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Urethral Caruncle

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.


Presentation

The majority of patients are asymptomatic [10], 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 [11]. 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.

Amyloidosis
  • N39 , 580–599 ) Kidney disease Glomerules Primarily nephrotic Non-proliferative Minimal change Focal segmental Membranous Proliferative Mesangial proliferative Endocapillary proliferative Membranoproliferative/mesangiocapillary By condition Diabetic Amyloidosis[en.wikipedia.org]
Renal Artery Stenosis
  • artery stenosis Renal ischemia Hypertensive nephropathy Renovascular hypertension Renal cortical necrosis Other Analgesic nephropathy Renal osteodystrophy Nephroptosis Abderhalden–Kaufmann–Lignac syndrome Urinary tract Ureter Ureteritis Ureterocele Megaureter[en.wikipedia.org]
Osteoporosis
  • […] assault Rape Femicide Gender discrimination Non-communicable diseases Cancer Lung cancer Breast cancer Uterine cancer Endometrial cancer Cervical cancer Papanicolaou test Ovarian cancer Cardiovascular disease Dementia Alzheimer's disease Bone health Osteoporosis[en.wikipedia.org]
Dysuria
  • A middle-aged woman presented with symptoms of frequency dysuria syndrome for the last 2 years. Local examination and cystoscopy revealed localized parurethral induration, tenderness and a urethral caruncle with chronic obliterative urethritis.[ncbi.nlm.nih.gov]
  • Dysuria should always include infection in the differential diagnosis, while hematuria requires more detailed evaluation.[symptoma.com]
  • BPS Government Medical College for Women Khanpur Kalan , Sonepat , Haryana , India Correspondence to Dr Gaurav Garg, gougarg{at}gmail.com Statistics from Altmetric.com urological surgery surgical oncology Description A 50-year-old woman presented with dysuria[casereports.bmj.com]
  • Reported in men. [2] Clinical: [3] /-Dysuria. /-Hematuria. Microscopic Features: [4] Polypoid or sessile lesion - covered with squamous epithelium or urothelium. /-Inflammation. /-Dilated blood vessels. See also Urethra . Genitourinary pathology .[librepathology.org]
  • Most urethral caruncles are asymptomatic; however, some may be painful, and others may be associated with dysuria. Larger necrotic lesions may bleed. Some caruncular lesions may look like urethral carcinoma.[diseasesatoz.com]
Dyspareunia
  • They can bleed and occasionally cause dysuria and dyspareunia . The caruncles can be removed by surgery, electric cauterization and then with suture repair.[en.wikipedia.org]
  • Painful micturition or dyspareunia. Bloody spotting with mild trauma. Pedunculated red mass that is tender to touch Sage Asked on August 4, 2016 in Disease.[curerator.com]
  • Occasionally they may present with dyspareunia and/or vaginal bleeding.[diseasesatoz.com]
  • During a 4-year follow-up period, the patient has been well with no dysuria, dyspareunia, or incontinence.[einj.org]
Urinary Retention
  • Retention - NIH (National Institute of Diabetes and Digestive and Kidney Diseases) [ Read More ][icdlist.com]
  • A urethral caruncle does not cause symptoms in patients; it is a cosmetic disorder, but can very rarely cause acute urinary retention.[thefreelibrary.com]
  • 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[emedicine.medscape.com]
Urethral Disease
  • Keywords : Divorce; urethral diseases; female ÖZET Üretral karunkülün genç bayanlarda ve üretral meanın alt dudağından başka bir yerde izlenmesi oldukça enderdir. Boşanmaya neden olan üretral karunkül henüz bildirilmemiştir.[turkiyeklinikleri.com]

Workup

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 [11]. 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.

Rectal Ulceration
  • A similar histologic pattern is also found in so-called solitary rectal ulcer syndrome and inflammatory cloacogenic polyps arising in the anorectal area.[ncbi.nlm.nih.gov]
Human Herpesvirus 8
  • Immunohistochemistry was performed in nine patients for Epstein-Barr virus, BK virus, human herpesvirus 8, human papillomavirus, adenovirus and anaplastic lymphoma kinase.[ncbi.nlm.nih.gov]

Treatment

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%) [12], all symptomatic patients should undergo surgical excision and subsequent histopathological evaluation to exclude neoplasms.

Prognosis

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 [8], 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 [9]. All symptomatic patients should undergo cystoscopy if the cause of symptoms is not determined through urinalysis or other laboratory findings.

Etiology

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.

Epidemiology

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 [4], presumably due to hormonal factors and irritation during repeated deliveries. Rare cases of urethral caruncles in males have been reported [5], while ethnic predilection has not been established.

Sex distribution
Age distribution

Pathophysiology

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 [6]. 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 [7].

Prevention

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.

Summary

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 [1]. 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 [2]. 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 [3]. 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.

Patient Information

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.

References

Article

  1. Kaneko G, Nishimoto K, Ogata K, Uchida A. A case of intraepithelial squamous cell carcinoma arising from urethral caruncle. Can Urol Assoc J. 2011;5(1):E14-16.
  2. Kaufman RH, Faro S, Brown D: Benign Diseases of the Vulva and Vagina, 5th Edition. Philadelphia: Elsevier Mosby;2005.
  3. Becker LE. Urethral Caruncle: a herald lesion for distal urethral stenosis. J Natl Med Assoc. 1975;67(3):228-230.
  4. Burkland CE. Common Lesions of the Urethra in Women. California Medicine. 1952;76(2):69-73.
  5. Karthikeyan K, Kaviarasan PK, Thappa DM. Urethral caruncle in a male: a case report. J Eur Acad Dermatol Venereol. 2002;16(1):72.
  6. Williamson SR, Scarpelli M, Lopez-Beltran A, et al; Urethral caruncle: a lesion related to IgG4-associated sclerosing disease? J Clin Pathol. 2013;66(7):559-562.
  7. Nakamoto T, Inoue Y, Ueki T, Niimi N, Iwasaki Y. Primary amelanotic malignant melanoma of the female urethra. Int J Urol. 2007;14(2):153-155. 
  8. Indudhara R, Vaidyanathan S, Radotra BD. Urethral tuberculosis. Urol Int. 1992;48(4):436-438.
  9. Ozkurkcugil C, Ozkan L, Tarcan T. The effect of asymptomatic urethral caruncle on micturition in women with urinary incontinence. Korean J Urol. 2010;51(4):257-259.
  10. Conces MR, Williamson SR, Montironi R, et al. Urethral caruncle: clinicopathologic features of 41 cases. Hum Pathol. 2012;43(9):1400-1404.
  11. Cimentepe E, Bayrak O, Unsal A, et al. Urethral adenocarcinoma mimicking urethral caruncle. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17:96.
  12. Fletcher SG, Lemack GE. Benign masses of the female periurethral tissues and anterior vaginal wall. Curr Urol Rep. 2008;9(5):389-396.

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Last updated: 2018-06-22 07:31