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A urethral caruncle is a benign polypoid mass of the urethral meatus, most commonly found in postmenopausal women.
Aetiology is not well understood. Lack of oestrogen may be a factor. Viral, autoimmune and inflammatory proliferative factors do not appear to be implicated.
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. Urethral caruncles are an unusual cause of postmenopausal bleeding.
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, 6]
- Carcinoma of the urethra.[7, 8, 9]
- Urethral leiomyoma.
- 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.
- In the elderly patient with oestrogen deficiency and symptoms, oestrogen cream may be useful.
- Warm salt baths and anti-inflammatory creams have been used, although some evidence suggests they lack efficacy.
- 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.
- Primary carcinomas arising from a urethral caruncle are rare but are known to occur.
If the diagnosis is correct, there is no associated mortality. Symptoms (if any) should subside with treatment.
Further reading and references
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.
Karthikeyan K, Kaviarasan PK, Thappa DM; Urethral caruncle in a male: a case report. J Eur Acad Dermatol Venereol. 2002 Jan16(1):72-3.
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.
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.
Nakamoto T, Inoue Y, Ueki T, et al; Primary amelanotic malignant melanoma of the female urethra. Int J Urol. 2007 Feb14(2):153-5.
Gunther V, Alkatout I, Lez C, et al; Malignant melanoma of the urethra: a rare histologic subdivision of vulvar cancer with a poor prognosis. Case Rep Obstet Gynecol. 20122012:385175. doi: 10.1155/2012/385175. Epub 2012 Dec 20.
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.
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.
Cimentepe E, Bayrak O, Unsal A, et al; Urethral adenocarcinoma mimicking urethral caruncle. Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jan17(1):96-8. Epub 2005 Apr 15.
Singh I, Hemal AK; Primary urethral tuberculosis masquerading as a urethral caruncle: a diagnostic curiosity! Int Urol Nephrol. 200234(1):101-3.
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.
Park DS, Cho TW; Simple solution for urethral caruncle. J Urol. 2004 Nov172(5 Pt 1):1884-5.
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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