228
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
MAY, 1975
Urethral Caruncle: A Herald Lesion for Distal Urethral Stenosis? LESLIE E. BECKER, M.D., FA.C.S., Associate Clinical Professor of Urology, University of Kansas Medical Center, Kansas City, Kansas and University of Missouri Medical Center, Kansas City, Missouri
amuel Sharp first described urethral caruncle in 1750.' The description of the lesion by numerous subsequent authors indicates that it is a fleshy growth on the lower half or posterior lip of the external urethral orifice or urethral meatus occurring in middle aged or older females. The lesion appears to be florid or dusky red in color; may vary in size from 1-2 millimeters to 1-2 centimeters, may be pedunculated or sessile; and may appear ulcerated, friable, velvety or hemorrhagic. The lesions have a remarkable tendency to recur. They vary in some series from a high of two thirds of cases with recurrence within the first five years to no recurrences following certain techniques. Jeffcoate2 classified the lesion as a true caruncle or a pseudo-caruncle. He defined the true caruncle as a vascular papilloma which presents as a scarlet polyp with a narrow pedicle invariably arising from the posterior lip of the urethral meatus. A pseudo-caruncle is a granuloma of the urethral meatus appearing as a diffuse sessile dull red lesion. He considered pseudo-caruncle as the result of urethritis, often accompanied by peri-urethritis. There is pouting of the posterior wall of the urethra. He suggested that infection appearing in the tissues of true caruncles is secondary. Infection in the tissues of the pseudo-caruncle is primary and is the cause of the hypertrophy of the tissue. Gutierrez3 divided these lesions into three topographical types: 1) those external to the meatus; 2) those internal to the meatus; and 3) those partly within and partly outside the meatus. Novak4 described three types depending on histologic structure: 1) the granulomatous variety made up primarily of granulation tissue; 2) the papillomatous variety with a lobulated or a tree-like pattern; and 3) the angiomatous or telangiectatic variety which is
rich in stromal blood vessels. There have been several anatomical explanations for the occurrence of urethral caruncle. Olcott5 indicates that the female urethra is composed of three layers, epithelial, subepithelial, and muscular. In the epithelial layer, there are numerous small glands. The subepithelial layer contains cavernous tissue and near the urethral meatus are two para-urethral glands of Skene. The caruncle appears in the urethral meatus, projects from the surrounding surface as outgrowth of the surface epithelium and may ultimately take on the character of a granuloma, papilloma or an angioma. The female urethra is a narrow membranous canal, 3 to 5 cm. long, with a functional diameter of about 6-8 mm. It is located behind the symphysis pubis, embedded in the anterior wall of the vagina with its direction obliquely downward and forward. It is slightly curved with the concavity directed anteriorly. Skene's glands usually open on the floor of the urethra a short distance from the meatus. The cavernous tissue is essentially the corpus spongiosum which forms a ring around the orifice of the urethra as well as the vagina. Distally, the urethra is adherent to the superior vaginal wall along the urethro-vaginal septum, but proximally as it joins the bladder, the urethra is more loosely attached to its surrounding structures. The para-urethral ducts and Skene's glands are lined by columnar epithelium containing mucus-secreting cells which drain into the urethra near the external urethral meatus. It would appear that the anatomic structure of the female urethra seems to encourage regional, as well as, circumscribed prolapse.6 The location of the urethral meatus results in constant exposure to trauma and irritation through childbirth and coitus and could result in varying degrees of prolapse of the
Vol. 67, No. 3
Urethral Stenosis
eipthelium from continued traumatic and irritative activity. It has been stated by several authors that urethral caruncles resemble internal hemorrhoids. Ferrier,7 in 1926, theorized that urethral caruncles resulted from ruptured cysts of Skene's ducts. He pointed out that caruncles practically always occur in the lower margin of the urethral meatus in the location of Skene's ducts drainage. Another observation of significance is that intra-urethral caruncles frequently were found behind a tight urethral meatus. This was noted by McKim, Smith and Rush in 1943.8 Novak4 stated that the caruncle develops as an ectropion of posterior urethral wall and is caused by postmenopausal shrinkage of the vaginal tissue. The histopathology of this lesion has consistent descriptive elements, although varied interpretations are offered. Depending upon the location, the caruncle is covered by transitional or squamous epithelium with inflammatory components and thin walled vessels which make it resemble a urethral hemorrhoid.9 The lesions often contain Skene's or para-urethral glands. Invaginations of the epithelial lining may appear to be displaced islands of atypical epithelium. This prominent histological feature may lead to an incorrect diagnosis of cancer. The tendency of the epithelium is to infold, invaginate or dip down into the stroma and form crypts."0 According to Marshall, Uson and Melicow," "Any localized urethral swelling which microscopically showed varying degrees of sub-epithelial inflammation, edema, vascularity and fibrosis covered by a layer of moderately hyperplastic squamous epithelium or urothelium was classified as a caruncle." It is quite apparent that urethral caruncle is a clinical, rather than a pathologic term. Many terms have been used to designate urethral caruncle. These include papillary angioma, vascular polyp, capillary angioma, urethral hemorrhoid and many others. According to Bell,'2 the urethral caruncle is a vascular growth and a chronic inflammatory lesion composed chiefly of dilated vessels and plasma cells. The surface is covered by stratified epithelium and glands are present in the growth. The symptoms of urethral caruncle have been reported by Pratt,9 to consist of painful
229
voiding in 51%, urethral bleeding in 49%, increased urinary frequency and urgency in 36%, and appearance of a mass in 41% of cases. The lesions may be asymptomatic or severely incapacitating. The size and location of the caruncle seem to have no bearing on the severity of the symptoms. The age range is from 40-70 years with post menopausal and multiparas accounting for the majority of the female patients. The presence of cervicitis and trichomoniasis has been mentioned by several authors including Nasah.13 The relationship, however, has not been consistently established. The treatment and recurrence of the lesion, seem to be interrelated. Some authors state that electrocoagulation or electroexcision, with electrocoagulation of the base of the lesion, seems to be superior to excisional methods. Other authors seem to indicate that various degrees of locally extended excision seem to be successful, however, in reviewing the previous reports of treatment of this condition, several salient features emerge: 1) there is clear-cut evidence of inflammation in most of these lesions, regardless of classification; 2) the lesion is usually located in relationship to Skene's glands; 3) the urethral meatus is usually tight or small; and 4) there appears to be some degree of prolapse of the epithelium. During recent years, there has been considerable attention directed to the entity "distal urethral stenosis," or urethral syndrome. 14 The pathologic features of urethral caruncle would appear to be related to these changes noted in the distal urethral segment and may suggest that successful managefient of the caruncle could be related to the management of periurethral fibrosis which results in distal urethral stenosis. The theory in this case, would be that peri-urethral fibrosis results in constriction of the cavernous elements in the sub-urethral stroma resulting in a localized vascular ectasia and prolapse which would present as a urethral caruncle. In reviewing the literature on successful treatment of lesions, Walther'° described overdilation of the urethra or meatotomy as the initial step in excision of the lesion. In 1948, Palmer, Emmett and McDonald6 reported that Deming in 1931'5 and Dodson in 194416
230
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
advocated urethroplasty as the method of treatment accepted by many surgeons. Deming described this procedure as a cuff excision. An incision is made through the epithelium around the external meatus with separation of the urethral epithelium from the muscle layer for a sufficient distance beyond the caruncle. The lesion is removed with the dissected epithelium, and the vaginal mucous membrane is sutured to the remaining urethral edge. Kickham'7 used a semicircular incision around the caruncle wide enough to include it and deep enough to include the full thickness of the epithelium. Stevens'8 advocated a similar procedure with follow-up urethral dilation to prevent formation of a stricture postoperatively.
MAY, 1975
end result of subepithelial or peri-urethral inflammation and scarring. This results from either inflammation of the para-urethral or Skene's ducts or other sources of chronic inflammation and irritation resulting in periurethral scarring and ectasia of peri-urethral cavernous sinuses. The successful treatment of caruncle depends upon the removal of the scar tissue. Recurrence may be the predictable result of failure to excise the scar tissue as well as the urethral caruncle. The author treated two cases by simple urethroplasty with disappearance of the caruncle without a direct attack, and has subsequently treated four cases with excision of the caruncle and urethroplasty combined. The follow-up period of all of these cases has been too brief to establish the validity of this claim, however, the possibility that urethral caruncle may be a herald lesion of distal urethral stenosis is strongly suggested. LITERATURE CITED
Fig. 1. Incisions for surgical removal of a caruncle.
On several occasions this author has treated patients with distal urethral stenosis who had an incidental urethral caruncle. Using the method of Richardson'4 the peri-urethral scar was excised and surprisingly, the caruncle disappeared during the procedure without ever having been directly attacked. This occurrence suggested a mode of treatment of caruncles based on the fact that peri-urethral fibrosis may be the causal agent for its formation. However, the fact that caruncles may contain carcinoma in situ,'0 a pathologic specimen of the lesion should always be submitted. A combined urethral caruncle excision and urethroplasty has been suggested (Fig. 1). SUMMARY
It is postulated that urethral caruncle is the
1. KELLY, H. A. Gynecology, D. Appleton Co., New York, 1928, p. 815. 2. JEFFCOATE, TN.A. Principles of Gynecology, 3rd Ed. Butterworth, London, p. 398. 3. GUTIERREZ, R. Urology Cut. Review, 40:223-231, 1936. 4. NOVAK, E. and R. WOODRUFF and J. DONALD. Novak's Gynecologic and Obstetric Pathology, 5th Ed., Saunders, Phila., 1962, pp. 47 & 674. 5. OLCOTT, C. T. Urethral Caruncle in the Female. Surg. Gyneco. & Obstet., 51:61-64, 1930. 6. PALMER, J. K. and J. L. EMMETT and J. R. McDONALD. Urethral Caruncle, Surg. Gynecol. & Obstet., 87:611-20, 1948. 7. FERRIER, PA. Urethral Caruncle, California & West Med., 24:500, 1926. 8. McKIM, G. F and P G. SMITH and T W RUSH. Jour. Urol., 49:187, 1943. 9. PRATT, J. H. Lesions of Female Urethra, Clin. Obstet. & Gyne., 19:229-37, 1967. 10. WALTHER, H.WE. Caruncle of the Urethra in the Female, J. Urol., 50:38-88, 1943. 11. MARSHALL, E C. and A. C. USON, and M. M. MELICOW Neoplasms and Caruncles of the Female Urethra. Surg. Gynecol. & Obstet., 110:723-33, 1960. 12. BELL, E. T. A Textbook of Pathology, 5th Ed., Lea & Febiger, Phila., 1944. 13. NASAH, B. T Urethral Caruncle, Jour. Obstet. & Gynecol., British Commonwealth, 75:781-3, 1968. 14. RICHARDSON, F H. External Urethroplasty for Treatment of the Urethral Syndrome in the Female. Abstracts of Practice of Urology Society of Australia, 24th Annual, 1971. 15. DEMING, C. L. New Eng. Jour. Med., 205:484, 1931. 16. DODSON, A. I. Urological Surgery. C.V. Mosby Co., St. Louis, 1944, pp. 603-606. 17. KICKHAM, E. L. Urethral Caruncle, Jour. Urol., 36:178-9, 1937. 18. STEVENS, WW LEWIS, Practice of Surgery, vol. 9, ch. 75, WF Prior Co., p. 22.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
MAY, 1975
Urethral Caruncle: A Herald Lesion for Distal Urethral Stenosis? LESLIE E. BECKER, M.D., FA.C.S., Associate Clinical Professor of Urology, University of Kansas Medical Center, Kansas City, Kansas and University of Missouri Medical Center, Kansas City, Missouri
amuel Sharp first described urethral caruncle in 1750.' The description of the lesion by numerous subsequent authors indicates that it is a fleshy growth on the lower half or posterior lip of the external urethral orifice or urethral meatus occurring in middle aged or older females. The lesion appears to be florid or dusky red in color; may vary in size from 1-2 millimeters to 1-2 centimeters, may be pedunculated or sessile; and may appear ulcerated, friable, velvety or hemorrhagic. The lesions have a remarkable tendency to recur. They vary in some series from a high of two thirds of cases with recurrence within the first five years to no recurrences following certain techniques. Jeffcoate2 classified the lesion as a true caruncle or a pseudo-caruncle. He defined the true caruncle as a vascular papilloma which presents as a scarlet polyp with a narrow pedicle invariably arising from the posterior lip of the urethral meatus. A pseudo-caruncle is a granuloma of the urethral meatus appearing as a diffuse sessile dull red lesion. He considered pseudo-caruncle as the result of urethritis, often accompanied by peri-urethritis. There is pouting of the posterior wall of the urethra. He suggested that infection appearing in the tissues of true caruncles is secondary. Infection in the tissues of the pseudo-caruncle is primary and is the cause of the hypertrophy of the tissue. Gutierrez3 divided these lesions into three topographical types: 1) those external to the meatus; 2) those internal to the meatus; and 3) those partly within and partly outside the meatus. Novak4 described three types depending on histologic structure: 1) the granulomatous variety made up primarily of granulation tissue; 2) the papillomatous variety with a lobulated or a tree-like pattern; and 3) the angiomatous or telangiectatic variety which is
rich in stromal blood vessels. There have been several anatomical explanations for the occurrence of urethral caruncle. Olcott5 indicates that the female urethra is composed of three layers, epithelial, subepithelial, and muscular. In the epithelial layer, there are numerous small glands. The subepithelial layer contains cavernous tissue and near the urethral meatus are two para-urethral glands of Skene. The caruncle appears in the urethral meatus, projects from the surrounding surface as outgrowth of the surface epithelium and may ultimately take on the character of a granuloma, papilloma or an angioma. The female urethra is a narrow membranous canal, 3 to 5 cm. long, with a functional diameter of about 6-8 mm. It is located behind the symphysis pubis, embedded in the anterior wall of the vagina with its direction obliquely downward and forward. It is slightly curved with the concavity directed anteriorly. Skene's glands usually open on the floor of the urethra a short distance from the meatus. The cavernous tissue is essentially the corpus spongiosum which forms a ring around the orifice of the urethra as well as the vagina. Distally, the urethra is adherent to the superior vaginal wall along the urethro-vaginal septum, but proximally as it joins the bladder, the urethra is more loosely attached to its surrounding structures. The para-urethral ducts and Skene's glands are lined by columnar epithelium containing mucus-secreting cells which drain into the urethra near the external urethral meatus. It would appear that the anatomic structure of the female urethra seems to encourage regional, as well as, circumscribed prolapse.6 The location of the urethral meatus results in constant exposure to trauma and irritation through childbirth and coitus and could result in varying degrees of prolapse of the
Vol. 67, No. 3
Urethral Stenosis
eipthelium from continued traumatic and irritative activity. It has been stated by several authors that urethral caruncles resemble internal hemorrhoids. Ferrier,7 in 1926, theorized that urethral caruncles resulted from ruptured cysts of Skene's ducts. He pointed out that caruncles practically always occur in the lower margin of the urethral meatus in the location of Skene's ducts drainage. Another observation of significance is that intra-urethral caruncles frequently were found behind a tight urethral meatus. This was noted by McKim, Smith and Rush in 1943.8 Novak4 stated that the caruncle develops as an ectropion of posterior urethral wall and is caused by postmenopausal shrinkage of the vaginal tissue. The histopathology of this lesion has consistent descriptive elements, although varied interpretations are offered. Depending upon the location, the caruncle is covered by transitional or squamous epithelium with inflammatory components and thin walled vessels which make it resemble a urethral hemorrhoid.9 The lesions often contain Skene's or para-urethral glands. Invaginations of the epithelial lining may appear to be displaced islands of atypical epithelium. This prominent histological feature may lead to an incorrect diagnosis of cancer. The tendency of the epithelium is to infold, invaginate or dip down into the stroma and form crypts."0 According to Marshall, Uson and Melicow," "Any localized urethral swelling which microscopically showed varying degrees of sub-epithelial inflammation, edema, vascularity and fibrosis covered by a layer of moderately hyperplastic squamous epithelium or urothelium was classified as a caruncle." It is quite apparent that urethral caruncle is a clinical, rather than a pathologic term. Many terms have been used to designate urethral caruncle. These include papillary angioma, vascular polyp, capillary angioma, urethral hemorrhoid and many others. According to Bell,'2 the urethral caruncle is a vascular growth and a chronic inflammatory lesion composed chiefly of dilated vessels and plasma cells. The surface is covered by stratified epithelium and glands are present in the growth. The symptoms of urethral caruncle have been reported by Pratt,9 to consist of painful
229
voiding in 51%, urethral bleeding in 49%, increased urinary frequency and urgency in 36%, and appearance of a mass in 41% of cases. The lesions may be asymptomatic or severely incapacitating. The size and location of the caruncle seem to have no bearing on the severity of the symptoms. The age range is from 40-70 years with post menopausal and multiparas accounting for the majority of the female patients. The presence of cervicitis and trichomoniasis has been mentioned by several authors including Nasah.13 The relationship, however, has not been consistently established. The treatment and recurrence of the lesion, seem to be interrelated. Some authors state that electrocoagulation or electroexcision, with electrocoagulation of the base of the lesion, seems to be superior to excisional methods. Other authors seem to indicate that various degrees of locally extended excision seem to be successful, however, in reviewing the previous reports of treatment of this condition, several salient features emerge: 1) there is clear-cut evidence of inflammation in most of these lesions, regardless of classification; 2) the lesion is usually located in relationship to Skene's glands; 3) the urethral meatus is usually tight or small; and 4) there appears to be some degree of prolapse of the epithelium. During recent years, there has been considerable attention directed to the entity "distal urethral stenosis," or urethral syndrome. 14 The pathologic features of urethral caruncle would appear to be related to these changes noted in the distal urethral segment and may suggest that successful managefient of the caruncle could be related to the management of periurethral fibrosis which results in distal urethral stenosis. The theory in this case, would be that peri-urethral fibrosis results in constriction of the cavernous elements in the sub-urethral stroma resulting in a localized vascular ectasia and prolapse which would present as a urethral caruncle. In reviewing the literature on successful treatment of lesions, Walther'° described overdilation of the urethra or meatotomy as the initial step in excision of the lesion. In 1948, Palmer, Emmett and McDonald6 reported that Deming in 1931'5 and Dodson in 194416
230
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
advocated urethroplasty as the method of treatment accepted by many surgeons. Deming described this procedure as a cuff excision. An incision is made through the epithelium around the external meatus with separation of the urethral epithelium from the muscle layer for a sufficient distance beyond the caruncle. The lesion is removed with the dissected epithelium, and the vaginal mucous membrane is sutured to the remaining urethral edge. Kickham'7 used a semicircular incision around the caruncle wide enough to include it and deep enough to include the full thickness of the epithelium. Stevens'8 advocated a similar procedure with follow-up urethral dilation to prevent formation of a stricture postoperatively.
MAY, 1975
end result of subepithelial or peri-urethral inflammation and scarring. This results from either inflammation of the para-urethral or Skene's ducts or other sources of chronic inflammation and irritation resulting in periurethral scarring and ectasia of peri-urethral cavernous sinuses. The successful treatment of caruncle depends upon the removal of the scar tissue. Recurrence may be the predictable result of failure to excise the scar tissue as well as the urethral caruncle. The author treated two cases by simple urethroplasty with disappearance of the caruncle without a direct attack, and has subsequently treated four cases with excision of the caruncle and urethroplasty combined. The follow-up period of all of these cases has been too brief to establish the validity of this claim, however, the possibility that urethral caruncle may be a herald lesion of distal urethral stenosis is strongly suggested. LITERATURE CITED
Fig. 1. Incisions for surgical removal of a caruncle.
On several occasions this author has treated patients with distal urethral stenosis who had an incidental urethral caruncle. Using the method of Richardson'4 the peri-urethral scar was excised and surprisingly, the caruncle disappeared during the procedure without ever having been directly attacked. This occurrence suggested a mode of treatment of caruncles based on the fact that peri-urethral fibrosis may be the causal agent for its formation. However, the fact that caruncles may contain carcinoma in situ,'0 a pathologic specimen of the lesion should always be submitted. A combined urethral caruncle excision and urethroplasty has been suggested (Fig. 1). SUMMARY
It is postulated that urethral caruncle is the
1. KELLY, H. A. Gynecology, D. Appleton Co., New York, 1928, p. 815. 2. JEFFCOATE, TN.A. Principles of Gynecology, 3rd Ed. Butterworth, London, p. 398. 3. GUTIERREZ, R. Urology Cut. Review, 40:223-231, 1936. 4. NOVAK, E. and R. WOODRUFF and J. DONALD. Novak's Gynecologic and Obstetric Pathology, 5th Ed., Saunders, Phila., 1962, pp. 47 & 674. 5. OLCOTT, C. T. Urethral Caruncle in the Female. Surg. Gyneco. & Obstet., 51:61-64, 1930. 6. PALMER, J. K. and J. L. EMMETT and J. R. McDONALD. Urethral Caruncle, Surg. Gynecol. & Obstet., 87:611-20, 1948. 7. FERRIER, PA. Urethral Caruncle, California & West Med., 24:500, 1926. 8. McKIM, G. F and P G. SMITH and T W RUSH. Jour. Urol., 49:187, 1943. 9. PRATT, J. H. Lesions of Female Urethra, Clin. Obstet. & Gyne., 19:229-37, 1967. 10. WALTHER, H.WE. Caruncle of the Urethra in the Female, J. Urol., 50:38-88, 1943. 11. MARSHALL, E C. and A. C. USON, and M. M. MELICOW Neoplasms and Caruncles of the Female Urethra. Surg. Gynecol. & Obstet., 110:723-33, 1960. 12. BELL, E. T. A Textbook of Pathology, 5th Ed., Lea & Febiger, Phila., 1944. 13. NASAH, B. T Urethral Caruncle, Jour. Obstet. & Gynecol., British Commonwealth, 75:781-3, 1968. 14. RICHARDSON, F H. External Urethroplasty for Treatment of the Urethral Syndrome in the Female. Abstracts of Practice of Urology Society of Australia, 24th Annual, 1971. 15. DEMING, C. L. New Eng. Jour. Med., 205:484, 1931. 16. DODSON, A. I. Urological Surgery. C.V. Mosby Co., St. Louis, 1944, pp. 603-606. 17. KICKHAM, E. L. Urethral Caruncle, Jour. Urol., 36:178-9, 1937. 18. STEVENS, WW LEWIS, Practice of Surgery, vol. 9, ch. 75, WF Prior Co., p. 22.
