The 5 Minute Urology Consult 3rd Ed.

URETHRAL CARUNCLE

Margarita M. Aponte, MD

Victor W. Nitti, MD, FACS

 BASICS

DESCRIPTION

• Urethral caruncle is a benign tumor consisting of friable mucosa at the posterior edge of the urethral meatus in females.

• Most are asymptomatic.

• Most common in postmenopausal females.

EPIDEMIOLOGY

Incidence

• Most common benign tumor of the female urethra.

• Occurs more frequently in postmenopausal women.

• Uncommon in childbearing years.

• Extremely rare in children.

Prevalence

Common in postmenopausal elderly women

RISK FACTORS

• Postmenopausal vaginal atrophy

• Chronic irritation to the urethral meatus

Genetics

No known genetic association

PATHOPHYSIOLOGY

• Mucosal ectropion of posterior urethral wall secondary to retraction of an atrophic vagina due to decreased estrogens

• Appears unrelated to any viral etiology

• Some cases may be related to the autoimmune phenomena of IgG4-associated disease

ASSOCIATED CONDITIONS

Vaginal atrophy

GENERAL PREVENTION

Prevention of vaginal atrophy

 DIAGNOSIS

HISTORY

• Determine menopausal status, as more common in postmenopausal females

• Incidental finding on pelvic exam in asymptomatic women

• Light bleeding or spotting on underwear

• Microscopic hematuria

• Vaginal irritation

• Occasional dyspareunia

• Voiding or obstructive symptoms infrequent

• Tenderness is infrequent

PHYSICAL EXAM

• Erythematous, soft, friable mass seen protruding from a segment of the urethral meatus and palpated on vaginal inspection

• Usually reddish, occasionally may appear blue or black

• Usually located at the ventral (posterior) urethral meatus

• May be tender to palpation

• Usually <1–2 cm

DIAGNOSTIC TESTS & INTERPRETATION

Lab

• There are no diagnostic lab tests

• Urine analysis may show RBCs or epithelial cells

• Urine cytology may identify malignancy but it is unrelated to the urethral caruncle

Imaging

Usually not required, may be visualized on MRI

Diagnostic Procedures/Surgery

• Urethroscopy: May help delineate extent of lesion and may be performed in the work up of microscopic hematuria

• Biopsy: Excisional or incisional.

– Not usually required for diagnosis, but indicated if mass is suspicious for malignancy, it increases in size or fails to respond to topical estrogen cream.

Pathologic Findings

• Papillomatous, granulomatous, and angiomatous varieties

• Histologic:

– Connective tissue containing many inflammatory cells and blood vessels and covered by an epithelial layer

– Evidence of necrosis, inflammation, and hemorrhage may be present.

• Transitional or stratified squamous epithelium

• 2% of caruncles have associated malignancy

• Case reports of intestinal heterotopia (1)[C]

DIFFERENTIAL DIAGNOSIS

• Urethral prolapse:

– Evagination of urethral mucosa

– Typically circumferential

– Seen in women of all ages (prepubertal through postmenopausal); caruncle is almost exclusively seen in post-menopausal females

• Malignancy:

– Urethral carcinoma:

 Uncommon

 Peak incidence 5th–7th decade

 Usually a firm, nontender, indurated mass

 Irritative and obstructive voiding symptoms may be associated

 Bleeding from urethra or on toilet tissue is more typical.

 Four subtypes of urethral carcinoma: Squamous cell, transitional cell, adenocarcinoma, melanoma (2)[B].

– Lymphoma

– Intestinal metaplasia

• Periurethral glans abscess

• Urethral polyp: Pediatric equivalent of urethral caruncle

• Urethral syndrome

• Urethral condyloma

• Urethral varices

• Thrombosis of urethral vein:

– Bluish, swollen, very tender lesion in similar location to caruncle

• Other causes of postmenopausal bleeding: Cervical, ovarian, uterine pathology

 TREATMENT

GENERAL MEASURES

• Most urethral caruncles are asymptomatic and do not require definitive treatment.

• Conservative management with sitz baths, topical estrogen creams, topical anti-inflammatory agents should be used in the majority of patients.

• Excessive or persistent bleeding of obstructive voiding symptoms may prompt treatment.

• If there is any doubt concerning the diagnosis, biopsy should be performed.

MEDICATION

First Line

• Topical estrogen: Apply cream 0.3 mg daily for 2 weeks then decrease to twice a week for maintenance.

– Due to minimal absorption, progesterone is not usually needed.

• Anti-inflammatory medications for mild discomfort, PO, or topical.

Second Line

Systemic estrogen replacement

SURGERY/OTHER PROCEDURES

• Excision:

– Outpatient procedure performed under local anesthesia with or without sedation

– Remove the entire caruncle and approximate the ventral urethral meatal mucosa to the vaginal epithelium

• Ligation (3)[C]:

– Outpatient procedure performed under local anesthesia

• Cryoablation

• Laser fulguration

ADDITIONAL TREATMENT

Radiation Therapy

Applicable only for certain distal urethral malignancies and not for urethral caruncle

Additional Therapies

Sitz baths may alleviate discomfort.

Complementary & Alternative Therapies

None

 ONGOING CARE

PROGNOSIS

Excellent

COMPLICATIONS

Urethral stricture or meatal stenosis with surgical excision

FOLLOW-UP

Patient Monitoring

• None specific

• Routine gynecologic follow-up as this is a benign lesion

Patient Resources

Urology Care Foundation: Benign Urethral Lesions. http://www.urologyhealth.org/urology/index.cfm?article=93

REFERENCES

1. Urakami S, Igawa M, Shiina H, et al. Urethral caruncle with coexistence of intestinal heterotopia. A case report. Int Urol Nephrol. 1997;29(3):341–344.

2. Marshall FC, Nishimoto K, Ogata K. Neoplasms and caruncles of the female urethra. Surg Gynecol Obstst. 1960;110:723.

3. Park DS, Cho W. Simple solutions for urethral caruncle. J Urol. 2004;172(5 Pt 1):1884–1885.

ADDITIONAL READING

• Dmochowski RR, Ganabathi K, Zimmern PE, et al. Benign female periurethral masses. J Urol. 1994;152:1943.

• Katz VL. Benign gynecologic lesions: Vulva, vagina, cervix, uterus, oviduct, ovary. In: Katz, ed. Comprehensive Gynecology, 5th ed. St. Louis: Mosby, 2007.

• North American Menopause Society. The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society. Menopause. 2007;14:355.

• Shah SR, Nitti VW: Benign vaginal wall masses and paraurethral lesions. In Nitti WW, Rosenblum R, Brucker BM (eds.) Vaginal Surgery for the Urologist. Philadelphia, PA: Elsevier Saunders; 2012;127–136.

See Also (Topic, Algorithm, Media)

• Urethra, Bleeding (Blood at Meatus)

• Urethra, Carcinoma, General Considerations

• Urethra, Diverticulum, Female (Urethral Diverticulum)

• Urethra, Mass

• Urethra, Prolapse (Female)

• Urethral Caruncle Image 

• Urethral Discharge

 CODES

ICD9

• 599.3 Urethral caruncle

• 627.3 Postmenopausal atrophic vaginitis

• V49.81 Asymptomatic postmenopausal status (age-related) (natural)

ICD10

• N36.2 Urethral caruncle

• N95.2 Postmenopausal atrophic vaginitis

• Z78.0 Asymptomatic menopausal state

 CLINICAL/SURGICAL PEARLS

• Urethral caruncles occur most frequently in postmenopausal women.

• Most are asymptomatic and do not need treatment.

• Biopsy is indicated if there is a suspicion for malignancy.

• Topical estrogen is the first-line treatment.

• Surgical intervention should be reserved for patients with larger symptomatic lesions or who fail conservative therapy.



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