Urethral Caruncle

A urethral caruncle is a benign granulomatous lesion of the distal urethra (usually posterior wall) covered by or transitional epithelium.¹

It is uncommon, but most often found in postmenopausal women. It can sometimes occur before the menopause. A single case has been reported in a man.³

History

Usually there are no symptoms but sometimes they are painful. There may be dysuria and occasionally they may bleed.⁴ It is an unusual cause of postmenopausal bleeding, in one series accounting for 2.5%.⁵

Examination

There is a soft smooth red fleshy lesion² or red ring of urethral mucosa protruding through the urethral orifice.⁶ It may appear to be polypoid (sessile or pedunculated). Urethral caruncles tend to be soft and may be tender whilst malignancy is usually firm and not tender.²

The main differential diagnosis is with urethral prolapse (occurs in younger women). This is more likely if the woman is around the menopause rather than elderly and almost invariably the case if the lesion is seen before the menarche. Rarities such as non-Hodgkin's lymphoma⁷ and intestinal polyp-like lesions⁸ have been described. If they are large, necrotic and bleed they may look like urethral carcinoma. Carcinoma can also look like a caruncle.⁹

If the diagnosis is clear there is no need for further investigation. If dysuria is present, a MSU should be sent for microscopy and culture to exclude urinary tract infection. Only if there is uncertainty about diagnosis is 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 recommended.
• If symptoms persist caruncles can be removed using cauterisation, laser vaporisation or excision. 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.¹⁰ Of these about 2% will show malignancy.¹ If the epithelium is not adequately everted during surgery, meatal stenosis may result.¹

If the diagnosis is correct, there is no associated mortality and symptoms, if any, should subside with treatment.