Urethral Caruncles: a Review of the Literature

Article ID: WMC003454 ISSN 2046-1690

Urethral Caruncles: A Review of the Literature

Corresponding Author: Mr. Anthony Kodzo - Grey Venyo, Urologist, Urology Department. North Manchester General Hospital - United Kingdom

Submitting Author: Mr. Anthony Kodzo - Grey Venyo, Urologist, Urology Department. North Manchester General Hospital - United Kingdom

Article ID: WMC003454 Article Type: Review articles Submitted on:04-Jun-2012, 05:20:00 PM GMT Published on: 05-Jun-2012, 11:56:49 AM GMT Article URL: http://www.webmedcentral.com/article_view/3454 Subject Categories:UROLOGY Keywords:Urethral Caruncles; Conservative treatment; Surgical treatment; Excision; Urethral prolapsed; Malignancy; Recurrence; Bleeding; Tuberculosis; Non-Hodgkins Lymphoma. How to cite the article:Venyo A . Urethral Caruncles: A Review of the Literature . WebmedCentral UROLOGY 2012;3(6):WMC003454 Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Source(s) of Funding: None

Competing Interests: None

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Urethral Caruncles: A Review of the Literature

Author(s): Venyo A

Abstract Introduction

Background: Urethral caruncles are benign lesions of Urethral caruncles, which quite often originate from the the distal urethra which have been most commonly posterior lip of the urethra, are described as fleshy described in post-menopausal women. Over the years, out-growths of the distal urethral mucosa. Urethral urethral caruncles had been described in women. caruncles are usually small but may grow as large as However, in 2012, Karthikeyan and associates [1] 1 cm to 2 cm in diameter [2]. Literature on urethral reported a urethral caruncle in a male. Urethral caruncles has been reviewed in this paper including a caruncles resemble a variety of urethral lesions discussion of various reported cases on urethral including: urethral carcinoma; urethral diverticulum; caruncles. urethral prolapse; peri-urethral gland abscess. Literature Review Objectives: To review the literature on urethral caruncles including: the aetiology, pathophysiology, presentation, investigation and management. Epidemiology: Sajadi and associates [2] stated that urethral caruncles are rare in the peri-menopausal and Results: Urethral caruncles quite often originate from pre-menopausal women but common in elderly the posterior lip of the urethra and they are described post-menopausal women. They also stated that as: fleshy out-growths of the distal urethral mucosa. urethral prolapses are similar in appearance to Urethral caruncles are usually small but may grow as urethral caruncles, but are circumferential whilst large as 1 cm to 2 cm in diameter. A variety of lesions urethral caruncles tend to be “Focal.” “Urethral have been reported that mimicked urethral caruncles prolapses” may occur in both post-menopausal and and some of these include: melanoma of urethra, pre-pubescent women [2]. On the other hand urethral tuberculosis, urethral leiomyoma, malignancy arising caruncles are seen almost exclusively in in a urethral caruncle. Conservative treatment is the post-menopausal women. treatment of choice for most cases of urethral caruncle. This includes: warm sitz-baths, topical oestrogen Aetiology and Pathophysiology: It has been creams, topical anti-inflammatory drugs. Surgical suggested that the likely first step in the development treatment is reserved for (a) large symptomatic lesions, of urethral caruncle is urethral prolapse caused by (b) cases in which conservative treatment has failed to urogenital atrophy following oestrogen deficiency [2]. It relieve symptoms, (c) cases of uncertain diagnosis. has also been suggested that chronic irritation as a Complications occurring after excision of urethral result of exposure of urethral mucosa contributes to caruncle include recurrence, meatal retraction and the out-growth, haemorrhage and necrosis of the stenosis. urethral caruncle [2]. A variety of lesions have been reported that mimicked urethral caruncles and some of Conclusions: Urethral caruncles are a fairly common these include: melanoma of urethra [3], tuberculosis disease, and most cases can be treated [4], [5], and urethral leiomyoma [6], [7], [8]. conservatively. Nevertheless, carcinoma arising from Nevertheless reports of these lesions are rare. In the urethral caruncle or urethral carcinoma resembling addition Kaneko and associates [9] reported a urethral caruncle has only been occasionally intra-epithelial squamous cell carcinoma arising in a reported. The patient’s condition should therefore, be urethral caruncle in 2 patients. carefully monitored when using conservative therapy for the management of urethral caruncle. Refractory or Sajadi and Kim [2] stated that urethral caruncles have large caruncles and caruncles with un-usual been reported: appearances should be treated aggressively surgically and carefully assessed for the presence of any 1. In the premenopausal patient and these may malignancy or other types of inflammatory lesions enlarge during pregnancy. including tuberculosis. 2. Urethral polyps are the paediatric equivalent of urethral caruncles and these may manifest in similar

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fashion. literature on the efficacy of conservative therapy.

Presentation: The majority of urethral caruncles are Surgical Therapy: Surgical intervention is usually the asymptomatic and are incidentally found clinically treatment of choice for: patients with large during pelvic examinations. The presenting symptoms symptomatic lesions; those with un-certain diagnosis; of other cases of urethral caruncle include: pain in the those with induration around the caruncle; in cases of urethra, dysuria, bleeding or noticing blood in the failure to respond to conservative therapy; atypical underpants or undergarments. It has been stated that appearances; or growth over time are indications for urethral caruncles are unlikely to explain voiding or excisional biopsy. It has been stated that tumours are storage symptoms [2]. Ozkurkcugil and associates [10] found in about 2% of urethral caruncles [2]. compared lower urinary tract symptoms and urodynamic factors in incontinent women with and Pre-operative Preparations: It has been suggested without urethral caruncles and they found no that standard vaginal preparations and pre-operative differences between the two groups. antibiotics are required for the surgical management of urethral caruncle [2]. Findings on Clinical Examination Clinical examination most often reveals: Intra-operative Details: The ensuing intra-operative 1. A reddish or pinkish exophytic lesion at the external details have been recommended [2]. urethral orifice 1. Cystoscopy should be performed initially to exclude 2. Pursuant to thrombosis, on rare occasions they may bladder and urethral abnormalities such as: carcinoma, look purple or black. diverticulum and abscess. 2. A urethral catheter should be inserted into the Based upon the above clinical findings the differential urinary bladder. diagnosis to consider is urethral carcinoma. 3. Stay sutures should be used in the epithelium to prevent mucosal retraction and meatal stenosis. Anatomy of the female urethra: The female urethra is 4. The lesion should be excised. a 4 cm to 5 cm tubular structure which is usually lined 5. The edges should be oversewn with 3-0 or 4-0 by non-keratinized stratified squamous epithelium absorbable sutures. distally and transitional epithelium proximally. The outer layers comprise of a complex network of smooth An alternative surgical treatment has been described muscle and vascular structures. by Park and Cho [11] for the removal of urethral caruncle and this involves ligation of the base of the Investigations: Urinalysis, urine microscopy and caruncle, allowing it to slough off within 1 week to 2 culture are necessary to exclude urinary tract infection weeks. The Park and Cho procedure does not require in cases of dysuria, urethral discomfort or urethral pain. anaesthesia or analgesics. In cases when the diagnosis is obvious on clinical examination and there is no haematuria cystoscopy is Post-operative management: A urethral catheter may not necessary. However, cystoscopy is required to rule be left in the urinary bladder and removed after 1 to 2 out more serious pathologies and in cases when the days to allow for appropriate healing of the urethral cause of haematuria has not been established. mucosa. Microscopic examination of the excised urethral caruncle looks like a bed of granulation tissue which is Follow-up: There is no specific follow-up covered by squamous epithelium (in cases of recommended in the literature if the histology of the caruncles of the distal urethra) and transitional lesions is reported to be benign. epithelium (in cases of caruncles of the proximal urethra).Infolding of the epithelium may create a Complications: It has been stated that if the papillary architecture and inflammatory infiltration is epithelium is not everted with the stay stitch, meatal common [2]. retraction and stenosis may occur [2].

Medical Therapy: It has been stated that [2] most Outcome and Prognosis: It has been stated that the urethral caruncles can be treated conservatively by outcome is excellent if the histological examination warm sitz-baths and vaginal oestrogen replacement confirms urethral caruncle and no other pathology [2]. and that topical anti-inflammatory may be helpful. Nevertheless, there is lack of information in the

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Discussion can be replaced. In cases of urehral prolapse, after a previous operation, the pouting would be irregular, but the replacement should still be possible. Shortening of the urethra may be apparent on endoscopy. Reports of urethral caruncle have appeared in the b. Varicosities which are bluish, elastic, and reduce literature over the last century. Ferrier in 1926 [12] under compression. stated that urethral caruncle occurs at any age from 6 c. Condylomata which are warty, multiple, and years to 90 years. In 1926 Ferrier stated that urethral painless. caruncle is most common in married women of midlife d. Cysts of Skene’s glands. [12]. Ferrier in 1926 stated that Virchow described e. Solid tumours of the urethra. Fibromas and urethral caruncle as a vascular polyp and John B carcinomas of the urethra are rare. They are firm and Murphy described urethral caruncle as a mucous apt to extend up the urethra. membrane wart. In 1926 Ferrier described the f. Carcinomatous glands may occur. macroscopic features of a urethral caruncle as follows: Grossly it is a vascular tumour, pin-head to raspberry As far back as 1926 Ferrier [12] stipulated that the in size, sessile or pedunculated, generally single, following conditions must be met in the surgical located nearly always on the posterior rim of the treatment of urethral caruncles: female urethral meatus. It is red, congested, more so a. Complete eradication. at menstruation, easily bleeding and often exquisitively b. Restoration to normal of the urethra, avoiding sensitive. Ferrier also in 1926 [12] stated that stricture or pulling down of the bladder neck. histologically urethral caruncle was composed of tufts c. Preserving a specimen for histological study. of capillaries in a fibrous and muscular stroma, d. Making the procedure simple, the inconvenience infiltrated according to its degree of inflammation with least, and the convalescence shortest. mono and polynuclear cells. No nerve elements had been demonstrated except in the squamous Ferrier [12] stated that various methods of treatment epithelium which is often ulcerated. had been used, but as emphasized by John B Murphy, the essential of all is complete ablation of that part of Ferrier in 1926 [12] stated that Edward L Young in the basement membrane bearing the “tumour”. If it is 1915 reported 19 cases of urethral caruncle, five of left the “tumour” would recur [12]. which were malignant. Of these, three were traced four to eight years later, and only one had a malignant Young and associates [8] reported six urethral recurrence. Edward L Young stated that the general caruncles in women aged 32 years to 82 years (mean experience would not point to so high a proportion of age 56 years) which contained atypical stromal cells malignancy. Of a larger series in which the removal which raised the concern for neoplasm. The atypical had been by cautery or excision, one third had benign cells varied from spindle to round, the latter, recurrences. All had noted a large proportion of predominating, and typically had scant cytoplasm. A recurrences. minority of the cells were binucleated and often had prominent nucleoli. A single mitotic figure was found in Ferrier in 1926 [12] stated that Crenshaw reported his the atypical cells in one case. The atypical cells were clamp and cautery method of removal in 1920 in which characteristically present in an oedematous out of 118 cases of urethral caruncle, four recurrences background containing numerous inflammatory cells occurred. Ferrier [12] suggested that it may be that and were focally crowded together in five cases. The perhaps because patients lived a distance away from differential diagnosis in this case included a florid their place of treatment all recurrences may not have reactive proliferation of lymphoid cells, but been reported. However, Ferrier stated that Crenshaw immunohistochemical stains failed to support a had confirmed that recurrences were not common lymphoid nature for the atypical cells, and also helped many but there were cases in which the growth had to exclude malignant lymphoma, the neoplasm most recurred again and again. often simulated. Because of the invariable additional component of the atypical spindle cells resembling Ferrier in 1926 [12] stated that the differential those described in the stroma of the female urinary diagnoses to be considered were: tract and in polyps in a variety of sites, the round cells likely represented a variant of this mesenchymal cell. a. Prolapsed urethral mucosa, which would be seen to Similar round mesenchymal cells have also been pout completely at the urethral meatus. Moreover, it documented in the gastrointestinal tract, especially in

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the stomach. Immunohistochemical stains in these carcinoma. The reported histologic features included series showed them to be positive for vimentin in four mixed hyperplastic urothelial and squamous lining, of four cases and for alpha smooth muscle actin in two overlying a variably fibrotic, oedematous, inflamed, of four cases. The prominence of round stromal cells and vascular stroma. Invaginations of urothelium in these cases appeared to be a distinctive feature of extending into the stroma were common (68%), urethral caruncles. Young and associates [8] stated showing rounded nests with cystic or glandular luminal that the presence of these cells should not lead to spaces, similar to urethritis cystic glandularis, without misinterpretation of the lesion to be a neoplastic intestinal metaplasia. Two observed lesions included process. an organizing thrombus, one with intravascular papillary endothelial hyperplasia. Twenty patients were Kaneko and associates [9] reported a 62-year-old treated with topical medications without resolution. patient who had occasional bleeding from a mass in Three lesions recurred (7%) after excision. A subset of the urethral meatus. She had been conservatively patients had a history of smoking or previous pelvic treated with steroid ointment for one year nevertheless, irradiation. They concluded that: the bleeding had persisted. The patient was therefore referred for further treatment. A reddish mass 1. Urethral caruncle is an uncommon lesion which may measuring 5 mm in diameter was noted at the clinically mimic benign and malignant conditions. posterior lip of the urethral meatus. The mass was 2. Awareness of the spectrum of clinical and diagnosed as a urethral caruncle and removed. histological differential diagnoses is important in Microscopically, the squamous epithelium which dealing with this uncommon disease. covered the urethral caruncle, was found to be keratinized, with the proliferation of atypical cells, with Nakamoto and associates [3] reported the case of a swollen nuclei in the entire mucosal layer. The mass 75-year-old woman who complained of a mass at the was finally diagnosed to be intra-epithelial squamous external urethral meatus. Urethral carunculectomy was cell carcinoma arising from the urethral caruncle. performed. The histological diagnosis was amelanotic Kaneko and associates [9] stated that most cases of malignant melanoma. She finally underwent en block urethral caruncle are frequently asymptomatic, but resection of urethra including bladder neck, uterus, some patients experience a lump or bleeding at the adnexa, vagina, and vulva. As a urinary diversion, she urethral meatus. Pugh [13] stated that the lesion is underwent a continent- chatheterizable stoma with an considered to be neither neoplastic nor pre-neoplastic, appendicovesicostomy according to the method but probably result from local trauma or inflammation. described by Mitrofanoff, and a Y-V graft for Nevertheless, carcinoma (1.6%) and Bowen’s disease reconstruction of the vulva. (0.8%) are extremely rarely and have been noted in 2.4% of patients with a clinical diagnosis of urethral Raspollini and associates [16] reported a 33-year-old caruncle [9]. Kaneko and associates [9] also stated man who presented with a 1.5 cm polypoid lesion at that the occurrence of intraepithelial squamous cell the edge of the external urethral meatus which carcinoma arising from a urethral caruncle is showed a gross appearance similar to that of a extremely rare and their search of the English urethral caruncle in the female. The histological literature revealed only one other cases in addition to features revealed a superficially ulcerated lesion their case totalling 2 cases. composed of colonic-type mucosal glands with focal regenerative atypia. They stated that this case Marshall and associates [14] reported that appeared to be the first reported case of an intraepithelial coexisted with “a benign appearing” intestinal-type polyp. The patient had no further urethral caruncle in only 1 of 376 patients who a problems after the excisional biopsy. urethral caruncle resection. Conces and associates [15] reported the clinicopathological features of 41 Cimentepe and associates [17] reported 57-year-old cases of urethral caruncle. They reported that the female with a urethral lesion that looked like a average patient age was 68 years (range 28 years to caruncle , but histological examination of the excised 87 years). The presenting symptoms were pain (37%), lesion was reported as urethral adenocarcinoma. haematuria (27%), dysuria (20%), in contrast to asymptomatic (32%). The clinical diagnosis favoured Singh and Hemal [18] stated that primary urethral malignancy in 10% of cases. Concurrent or tuberculosis associated with a urethral caruncle is an subsequent urothelial carcinoma was present for 5 extremely rare entity and that their reported case was patients (12%), although none developed urethral the second of such cases to be reported. They

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reported a middle-aged woman who presented with 4. Indudhara R, Vaidyanathan S, Radotra B D. symptoms of frequency dysuria syndrome for 2 years. Urethral tuberculosis. Urol Int. 1992; 48(4): 436 – 438 They also reported that local examination and [Medline] cystoscopy localized paraurethral induration, 5. Singh I, Hemal A K. Primary urethral tuberculosis tenderness, and urethral caruncle with chronic masquerading as a urethral caruncle: a diagnostic obliterative urethritis. Trans-vaginal ultrasound scan curiosity. Int Urol Nephrol. 2002; 34(1): 101 – 103 revealed a solid lesion arising from the posterior [Medline] urethral wall. Excision of the caruncle and 6. Saroha V, Dhingra K K, Gupta P, Khurana N. trans-urethral resection of the paraurethral mass Urethral leiomyoma mimicking a caruncle. Taiwan J lesion revealed chronic granulomatous inflammation Gynecol. 2010 Dec; 49(4): 523 – 524 [Medline] with chronic urethritis and fibrocollagenous tissue. 7. Khatib R A, Khalil A M, Tawil A N, Shamseddine A I, Kaspar H G, Suidan F J. Non-Hodgkin’s lymphoma Karthikeyan and associates [1] reported a urethral presenting as a urethral caruncle. Gynecol Oncol. caruncle in a 60-year-old male labourer. They stated 1993 Sep; 50(3): 389 – 393 [Medline]. that its occurrence had not been previously reported in 8. Young R H, Oliva E, Garcia J A, Bhan A K, Clement the literature. P B. Urethral caruncle with atypical stromal cells simulating lymphoma or sarcoma – a distinctive Atalay and associates [19] stated that Non-Hodgkin’s pseudoneoplastic lesion of females: A report of six lymphoma of the female urethra was extremely rare cases. Am. J Surg Pathol. 1996 Oct; 20 (10): 1190 – and to their knowledge only ten cases had previously 1195 [Medline]. been reported in the literature and their reported case 9. Kaneko G, Nishimoto K, Ogata K, Uchida A. A case was the 11th case of Non-Hodgkin’s lymphoma of the of intraepithelial squamous cell carcinoma arising from female urethra presenting as a caruncle. urethral caruncle. Can Urol Assoc J. 2011 Feb; 5(1): E 14 – 16 [Medline] Conclusions 10. Ozkurcugil C, Ozkan L, Tarcan T. The effect of asymptomatic urethral caruncle on micturition in women with urinary incontinence Korean J Urol. 2010 Urethral caruncle is a fairly common disease, and Apr; 51(4): 257 – 259 [Medline] most cases of urethral caruncle can be treated 11. Park D S, Cho T W. Simple solution for urethral conservatively. Nevertheless, carcinoma arising from caruncle. J Urol 2004 Nov; 172 (5 Pt 1): 1884 – 1885 the urethral caruncle or urethral carcinoma resembling [Medline] a urethral caruncle has only been occasionally 12. Ferrier P A. Urethral Caruncle. Califonia and reported. The patient’s condition should therefore, be Western Medicine 1926; 24(4): 500 - 501 carefully monitored when using conservative therapy 13. Pugh R C. Systemic Pathology, 3rd edition. for the management of urethral caruncle. Refractory Philadelphia, PA: W B Saunders Company. The or large caruncles and caruncles with un-usual Kidneys: Urinary Tract. 1992; 745 appearances should be treated aggressively surgically 14. Marshall F C, Uson A C, Melicow M M. Neoplasia and carefully assessed for the presence of any and caruncles of the female urethra. Surg Gynecol malignancy or other types of inflammatory lesions Obstet. 1960; 110: 723 – 733 [PubMed] including tuberculosis. 15. Conces M R, Williamson S R, Montironi R, Lopez-Beltran A, Scarpelli M, Cheng L. Urethral References Caruncle: clinicopathologic features of 41 cases. Human Pathology 2012 Mar 5; can be seen at: http://dxdoi.org/10.1016/jhumpath.2011.10.015 1. Karthikeyan K, Kaviarasan P K, Thappa D M. 16. Raspollini M R, Nicita G, Mikuz G. Int J Surg Urethral caruncle in a male: a case report. J Eur Acad Pathol. Mar 13; [Epub ahead of print] PMID: 22415058. Dermatol Venereol. 2002 Jan; 16(1): 72 – 73 [Medline] 17. Cimentepe E, Bayrak O, Uncal A, Koc A, Ataoglu 2. Sajadi K P, Kim E D. Urethral Caruncle treatment & O, Balbay M D. Urethral adenocarcinoma mimicking Management emedicine 2011 Aug 15 can be found at: urethral caruncle. Int Urogynecol J pelvic Floor emedicine-medscape.com/article443099-overview. Dysfunct. 2006 Jan; 17(1): 96 – 98 3. Nakamoto T, Inoue Y, Ueki T, Niimi N, Iwasaki Y. 18. Singh I, Hemal A K. Primary urethral tuberculosis Primary amelanotic malignant melanoma of the female masquerading as a urethral caruncle: a diagnostic urethra. Int J Urol. 2007 Feb; 14(2):153 – 155 curiosity! Int Urol Nephrol 2002; 34(1): 101 – 103 [Medline] 19. Atalay A C, Karaman M I, Basak T, Utkan G,

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Ergenekon E. Non-Hodgkin’s lymphoma of the female urethra presenting as a caruncle. Int Urol Nephrol. 1998; 30(5): 609 – 610

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Reviews Review 1

Review Title: Urethral Caruncles

Posted by Dr. Emad Bakir on 17 Jun 2012 03:16:05 PM GMT What are the main claims of the paper and how important are they?: It is an interesting paper which adresses the importance of this entities and the differential diagnosis but also the management of this common post menopausal disease by women.

It is a very good paper in refreshing the minds of urologists and think about this disease , however the mostrecent finding is bySajedi where a urethral Caruncle has been found by a male,suggesting this disease might be underestimatet by males or may be asymptomatic. Interesting ould be the cadaver findings and if urethral caruncles are found bymales and females in equal numbers.

yes

If a protocol is provided, for example for a randomized controlled trial, are there any important deviations from it? If so, have the authors explained adequately why the deviations occurred? NA

yes, try to find out from cadaver species if urethral caruncles are equaly seen by males and females.

Rating: 8 Comment: Good paper, which helps understand disease and management and encourage further research in the sex distribution.

Competing interests: No Invited by the author to make a review on this article? : No Have you previously published on this or a similar topic?: No Experience and credentials in the specific area of science: Consultant Radiologist/Uroradiologist

How to cite: Bakir E.Urethral Caruncles[Review of the article 'Urethral Caruncles: A Review of the Literature ' by ].WebmedCentral 1970;3(6):WMCRW001935

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