Disclosure Urethral caruncles are benign, distal urethral lesions most commonly found in postmenopausal females. Recently, a case of urethral caruncle has also been described in a male. Because urethral caruncles sometimes look like urethral carcinoma, they may be alarming to the untrained eye. The differential diagnosis includes urethral diverticulum, urethral prolapse, urethral carcinoma, and periurethral gland abscesses. 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 reach 1-2 cm in diameter. Frequency: Urethral caruncles are common in elderly women but are rare in perimenopausal women. Urethral prolapse has a similar appearance, but it is more common in preadolescent girls. 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 resulting from estrogen deficiency. Chronic irritation contributes to the growth, hemorrhage, and necrosis of the lesion.
Microscopically, a urethral caruncle looks like 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 1).
Urethral caruncles may be associated with tuberculosis, intestinal ectopia, and unusual neoplasms; however, reports of these associations are rare. Clinical: Most urethral caruncles are asymptomatic; however, some may be painful, and others may be associated with dysuria. Many present as bleeding or blood on the undergarments. Some caruncular lesions may look like urethral carcinoma.
Conservative therapy (ie, warm sitz baths, topical estrogen creams, topical anti-inflammatory drugs) is appropriate for most patients. Surgical intervention should be reserved for patients with larger symptomatic lesions and for those with uncertain diagnoses.
Relevant Anatomy: The female urethra is a 4- to 5-cm tubular structure. It is normally lined distally by squamous epithelium and proximally by transitional epithelium. 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. |
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Lab Studies:
Diagnostic Procedures:
Medical therapy: Treat most patients conservatively with warm sitz baths. Topical estrogen creams and topical anti-inflammatory drugs may also be useful. Surgical therapy: Reserve surgical intervention for patients with larger symptomatic lesions and for those with uncertain diagnoses. Tumors are found in approximately 2% of urethral caruncles. Preoperative details: Standard vaginal preparation and antibiotics are recommended. Intraoperative details: Removal is usually an outpatient operation and involves the following steps:
Postoperative details: A Foley catheter may be left in place for a 1-2 days; however, this is probably not necessary for patients with smaller lesions. Follow-up care: If the lesion is benign, no special follow-up other than a routine postoperative visit is required.
If the epithelium is not everted adequately with the stay-stitch, meatal stenosis may occur.
The prognosis is excellent.
Urethral caruncle management is straightforward. As the etiology of these lesions is better elucidated, improvements in medical therapies may obviate surgery.
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