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Urethral Caruncle Surgery India

Urethral caruncle is a term that describes a benign polypoidal growth at the urethral meatus. It is most commonly observed in postmenopausal women. Certain tumors can masquerade as a urethral caruncle. The caruncle may be asymptomatic or it can present with dysuria and bloody discharge. The diagnosis is made by microscopic examination, while treatment includes excision in symptomatic patients.

Presentation

The majority of patients are asymptomatic, and the diagnosis of urethral caruncle is incidental either during a physical examination or during invasive diagnostic procedures. Patients most often complain of painful and frequent urination, with or without hematuria. During the physical examination, patients frequently report pain during urethral palpation and the lesion can be diagnosed during inspection and palpation because it often protrudes from the external urethral meatus. This lesion may be significantly debilitating for patients and cause significant distress.

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 urethra.

• Carcinoma of the urethra.

• Tuberculosis.

• Lymphoma.

• Urethral leiomyoma.

• 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.

• 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.

Treatment

For patients with asymptomatic urethral caruncles, treatment is usually not indicated. In symptomatic patients, initial management strategies may include topical estrogen creams and sitz baths, together with non-steroidal anti-inflammatory drugs (NSAIDs) to manage pain. However, there is limited data on their efficacy. On the other hand, surgical excision is the definite treatment measure and is recommended for patients with severe symptoms. Although studies have shown very low rates of malignant tumors mimicking as urethral caruncle (about 2.4%), all symptomatic patients should undergo surgical excision and subsequent histopathological evaluation to exclude neoplasms.

Prognosis

Because the majority of patients are asymptomatic and surgical treatment is successful when indicated, the prognosis is generally good. However, in very rare cases, patients may be misdiagnosed and the caruncle may mask the presence of a malignant tumor, which can be particularly dangerous in the case of malignant melanoma, because of its metastatic potential. Other tumors that have been reported include squamous cell carcinoma, transitional cell carcinoma, while tuberculosis has also been reported initially as urethral caruncle. All symptomatic patients should undergo cystoscopy if the cause of symptoms is not determined through urinalysis or other laboratory findings.

Etiology

The exact reason why urethral caruncle develops is not entirely understood, but certain factors have been implied in its development. Presumably, lack of estrogen during menopause leads to atrophy of the urothelium, which is thought to be a risk factor for urethral prolapse and development of caruncle, while chronic inflammation due to currently unknown etiologies may contribute as well.

Epidemiology

Prevalence rates of this benign tumor have not been reported, as the majority of patients are asymptomatic, but it is referred to as one of the most common benign tumors of the urethra. This lesion is most commonly encountered in postmenopausal women, presumably due to hormonal factors and irritation during repeated deliveries. Rare cases of urethral caruncles in males have been reported, while ethnic predilection has not been established.