Urethral Caruncle

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Urethral caruncles are benign, distal urethral lesions that are most commonly found in postmenopausal women, although rare cases have been reported in girls, and a case of urethral caruncle has also been described in a male. [1, 2, 3] Urethral caruncles resemble various urethral lesions, including carcinoma. The differential diagnoses of urethral caruncle include the following:

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. Possible indications for excisional biopsy include the following:

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.

Urethral caruncles are common in elderly postmenopausal women but are rare in girls or premenopausal or perimenopausal women. [5, 3]  Urethral prolapse is similar in appearance, but is circumferential while caruncles are focal. Urethral prolapse may occur in prepubescent girls or postmenopausal women, whereas caruncles are seen almost exclusively in the latter. 

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

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, [6] tuberculosis, [7, 8] intestinal ectopia, lymphoma, [9, 10] and urethral leiomyoma [11] 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 two patients. [12] 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.

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. [13] Isolated case reports of urinary retention from urethral caruncle do exist, however. [14]

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

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.

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.

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

Conces MR, Williamson SR, Montironi R, Lopez-Beltran A, Scarpelli M, Cheng L. Urethral caruncle: clinicopathologic features of 41 cases. Hum Pathol. 2012 Sep. 43(9):1400-4. [Medline].

Karthikeyan K, Kaviarasan PK, Thappa DM. Urethral caruncle in a male: a case report. J Eur Acad Dermatol Venereol. 2002 Jan. 16(1):72-3. [Medline].

Gamage M, Beneragama D. Urethral Caruncle Presented as Premature Menarche in a 4-Year-Old Girl. Case Rep Pediatr. 2018. 2018:3486032. [Medline]. [Full Text].

Bansal N, Garg G, Vashist S. Primary malignant melanoma of urethra mimicking as urethral caruncle. BMJ Case Rep. 2018 Jul 30. 2018:[Medline].

Chiba M, Toki A, Sugiyama A, Suganuma R, Osawa S, Ishii R, et al. Urethral caruncle in a 9-year-old girl: a case report and review of the literature. J Med Case Rep. 2015 Mar 28. 9:71. [Medline]. [Full Text].

Nakamoto T, Inoue Y, Ueki T, Niimi N, Iwasaki Y. Primary amelanotic malignant melanoma of the female urethra. Int J Urol. 2007 Feb. 14(2):153-5. [Medline].

Indudhara R, Vaidyanathan S, Radotra BD. Urethral tuberculosis. Urol Int. 1992. 48(4):436-8. [Medline].

Singh I, Hemal AK. Primary urethral tuberculosis masquerading as a urethral caruncle: a diagnostic curiosity!. Int Urol Nephrol. 2002. 34(1):101-3. [Medline].

Chen YR, Hung LY, Chang KC. Mucosa-associated lymphoid tissue-type lymphoma presenting as a urethral caruncle with urinary bladder involvement. Int J Urol. 2014 Oct. 21 (10):1073-4. [Medline]. [Full Text].

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. 1996 Oct. 20(10):1190-5. [Medline].

Saroha V, Dhingra KK, Gupta P, Khurana N. Urethral leiomyoma mimicking a caruncle. Taiwan J Obstet Gynecol. 2010 Dec. 49(4):523-4. [Medline].

Kaneko G, Nishimoto K, Ogata K, Uchida A. A case of intraepithelial squamous cell carcinoma arising from urethral caruncle. Can Urol Assoc J. 2011 Feb. 5(1):E14-6. [Medline]. [Full Text].

Ozkurkcugil C, Ozkan L, Tarcan T. The effect of asymptomatic urethral caruncle on micturition in women with urinary incontinence. Korean J Urol. 2010 Apr. 51(4):257-9. [Medline]. [Full Text].

Coban S, Bıyık I. Urethral caruncle: Case report of a rare acute urinary retension cause. Can Urol Assoc J. 2014 Mar. 8 (3-4):E270-2. [Medline]. [Full Text].

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. 2012 Nov 30. [Medline].

Park DS, Cho TW. Simple solution for urethral caruncle. J Urol. 2004 Nov. 172(5 Pt 1):1884-5. [Medline].

Martin FM, Rowland RG. Urologic malignancies in pregnancy. Urol Clin North Am. 2007 Feb. 34(1):53-9. [Medline].

Petersen RO, Stein BS. Genitourinary Pathology. Practice of Urology. New York, NY: Norton Medical Books; 1993. 48.

Rovner ES. Bladder and Female Urethral Diverticula. Wein AJ, Kavoussi LR, Partin AW, Peters CA, eds. Campbell-Walsh Urology. 11th ed. Philadelphia, PA: Elsevier; 2016. Vol 3: 2140-68.

Kamran P Sajadi, MD Assistant Professor, Department of Urology, Oregon Health and Science University School of Medicine

Kamran P Sajadi, MD is a member of the following medical societies: American Urogynecologic Society, American Urological Association, Endourological Society, Oregon Medical Association, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction, Western Section of the American Urological Association

Disclosure: Nothing to disclose.

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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

Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, SWOG

Disclosure: Nothing to disclose.

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

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Sexual Medicine Society of North America, Tennessee Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Endo, Avadel.

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

Allen Donald Seftel, MD is a member of the following medical societies: American Urological Association

Disclosure: Received consulting fee from lilly for consulting; Received consulting fee from abbott for consulting; Received consulting fee from auxilium for consulting; Received consulting fee from actient for consulting; Received honoraria from journal of urology for board membership; Received consulting fee from endo for consulting.

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

Ann Y Becker, MD is a member of the following medical societies: American Medical Women’s Association, American Urological Association, and Society of Women in Urology

Disclosure: Nothing to disclose.

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

Scott Rutchik, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Urethral Caruncle

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