Background

Urethral caruncle is a benign condition characterized by inflammation, commonly found at the urethral meatus in females. It typically manifests as a small, flesh-like growth near the urethral opening and can lead to various urinary symptoms like pain, discomfort, and bleeding during urination.  

Primarily affecting postmenopausal women, urethral caruncle can also occur in younger females and, albeit rarely, in males. Factors such as hormonal fluctuations, urinary tract infections, and mechanical irritation from sexual activity or hygiene practices may contribute to its development. 

Epidemiology

Urethral caruncle occurred mostly in post-menopausal females. It may also occur in girls but rarely. 

Relative estrogenic shortage can occur in premenopausal women because of nursing, postpartum conditions, or exogenous oral contraceptives. 

Anatomy

Pathophysiology

Hormonal changes: Estrogen deficiency, especially prevalent in postmenopausal women, is a significant factor in the development of urethral caruncle. Diminished estrogen levels result in the thinning and atrophy of the mucosal lining, rendering it more susceptible to irritation, inflammation, and injury. Some patients with urethral caruncle have experienced symptom relief and improvement in their condition with estrogen replacement therapy. 

Inflammation and irritation: Extended contact with substances such as strong soaps, fragrances, vaginal douches, or infectious agents can result in persistent inflammation of the urethral meatus. This ongoing inflammation can disrupt the usual structure of the mucosal lining by releasing inflammatory mediators, which may contribute to the development of a caruncle. 

Changes in Vascular Supply: Alterations in the vascular network supplying the urethral meatus may also play a role in the development of urethral caruncle. Increased blood flow may exacerbate tissue irritation and promote the growth of a caruncle. 

Etiology

Chronic Irritation: Extended contact with irritants or inflammatory substances can cause the urethral mucosa to become chronically irritated, which puts people at risk of developing urethral caruncles. Harsh soaps, fragrances, vaginal douches, and certain hygiene habits are examples of common irritants.  

Mechanical Trauma: Mechanical trauma to the urethral meatus, such as friction during sexual intercourse, insertion of tampons or urinary catheters, or aggressive hygiene practices, can cause injury to the delicate mucosal lining. Repetitive trauma or friction can lead to the formation of small tears or abrasions in the urethral tissue, which may subsequently heal with the formation of a caruncle. 

Inflammatory Conditions: Underlying inflammatory conditions affecting the urogenital tract, such as urethritis, vaginitis, or dermatologic conditions like lichen sclerosus, may predispose individuals to develop urethral caruncle. Chronic inflammation of the urethral mucosa can disrupt its normal structure and function, leading to the formation of inflammatory lesions like caruncles. 

Genetics

Prognostic Factors

The prognosis of the urethral caruncle is generally favorable, as it is a benign lesion that rarely progresses to severe complications or malignancy. With appropriate diagnosis and management, most patients experience symptomatic relief and resolution of the lesion. 

Clinical History

• Age group 

Urethral caruncle can occur across a wide age range, but it is most observed in postmenopausal women. While it can affect females of any age, including children, adolescents, and premenopausal adult. 

Postmenopausal women are more likely to experience thinning of the urethral mucosa and weakening of the surrounding tissues, making them prone to the development of urethral caruncle. 

• Associated Comorbidity or Activity: 

Hormonal Changes: Urethral caruncles are frequently linked to hormonal changes, especially the lower estrogen levels that postmenopausal women experience. Urethral caruncles can occur because of urogenital atrophy, urethral mucosa thinning, and increased susceptibility to irritation and inflammation caused by low estrogen levels. 

 Urinary Tract Infections: UTIs that are persistent or recurrent could aggravate and inflame the urethral mucosa, which may raise the risk of urethral caruncle development. On the other hand, urethral caruncles can cause obstruction or insufficient bladder emptying, which can make people more susceptible to urinary stasis and recurrent UTIs. 

Sexual Activity: Intercourse can aggravate symptoms or hasten the formation of urethral caruncle, especially when it involves friction or trauma to the urethral meatus.  

Good Hygiene Habits: Harsh soaps, scented products, and excessive genital cleansing are examples of aggressive or abrasive hygiene habits that can irritate the urethral mucosa and cause inflammation. In addition, improper wiping methods or the use of rough toilet paper might aggravate symptoms or interfere with the healing process for those who have urethral caruncles. 

Vaginal Atrophy: Women who have vaginal atrophy or other gynecological disorders that cause the urethral and vaginal tissues to shrink and dry up may be more susceptible to urethral caruncles. Treatments like radiation therapy, certain medical disorders, or hormonal changes related to menopause can all cause vaginal shrinkage. 

Chronic Inflammatory Conditions: People who suffer from urogenital tract inflammatory diseases including urethritis, vaginitis, or lichen sclerosus may be more susceptible to developing urethral caruncles. Prolonged inflammation of the urethral mucosa can cause structural and functional abnormalities, resulting in the development of inflammatory lesions such as caruncles. 

• Acuity of Presentation: 

Dysuria or painful urination: One of the most typical signs of urethral caruncles is dysuria. It is possible for patients to feel mild to severe burning, stinging, or discomfort when urinating. 

Urinary Frequency and Urgency: The caruncle’s irritation of the urethral mucosa may result in increased frequency and urgency of urination. Even when the bladder is not full, patients may have sudden or increased urges to urinate. 

Pain or Discomfort: Individuals who have urethral caruncles may feel pain or discomfort in the genital area, especially when urinating or having sex. The urethral opening may be the only location of pain, or it may spread to the surrounding tissues. 

 Urinary Retention: Urinary retention is a rare side effect of urethral caruncles that causes patients to have trouble emptying their bladder entirely. This may cause discomfort in the lower abdomen, a feeling of incomplete voiding, or even incontinence from urine overflow. 

Evident Lesion: Patients may occasionally observe a growth or lesion that is evident at the urethral meatus. The typical appearance of a urethral caruncle is a tiny, fleshy mass that protrudes from the urethral entrance; it can vary in size and colour, usually appearing red or pink. 

Physical Examination

External Genital Examination: Start by looking for any obvious abnormalities, including erythema, edema, or lesions, on the external genitalia. Keep an eye out for any skin changes, discharge, or inflammation in the vulvar and perineal areas. 

 Inspection of the Urethral Meatus: To view the urethral meatus, gently split the labia minora. Look closely for any signs of a fleshy lump or lesion on the meatus; these can be pinkish or reddish protrusions. Any abnormalities should be noted, along with their size, shape, colour, and position. 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Urethral Prolapse: The urethral caruncle usually manifests as a unilateral lesion, whereas the urethral prolapse frequently comprises circumferential protrusion of the urethral mucosa. 

Urethral Diverticulum: This pouch-like protrusion of the urethral wall can produce symptoms including hematuria, dysuria, and frequent urination that are like those of urethral caruncles. It could be required to do imaging tests, like urethrography or MRI, to distinguish between the two disorders. 

Urethral Cyst: Benign fluid-filled sacs that can form along the urethra are called urethral cysts. They can cause symptoms like those of the urethral caruncle and may manifest as palpable lumps at the urethral meatus. To confirm the existence of a cyst, aspiration or imaging procedures may be necessary for a differential diagnosis. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Conservative Management: Warm Sitz Baths: Immersion in warm water can ease pain and encourage pelvic muscle relaxation. 

Topical estrogen therapy: Especially for postmenopausal women, topical estrogen cream or ointment administered to the urethral meatus can help enhance tissue integrity and reduce inflammation. 

Symptomatic Relief: To ease pain and discomfort during urination, over-the-counter painkillers like paracetamol or nonsteroidal anti-inflammatory medications may be suggested. 

 Surgical Excision: In cases where conservative management is not working or where there are characteristic symptoms like bleeding, urinary obstruction, or recurrent infections, surgical excision of the urethral caruncle may be warranted.  

Hormonal Therapy: Estrogen therapy can be administered orally, transdermally, or vaginally, depending on patient preference and individual considerations. 

Regular follow-up and monitoring may be necessary to assess treatment response and adjust hormone therapy as needed. 

Preventive Measures: 

Avoidance of Irritants: Patients should be advised to avoid harsh soaps, perfumed products, and other irritants that can exacerbate symptoms or delay healing. 

Hygiene Practices: Encourage gentle cleansing of the genital area with mild soap and water and recommend wiping from front to back after urination to prevent contamination of the urethral meatus. 

Regular Follow-up: Patients should undergo regular follow-up evaluations to monitor for recurrence of symptoms or complications and to assess treatment efficacy. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

lifestyle-modifications-in-treating-urethral-caruncle

Hygiene Practices:  

Gently Cleansing: Advise patients to wash their genitalia with water and a light, scent-free soap. Scented items and harsh soaps might aggravate symptoms by irritating the urethral meatus. 

Appropriate Wiping Technique: Tell patients to wipe from front to back after urinating to avoid feces contaminating the urethral meatus, which raises the risk of infection and irritation. 

Clothes Options:  

Loose-Fitting Apparel: It is recommended to wear loose-fitting undergarments and clothing composed of breathable materials, such as cotton. Wearing clothing that is too tight might increase sweat and friction in the vaginal area, which may worsen discomfort. 

Avoidance of Irritants: Avoid synthetic materials and form-fitting undergarments with elastic bands since they may irritate and press against the urethral meatus. 

Personal Care Products:  

pH-Balanced Cleansers: To preserve the skin’s natural acidity and avoid upsetting the vaginal and urethral flora, suggest using pH-balanced cleansers that are specially designed for the genital area. 

Avoidance of Irritants: 

Reducing Exposure to Potential Irritants: Suggest to patients to stay away from products that may irritate their vagina, such as spermicides, vaginal douches, and some lubricants, since they may upset the normal balance of their genital microbiota and raise their risk of inflammation. 

Quitting Smoking: Patients who smoke should be encouraged to give up since tobacco smoke contains a variety of irritants and toxins that can worsen inflammation and slow the healing of wounds in the genital area. 

Techniques for Stress Management and Stress Reduction: Suggest methods for reducing stress and enhancing general well-being, such as yoga, deep breathing exercises, mindfulness meditation, or relaxation techniques. Prolonged stress has the potential to worsen inflammation and heighten symptoms. 

Environmental Hygiene:  

Cleanliness of Toilet Seats: Tell patients to use toilet paper or disposable seat coverings as a protective barrier and to make sure that toilet seats in public toilets are clean. Urinary tract infections can become more likely because of contact with polluted surfaces. 

Effectiveness of intravaginal estrogen in treating urethral caruncle

estradiol vaginal :

Dosage regimens and recommended treatment durations differ for specific products. Generally, vaginal inserts or creams are prescribed for one time-a-day use over one to two weeks, after which a lower dosage is advised, transitioning to a maintenance dose of weekly two to three times. 

role-of-surgery-in-treating-urethral-caruncle

When conservative treatment is ineffective in treating a urethral caruncle or when the lesion is causing substantial discomfort, bleeding, or obstruction, surgery may be an option. The purpose of surgery is to remove the caruncle and encourage the urethral mucosa to recover.  

Excisional Surgery: 

In an excisional procedure, the urethral caruncle and any afflicted surrounding tissue are removed entirely. Usually, this treatment is carried out in an outpatient environment while under local anesthesia. 

After the lesion is thoroughly excised, the borders of the mucosa are often sutured together to aid in wound healing and avoid recurrence. The surgeon uses sharp dissection or electrocautery to achieve total removal while minimizing harm to surrounding good tissue. 

Pain treatment, sitz baths, and topical antibiotics are examples of postoperative care that may be necessary. 

role-of-management-in-treating-urethral-caruncle

Evaluation and Diagnosis: 

 Symptom Evaluation: The initial stage entails a comprehensive review of the patient’s medical background and current symptoms, which may include genital discomfort, pelvic pain, and urine issues. 

Physical Examination: This examination should include an evaluation of the urethral meatus and external genitalia. 

Diagnostic Tests: To assess urinary tract function and rule out other urinary tract diseases, additional diagnostic tests, such as urinalysis, urine culture, and imaging studies, may be carried out. 

Conservative Management: 

Symptomatic Relief: The goal of conservative management techniques is to reduce discomfort and symptoms. This could involve changing one’s way of living to stay away from irritants, drink enough water, and take proper care of one’s genitalia. 

Topical Therapies: To enhance tissue quality and lessen inflammation of the urethral mucosa, topical estrogen cream or ointment may be administered, especially to postmenopausal women. 

Surgical Intervention: 

Surgical intervention may be considered if conservative methods are insufficient in relieving symptoms or if the urethral caruncle is causing severe discomfort, bleeding, or blockage. 

Surgical intervention aims to remove the urethral caruncle altogether while preserving the surrounding healthy tissue and promoting optimal wound healing. Surgical options include excisional surgery, laser ablation, cryotherapy, or transurethral resection, depending on the size and location of the lesion, patient preference, and surgeon expertise. 

Postoperative Care: 

Patients need postoperative care after surgery to monitor for complications, promote wound healing, and manage postoperative symptoms. This care may involve antibiotics to prevent infection, pain management to reduce discomfort, and wound care and hygiene instructions. During the early stages of their recovery, patients may also be recommended to refrain from sexual activity, intense physical activity, and other activities that could aggravate the surgical site. 

Long-Term Follow-Up: 

Patients should be informed about preventive measures, such as avoiding irritants and maintaining good genital hygiene, to minimize the risk of recurrence.  

Patients and their healthcare practitioner should schedule routine examinations, who may conduct repeat examinations and diagnostic tests as needed to ensure the resolution of symptoms and the absence of recurrence. 

Medication

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References

Urethral caruncle in a perimenopausal female: Dramatic response to topical estrogen cream – PMC (nih.gov)