Approach Considerations
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.
Medical Care
Most urethral caruncles can be treated conservatively with warm sitz baths and vaginal estrogen replacement. Topical anti-inflammatory drugs may also be useful. Unfortunately, data on the efficacy of conservative management are lacking in the literature. In fact, a review of current literature completed in 2020 was unable to find any published systematic studies on the conservative management of urethral caruncles. [23]
Nevertheless, anecdotal experience indicates that vaginal estrogen replacement is effective for many cases. Patients may notice symptomatic improvement within 6 weeks, but maximal effect of vaginal estrogen therapy is in 3 to 6 months.
Surgical Care
Reserve surgical intervention for patients with larger symptomatic lesions and for those with uncertain diagnoses. Tumors are found in approximately 2% of urethral caruncles. [13] Possible indications for excisional biopsy include the following:
-
Induration
-
Failure to respond to conservative therapy
-
Atypical appearance
-
Growth over time
Cystourethroscopy should be performed if surgical excision is undertaken, to exclude bladder and urethral abnormalities. Many urologists perform a cystoscopy in the office upon initial patient presentation to rule out other pathologies (eg, carcinoma, diverticulum, abscess).
Preoperative Details
Standard vaginal preparation and preoperative antibiotics are recommended.
Intraoperative Details
Excision is usually an outpatient operation and involves the following steps:
-
Place a Foley catheter
-
Use stay-sutures in the epithelium to prevent mucosal retraction and meatal stenosis
-
Excise the lesion
-
Oversew the edges with 3-0 or 4-0 absorbable sutures (chromic or polyglactin)
Park and Cho have described an alternative technique for removal of a urethral caruncle whereby the base of the caruncle is ligated, allowing it to slough off after 1-2 weeks. [24] Their technique requires neither anesthesia nor analgesics.
Postoperative Details
Following surgical excision, ensure patient can void adequately. If the patient is unable to void postoperatively or the surgery involved extensive excision, a Foley catheter may be left in place for 1-2 days to allow for appropriate healing of the urethral mucosa.
Complications
If the epithelium is not everted adequately with the stay-stitch, meatal retraction and stenosis may occur.
Long-Term Monitoring
If the lesion is benign, no special follow-up is required. However, patients who developed caruncles secondary to genitourinary syndrome of menopause should remain on vaginal estrogen to prevent new occurrences.
-
This image shows marked vascular engorgement and a polymorphous inflammatory infiltrate in the stroma. Surface epithelium is benign. Courtesy of GT MacLennan, MD.
-
Photographs show the preoperative (a) and postoperative (b) appearance of a urethral caruncle in a 9-year-old girl. Courtesy of Journal of Medical Case Reports, Springer Nature.
