Urethral caruncles are benign, distal urethral lesions that are most commonly found in postmenopausal women, although a case of urethral caruncle has also been described in a male. [1, 2] Urethral caruncles resemble various urethral lesions, including carcinoma. The differential diagnoses of urethral caruncle include the following:
Periurethral gland abscesses
Most urethral caruncles can be treated conservatively with warm sitz baths and vaginal estrogen replacement. Surgical intervention may be indicated for patients with larger symptomatic lesions and for those with uncertain diagnoses. Possible indications for excisional biopsy include the following:
Failure to respond to conservative therapy
Growth over time
Urethral caruncles, which often originate from the posterior lip of the urethra, may be described as fleshy outgrowths of distal urethral mucosa. They are usually small but can grow to 1 cm or more in diameter.
Urethral caruncles are common in elderly postmenopausal women but are rare in premenopausal or perimenopausal women.  Urethral prolapse is similar in appearance, but is circumferential while caruncles are focal. Urethral prolapse may occur in prepubescent girls or postmenopausal women, whereas caruncles are seen almost exclusively in the latter.
Urethral caruncles may develop from several simultaneous processes, as discussed in the Pathophysiology section.
The first step in the development of a urethral caruncle is likely distal urethral prolapse caused by urogenital atrophy due to estrogen deficiency. Chronic irritation, where the urethral mucosa is exposed, contributes to the growth, hemorrhage, and necrosis of the lesion.
Cases of urethral melanoma,  tuberculosis, [5, 6] intestinal ectopia, lymphoma, [7, 8] and urethral leiomyoma  masquerading as urethral caruncle have been reported; however, reports of these associations are rare. Intraepithelial squamous cell carcinoma arising within a urethral caruncle has been reported in two patients.  Additionally, urethral caruncles have been reported to occur rarely in the premenopausal patient and may enlarge during pregnancy. Urethral polyps are the pediatric equivalent of urethral caruncles and manifest in a similar fashion.
Most urethral caruncles are asymptomatic and are incidentally noted on pelvic examination; however, some may be painful and others may be associated with dysuria. Many individuals with a urethral caruncle present with bleeding or, more commonly, with the patient noticing blood on undergarments.
Urethral caruncles are unlikely to explain voiding or storage symptoms in women. In fact, a comparison of lower urinary tract symptoms and urodynamic factors in incontinent women with and without caruncles found no differences.  Isolated case reports of urinary retention from urethral caruncle do exist, however. 
On examination, caruncles most often appear clinically as a pink or reddish exophytic lesion at the urethral meatus; in rare cases, they are purple or black secondary to thrombosis. Some caruncular lesions may resemble urethral carcinoma.
Conservative therapy (ie, warm sitz baths, topical estrogen creams, topical anti-inflammatory drugs) is appropriate in most patients. Surgical intervention should be reserved for patients with larger symptomatic lesions, for those in whom conservative therapy fails to elicit a response, and for those with uncertain diagnoses.
The female urethra is a 4- to 5-cm tubular structure. It is normally lined by nonkeratinized stratified squamous epithelium distally and transitional epithelium proximally. Outer layers have a complex network of smooth muscle fibers and vascular structures.
Surgical therapy should be reserved for women with larger symptomatic lesions and for women with uncertain diagnoses.
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