Urethral caruncle

A urethral caruncle is a benign fleshy outgrowth at the urethral meatus that occurs mainly at posterior lip of urethra¹ .

Epidemiology

It is uncommon, but is most commonly found in postmenopausal women¹² .

Aetiology

Aetiology is not well understood. Lack of oestrogen may be a factor. Viral, autoimmune and inflammatory proliferative factors do not appear to be implicated³ .

Presentation

Urethral caruncles are typically asymptomatic and are mostly reported as incidental findings during pelvic examination. Common symptoms include bleeding, haematuria, pain, dysuria or a lump¹ .

History²

Often there are no symptoms but sometimes they are painful. There may be dysuria and occasionally they may bleed. Urethral caruncles do not appear to have a detrimental effect on micturition or continence⁴ . Urethral caruncles are an unusual cause of postmenopausal bleeding.

Examination

There is a soft smooth red fleshy lesion or red ring of urethral mucosa protruding through the urethral orifice. It may appear to be polypoid (sessile or pedunculated). They may (rarely) thrombose and turn purple or black. Urethral caruncles tend to be soft and may be tender whilst malignancy is usually firm and not tender.

Differential diagnosis

The main differential diagnosis is urethral mucosal prolapse. The following conditions have been reported to present masquerading as a urethral caruncle:

• Malignant melanoma of the urethra⁵ .

• Carcinoma of the urethra⁶⁷ .

• Urethral tuberculosis.

• Lymphoma.

• Urethral leiomyoma⁸ .

• Intestinal ectopia.

Investigations

If the diagnosis is clear there is no need for further investigation. If dysuria is present, a midstream specimen of urine (MSU) should be sent for microscopy and culture to exclude urinary tract infection. Only if there is uncertainty about diagnosis are cystoscopy and biopsy indicated.

Management

If the diagnosis is clear and the lesion is asymptomatic then no further action is required. Management options include:

• In perimenopausal and postmenopausal women, oestrogen cream may be useful⁹ .

• Warm salt baths and anti-inflammatory creams have been used, although some evidence suggests they lack efficacy² .

• If symptoms persist, caruncles can be removed using cauterisation, laser vaporisation, excision or even ligation. Cryotherapy or surgical excision may also be used.

• Surgical intervention is indicated only if the lesions are large or the diagnosis is uncertain.

Prognosis

If the diagnosis is correct, there is no associated mortality. Symptoms (if any) should subside with treatment.

Primary carcinomas arising from a urethral caruncle are rare but are known to occur¹⁰ .