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.