Urethral caruncle is a term that describes a benign polypoidal growth at the urethral meatus. It is most commonly observed in postmenopausal women. Certain tumors can masquerade as a urethral caruncle. The caruncle may be asymptomatic or it can present with dysuria and bloody discharge. The diagnosis is made by microscopic examination, while treatment includes excision in symptomatic patients.
The majority of patients are asymptomatic , and the diagnosis of urethral caruncle is incidental either during a physical examination or during invasive diagnostic procedures. Patients most often complain of painful and frequent urination, with or without hematuria . During the physical examination, patients frequently report pain during urethral palpation and the lesion can be diagnosed during inspection and palpation because it often protrudes from the external urethral meatus. This lesion may be significantly debilitating for patients and cause significant distress.
Symptoms that are reported by patients are nonspecific and can be due to various causes, which is why a detailed diagnostic workup should be performed. Dysuria should always include infection in the differential diagnosis, while hematuria requires more detailed evaluation. Urinalysis should be performed to look for leukocytes, and nitrites (to exclude gram-negative bacterial pathogens) and bacterial cultures must be obtained. Hematuria may occur due to various causes, including infections, glomerulonephritis, and trauma. At the least, an abdominal ultrasound should also be performed . However, the key element in diagnosing urethral caruncle is a thorough physical examination. Since this lesion is almost exclusively seen in the proximity of the external urethral meatus, inspection, and sometimes palpation may reveal a polypoidal growth and thus help with the initial diagnosis.
Once a suspicion toward urethral caruncle is made, cystoscopy is indicated for all patients, especially for those in whom the cause of hematuria has not been found. Together with excision of the caruncle, subsequent microscopic evaluation can confirm the diagnosis. It is important to confirm the diagnosis on histopathology as urethral neoplasms can go undiagnosed if only macroscopic evaluation is performed . The histopathological examination can reveal the presence of inflammatory cells, fibrous connective tissue and abundant blood vessels covered by hyperplastic epithelium, while immunohistochemical staining should be performed to rule out the presence of malignant tumors.
For patients with asymptomatic urethral caruncles, treatment is usually not indicated. In symptomatic patients, initial management strategies may include topical estrogen creams and sitz baths, together with non-steroidal anti-inflammatory drugs (NSAIDs) to manage pain. However, there is limited data on their efficacy. On the other hand, surgical excision is the definite treatment measure and is recommended for patients with severe symptoms. Although studies have shown very low rates of malignant tumors mimicking as urethral caruncle (about 2.4%) , all symptomatic patients should undergo surgical excision and subsequent histopathological evaluation to exclude neoplasms.
Because the majority of patients are asymptomatic and surgical treatment is successful when indicated, the prognosis is generally good. However, in very rare cases, patients may be misdiagnosed and the caruncle may mask the presence of a malignant tumor, which can be particularly dangerous in the case of malignant melanoma , because of its metastatic potential. Other tumors that have been reported include squamous cell carcinoma, transitional cell carcinoma, while tuberculosis has also been reported initially as urethral caruncle . All symptomatic patients should undergo cystoscopy if the cause of symptoms is not determined through urinalysis or other laboratory findings.
The exact reason why urethral caruncle develops is not entirely understood, but certain factors have been implied in its development. Presumably, lack of estrogen during menopause leads to atrophy of the urothelium, which is thought to be a risk factor for urethral prolapse and development of caruncle, while chronic inflammation due to currently unknown etiologies may contribute as well.
Prevalence rates of this benign tumor have not been reported, as the majority of patients are asymptomatic, but it is referred to as one of the most common benign tumors of the urethra. This lesion is most commonly encountered in postmenopausal women , presumably due to hormonal factors and irritation during repeated deliveries. Rare cases of urethral caruncles in males have been reported , while ethnic predilection has not been established.
The model for the pathogenesis of urethral caruncle is still missing some key elements and a clear mechanism of how this lesion occurs. Several theories have been proposed, including mechanical, hormonal and inflammatory factors . Firstly, it is suspected that sexual intercourse and childbirth have significant irritating effects on the urethra, thus contributing to urethral prolapse and eventual formation of caruncle. Additionally, estrogen deficiency is known to induce atrophy of transitional epithelium, which covers the urinary bladder and the urethra, and is suspected to be a contributing factor. Although infections have rarely been implicated as possible causes of this lesion, chronic inflammation is also hypothesized to be a factor in the pathogenesis, which is supported by the fact that inflammatory infiltrates are almost always observed in the microscopic examination of the lesion. Autoimmune processes have also been investigated as possible factors, specifically IgG antibodies .
Current prevention strategies could be aimed at identifying the exact prevalence rates of this lesion through a systematic examination of patients with complaints that can be caused by this tumor. Additionally, rates of malignant tumors hiding under the caruncle could be confirmed with larger studies.
Urethral caruncle is one of the most common benign tumors of the urethra and develops on the posterior lip of the urethral meatus in the majority of cases . Several terms have been used in describing this benign polypoidal growth. Hallmarks of this lesion are pathological changes such as chronic localized subepithelial inflammation with swelling, abundance of blood vessels, fibrosis and presence of either hyperplastic squamous epithelium or urothelium that surrounds the inflammatory cells . The exact reason why urethral caruncle develops is not known. Factors such as chronic inflammation and irritation due to sexual activity and multiple births have been suspected to contribute to its development. It is most commonly diagnosed in postmenopausal women and patient age has been reported to range between 40-70 years . The clinical presentation of urethral caruncle is primarily without symptoms, but symptoms such as dysuria, urinary incontinence, and bloody discharge have been observed and can be severely debilitating for the patient. Because malignant tumors, including cancers of urogenital origin, lymphomas, and melanoma masquerade as a urethral caruncle, this condition should be carefully evaluated and excluded as a cause when patients present with such symptoms. The initial diagnosis can be made by performing a thorough physical examination, including palpation of the urethra and urinalysis, to exclude other possible causes of symptoms, such as infection. Cystoscopy is a modality used to visualize the caruncle, while a definite diagnosis can be made by excision and subsequent microscopic examination. Excision is also the primary form of treatment. Asymptomatic patients do not usually require treatment.
Urethral caruncle is a term that describes a benign polypoidal growth at the urethral opening. It is most commonly diagnosed in postmenopausal women, presumably because hormonal changes have an effect on the urethral epithelium, but also because multiple childbirths and sexual intercourse may have an irritating effect on the urethra. Other factors have been implicated in the development of this benign tumor as well, such as autoimmune processes. However, the exact cause remains unknown. The majority of patients with urethral caruncle are asymptomatic, while symptomatic patients may commonly report problems such increased frequency, irritation and pain during urination, incontinence, blood in urine or spots of blood on clothes. The initial diagnosis of urethral caruncle can be made during a physical examination, by inspection and palpation of the urethra. Usually, the caruncle protrudes from the urethra, and is painful on palpation, after which a definite diagnosis can be made. Cystoscopy, which provides a direct view into the urethra by inserting a cystoscope guided by a camera, is performed to visualize the caruncle. Once the lesion is visualized, a sample of the caruncle is taken for histopathological examination and then it is entirely removed. In very rare cases,malignant tumors, such as squamous cell carcinoma or malignant melanoma can masquerade as a urethral caruncle. So a pathological evaluation is essential to exclude underlying tumors as a possible cause of this lesion. Treatment is indicated only for symptomatic patients, and comprises surgical removal of the caruncle, while asymptomatic patients do not require therapy.