The urethral caruncle is one of the most common urethral lesions in postmenopausal women. It appears as a polypoid lesion at the exit of the urethra. Symptoms of the disease are manifested mainly in the form of urinary complaints. Complaints may be more depending on the size of the lesion. In this article, I will give general information about the causes, symptoms and treatment of caruncle with my own experience.

What is the urethral caruncle?

The urethral caruncle is benign lesions of vascular origin, seen at the tip and posterior surface of the urethral opening in women. It is one of the most common urethral lesions in women. It can sometimes be seen with a raspberry-like stem. It mainly occurs in postmenopausal women. It can be seen very rarely in childhood.

Does caruncle mean prostate in women?

The prostate is an organ found in men. Women do not have a prostate. Skene’s glands, located in the urethra (urinary tract after the bladder) in women, are thought to be a remnant similar to the prostate gland in men. Studies have shown that Skene’s glands produce PSA (prostate specific antigen) like prostate tissue in men. In female patients with a large caruncle that covers the urethra, complaints similar to prostate enlargement in older men occur. BPH occurs in men at an advanced age. Likewise, caruncle disease seen in women is mostly seen after menopause. In other words, these two diseases are seen in advanced ages.

What are the signs/symptoms of the caruncle?

Most of the time, it may not cause any symptoms. Sometimes, patients apply to the urology physician with complaints related to the disease. The most common complaints in patients with caruncles are:

• Palpable mass/swelling at the mouth of the urethra
• Burning while urinating (dysuria)
• Pain during intercourse
• Blood in the urine (hematuria)
• Sensation of pressure in the perineal region
• Difficulty urinating
• Intermittent urination
• Menstrual irregularity
• Groin pain

What are the causes of caruncle?

The disease is usually seen after menopause. It is thought to be caused by a lack of estrogen. It is extremely rare in premenopausal women. It has been reported in the literature that it is also seen in childhood, but this is extremely rare.

Caruncle examination

The caruncle is seen just at the beginning of the urethra on examination in the gynecological position. They are mostly red lesions 1.5-2 cm in diameter, sometimes protruding from the mouth of the urethra. May bleed on touch. In very large lesions, it appears as a pedunculated polyp-like lesions that are red on the surface and bleed on touch.

How is the diagnosis of urethral caruncle made?

It is easy to diagnose this disease. No further examinations are required. The diagnosis is easily made by the patient’s complaints and examination.

• A reddened polypoid lesion is seen in the posterior part of the urethra orifice at 6 o’clock position.
• Sometimes the urethra may protrude (urethral prolapse)
• In suspicious cases, biopsy is taken. There is no risk of cancer.
• Cystoscopy is usually not required. However, it can be done to evaluate the inside of the urethra.
• Urine microscopy: It is not very necessary for diagnosis. It can help differentiate from infection. Microscopic hematuria (blood in the urine) may be seen in the urinalysis.
• Recurrent urinary tract infections: As a result of incomplete emptying of the urine, excess urine remains in the bladder and as a result, frequent recurrent urinary tract infections (UTIs) are seen. Caruncle should also be considered in women with recurrent UTIs.

Treatment of the urethral caruncle

Caruncle treatment varies according to the size of the lesion and the excess of complaints. It is possible to examine the treatment in two groups:

• Medical treatment: Since the factor in medical treatment, that is, in drug treatment, is estrogen deficiency, oestrogen-containing creams can be used locally. In addition, anti-inflammatory drugs can also be effective.
• Surgical treatment (surgery): If the caruncle is large and the complaints are high, then the lesion must be surgically removed. We call this procedure caruncle excision.

How is caruncle surgery done?

Caruncle surgery is not a very complicated operation. It is a minor surgical intervention performed under sedation or local anesthesia.

We usually perform our patients with local anesthesia. A local anesthetic drug is given around the caruncle and the lesion is removed as a whole by cutting from the junction, the urethra. We call this procedure caruncle excision. Then, the bleeding foci are cauterized and the wound is closed by suturing. After the procedure, we insert a urethral catheter into the urethra to be withdrawn a few days later. No hospitalization is required, patients are discharged with oral antibiotics and painkillers.

Does the caruncle cause bladder prolapse?

Bladder prolapse or prolapse is a condition seen in women who have had multiple and difficult vaginal deliveries. As the support ligaments that hang the bladder are loosened, the bladder sags. Caruncle and bladder prolapse are different conditions. In the literature, rare cases of bladder prolapse associated with the greater caruncle have been reported. We did not encounter such large cases in our patients.

What diseases is the caruncle confused with?

Diagnosis of caruncle is easy in experienced hands. Sometimes it can be confused with other diseases. In doubtful cases, a biopsy should be taken. Definitive diagnosis is made by biopsy. The caruncle is most often confused with the following diseases;

• Urethra cancer
• Sarcomas originating from the urethra
• lymphoma
• Malignant melanoma
• Transitional epithelial cell cancer arising from the urethra
• Squamous cell cancers originating from the urethra

Does the caruncle heal spontaneously without treatment?

Not every caruncle case needs to be treated surgically. In small and mild cases, local estrogen creams and anti-inflammatory and pain relievers are given. If the lesion is very large and the complaints are too many, spontaneous healing will not occur. You definitely need surgery. Conditions serious enough to impair kidney function are rarely seen.

The 62-year-old has complaints of frequent urination, forced and intermittent urination, and recurrent urinary tract infections. In ultrasonography, we detected hydronephrosis (swelling, enlargement of the kidneys) in both kidneys and excessive amount of residual urine (remaining urine in the bladder after urination) in the bladder. Urea and creatinine levels were found to be high in blood tests. In our examination, we detected a caruncle extending into the urethra about 1.5×2 cm at the mouth of the urethra. We performed caruncle surgery (caruncle excision) under local anesthesia for our patient.

In the pathological examination, the tissue was evaluated to be exactly the same as a prostate enlargement (BPH)-like structure seen in men. No cancer was observed in studies on prostate cancer. There was no recurrence in the long-term follow-up of our patient. His complaints improved. Hydronephrosis in the kidneys regressed. Blood urea and creatinine levels returned to normal.

Although the urethral caruncle is accepted as the equivalent of BPH in men in the literature, such a typical case has not been reported. Cases up to kidney damage are extremely rare if not treated in this way.

Is the caruncle dangerous if left untreated?

This disease is not a dangerous disease. In the very small and early stage, if there are not many complaints, there is usually no need for treatment. If the caruncle enlarges and causes serious urination complaints by preventing urine output, surgery is absolutely necessary.

Does the caruncle recur after surgery?

There is no recurrence after caruncle surgery. If recurrence occurs, it is due to the incomplete removal of the caruncle. We did not encounter any relapsed cases in the follow-ups after our surgeries.

Which department/doctor performs the caruncle surgery?

Caruncle is a urological disease. The last part of the urinary tract is formed at the exit of the urethra. In this respect, this disease is a urinary system disease and should be done by a urologist.

Is the urethral caruncle a dangerous disease?

Urethral caruncle is not a dangerous disease. It does not turn into cancer. After surgical removal of the lesion, the part must be sent to pathology. If it is clear, no additional treatment is required.

Abstract: The urethral caruncle is a lesion that develops from the posterior wall at the end of the urethra and at the 6 o’clock position. It is non-cancerous, benign. If there are no complaints and if it is minor, no treatment is required. Estrogen and anti-inflammatory therapy are effective in those with mild to moderate complaints and in less severe cases. If it is large and the complaints are excessive, the caruncle should be removed surgically. The surgery is simple and does not require anesthesia. No hospitalization required. Patients return to their normal daily lives within a few days.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY