Urol Clin North Am. Feb 2007;34(1):53-9. [View Abstract]
  14. Petersen RO, Stein BS. Genitourinary Pathology. In: Practice of Urology. New York, NY: Norton Medical Books; 1993:48.
  15. Rovner ES. Bladder and urethral diverticula. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA. Campbell-Walsh Urology. Vol 3. 9th ed. Philadelphia, PA: WB Saunders Co; 2007:2361-72.

This image shows marked vascular engorgement and a polymorphous inflammatory infiltrate in the stroma. Surface epithelium is benign. Courtesy of G.T. MacLennan, MD.

This image shows marked vascular engorgement and a polymorphous inflammatory infiltrate in the stroma. Surface epithelium is benign. Courtesy of G.T. MacLennan, MD.