Urethral Caruncle

Authored by , Reviewed by Dr Laurence Knott | Last edited | Meets Patient’s editorial guidelines

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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.

A urethral caruncle is a benign fleshy outgrowth at the urethral meatus that occurs mainly at posterior lip of urethra[1].

It is uncommon, but is most commonly found in postmenopausal women[1, 2].

Aetiology is not well understood. Lack of oestrogen may be a factor. Viral, autoimmune and inflammatory proliferative factors do not appear to be implicated[3].

Urethral caruncles are typically asymptomatic and are mostly reported as incidental findings during pelvic examination. Common symptoms include bleeding, haematuria, pain, dysuria or a lump[1].

History[2]

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 continence[4]. 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.

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 urethra[5].
  • Carcinoma of the urethra[6, 7].
  • Urethral tuberculosis.
  • Lymphoma.
  • Urethral leiomyoma[8].
  • Intestinal ectopia.

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.

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 useful[9].
  • Warm salt baths and anti-inflammatory creams have been used, although some evidence suggests they lack efficacy[2].
  • 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.

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 occur[10].

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Further reading and references

  1. Verma V, Pradhan A; Management of urethral caruncle - A systematic review of the current literature. Eur J Obstet Gynecol Reprod Biol. 2020 May248:5-8. doi: 10.1016/j.ejogrb.2020.03.001. Epub 2020 Mar 6.

  2. Conces MR, Williamson SR, Montironi R, et al; Urethral caruncle: clinicopathologic features of 41 cases. Hum Pathol. 2012 Sep43(9):1400-4. doi: 10.1016/j.humpath.2011.10.015. Epub 2012 Mar 6.

  3. Williamson SR, Scarpelli M, Lopez-Beltran A, et al; Urethral caruncle: a lesion related to IgG4-associated sclerosing disease? J Clin Pathol. 2013 Jul66(7):559-62. doi: 10.1136/jclinpath-2012-201218. Epub 2012 Nov 30.

  4. Ozkurkcugil C, Ozkan L, Tarcan T; The effect of asymptomatic urethral caruncle on micturition in women with urinary incontinence. Korean J Urol. 2010 Apr51(4):257-9. doi: 10.4111/kju.2010.51.4.257. Epub 2010 Apr 20.

  5. Safadi A, Schwalb S, Ben-Shachar I, et al; Primary malignant urethral melanoma resembling a urethral caruncle. Urol Case Rep. 2017 Sep 915:28-29. doi: 10.1016/j.eucr.2017.08.004. eCollection 2017 Nov.

  6. Shim JS, Oh MM, Lee JG, et al; Anterior urethrectomy for primary carcinoma of the female urethra mimicking a urethral caruncle. Int Neurourol J. 2013 Dec17(4):197-9. doi: 10.5213/inj.2013.17.4.197. Epub 2013 Dec 31.

  7. Tatemichi Y, Oikawa H, Maesawa C, et al; Detection of human papillomavirus in a urothelial carcinoma mimicking urethral caruncle. Int J Urol. 2010 Feb17(2):189-91. doi: 10.1111/j.1442-2042.2009.02434.x.

  8. Saroha V, Dhingra KK, Gupta P, et al; Urethral leiomyoma mimicking a caruncle. Taiwan J Obstet Gynecol. 2010 Dec49(4):523-4. doi: 10.1016/S1028-4559(10)60110-6.

  9. Balai M, Gupta LK, Kumari A; Urethral caruncle in a perimenopausal female: Dramatic response to topical estrogen cream. Indian J Urol. 2018 Oct-Dec34(4):308-309. doi: 10.4103/iju.IJU_200_18.

  10. Kaneko G, Nishimoto K, Ogata K, et al; A case of intraepithelial squamous cell carcinoma arising from urethral caruncle. Can Urol Assoc J. 2011 Feb5(1):E14-6. doi: 10.5489/cuaj.10027.

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