Giant Urethral Caruncle Presenting as Genital Prolapse Fatih Hizli,1 Kadir Çetinkaya,2 Gülay Bilir,3 Halil Başar1 Departments of Urology,1 Obstet- rics and Gynecology2 and Pathol- ogy,3 Oncology Training and Re- search Hospital , Ankara, Turkey. Corresponding Author: Fatih Hizli, MD. Department of Urology, Oncology Training and Research Hospital, 06530 Demetevler, Ankara, Turkey. Tel: +90 312 336 0909/5607 Fax: +90 312 345 4979 E-mail: fatihhizli33@yahoo.com Received July 2013 Accepted December 2013 Keywords: urethral diseases; diagnosis; diverticulum; female; differential; diagnostic errors. INTRODUCTION Urethral caruncles usually arise from the posterior lip of the urethral meatus. Although the etiology of urethral caruncles is still undetermined, they are the most common benign tumors of the female urethra.(1) Most cases are frequently asymptomatic, but, sometimes patients feel a lump or bleeding at the urethral meatus. Symptoms are dysuria, dyspareunia, hematuria and rarely asensation of pressure in the perineal region. In this report we present a case of urethral caruncle mimicking a genital prolapse. CASE REPORT A 56-year-old woman was referred to the urology clinic with hematuria and a feeling of a lump in her genital region. Complaints of dysuria and dyspareunia were also emphasized by the patient. There was no stress or urge incontinence. When she became aware of the mass, she visited a gynecology clinic and was referred to our clinic. Our patient entered the menopausal period 7 years ago. On pelvic examination, there was a 6 × 3 cm lump protruding circumferentially from the urethra and suggesting urethral caruncle macro- scopically at the external urethral meatus looking like a genital prolapse (Figure 1). There was no cystocele view observed. The lesion was reddish, raspberry-like and a bloody leakage occurred upon touching. The patient was placed in the dorsolithotomy position under regional anesthesia. Initially, we performed urethrocystoscopy, which revealed no abnormal lesions in either the bladder or urethra. The vulvar skin, vaginal mucosa and cervical region had normal appearance. Rectal examination was non-revealing. The lesion was totally resected and an 18 French (F) Foley silicon catheter was placed for urine drainage. The postoperative period was uneventful and no signs of residual complaints were ob- 1841 Case Report CASE REPORT UROLOGY JOURNAL Vol. 11 No. 04 July - August 2014 1842 Urethral Caruncle-Hizli et al treatment modalities including steroid and estrogen creams for a few years, but in the end the lesion did not regress. Finally, the lesion was totally resected circumferentially and the patient was cured. In this case, a giant urethral caruncle affected the patient’s quality of life. The urethral caruncle caused an obstruction by its mass effect. Urethral ca- runcles are the most common lesions of the urethra among elderly and middle aged women. A urethral caruncle resembling a genital prolapse has been reported in the literature.(11) CONCLUSION To the best of our knowledge, our patient is the second reported case of urethral caruncle resembling a genital prolapse in the English liter- ature. Thus, a patient’s situation should be carefully observed when conservative therapy is selected. Great or persistent caruncles and those with an abnormal view should be surgically treated aggressively and carefully evaluated and pursued for the presence of any potential malignancy. CONFLICT OF INTEREST None declared. REFERENCES 1. Cimentepe E, Bayrak O, Unsal A, Koç A, Ataoğlu O, Balbay MD. Ure- thral adenocarcinoma mimicking urethral caruncle. Int Urogynecol J Pel- vic Floor Dysfunct. 2006;17:96-8. 2. Pugh RC. The Kidneys: The Urinary Tract. Systemic Pathology. 3rd edition. Philadelphia, PA: W.B. Saunders Company; 1992. p. 745. 3. Conces MR, Williamson SR, Montironi R, Lopez-Beltran A, Scarpelli M, Cheng L. Urethral caruncle: clinicopathologic features of 41 cases. Hum Pathol. 2012;43:1400-4. 4. Türkeri L, Simšek F, Akdaş A. Urethral caruncle in an unusual location occurring in prepubertal girl. Eur Urol. 1989;16:153-4. served. The patient was discharged on the second postoperative day, and the urethral catheter was removed on the seventh day. Microscopic examination of the specimen revealed a transitional epi- thelium covering the stroma with inflammation and extravasated red blood cells and prominent vascularity observed (Figure 2). Histo- pathologic examination of the urethral lesion was reported as a ure- thral caruncle. DISCUSSION Urethral caruncles are the most common lesions of the urethra among females. They occur commonly in middle aged and elderly women. They are inflammatory nodules arising at the posterior lip of the ex- ternal meatus, present as solitary, soft, raspberry-like pedunculated tumors and are commonly seen after menopause.(1) Grossly, caruncles are nodular or pedunculated erythematous lesions that may bleed easi- ly.(2) Caruncles microscopically involve dense polymorphous infiltrate rich in lymphocytes, which is common to all types, but other reactive patterns may predominate. These include fibrocapillary proliferation (granulomatous), epithelial hyperplasia (papillomatous), hypervascu- larity (angiomatous) and also intestinal metaplasia (mucinous). Urethral caruncles in 32% of cases are asymptomatic and usually are found in postmenopausal women.(3) When present, the most common symptoms are dysuria, pain or discomfort, dyspareunia and rarely bleeding. The mass is quite swollen and bleeds easily.(4) Although the caruncles are considered as benign tumors, they need to be treated with surgical intervention; pathologic specimens should carefully be evaluated for having any malignancy and treatment plans established based on the results. When the lesion is atypical in view or behavior, surgical excision may be required to exclude other entities. Malignant melanoma, non-Hodgkin’s lymphoma, tuberculosis, intes- tinal metaplasia and ovarian tumor have been reported either to coexist with or to mimic urethral caruncles.(5-9) The management of a urethral caruncle consists of local surgical ex- cision, cryotherapeutic ablation or, conservatively, local application of estrogen and steroid creams.(10) The patient in this case had various Figure 1. (A) Intraoperative appearance of the lesion, (B) view of excised lesion. Figure 2. Histopathologic appearance of the urethral caruncle (Hematoxylin & Eosin, × 40). 5. Indudhara R, Vaidyanathan S, Radotra BD. Urethral tuberculosis. Urol Int. 1992;48:436-8. 6. Khatib RA, Khalil AM, Tawil AN, Shamseddine AI, Kaspar HG, Suidan FJ. Non-Hodgkin’s lymphoma presenting as a urethral caruncle. Gynecol Oncol. 1993;50:389-93. 7. Lopez JI, Angulo JC, Ibanez T. Primary malignant melanoma mimicking urethral caruncle. Case report. Scand J Urol Nephrol. 1993;27:125-6. 8. Willett GD, Lack EE. Periurethral colonic-type polyp simulating urethral caruncle. A case report. J Reprod Med. 1990;35:1017-8. 9. Atalay AC, Karaman MI, Basak T, Utkan G, Ergenekon E. Non-Hod gkin’s lymphoma of the female urethra presenting as a caruncle. Int Urol Nephrol. 1998;30:609-10. 10. Singh I, Hemal AK. Primary urethral tuberculosis masquerading as a ure- thral caruncle: a diagnostic curiosity! Int Urol Nephrol. 2002;34:101-3. 11. Lammes FB. [Diagnostic image (110). An elderly woman with micturiti- on problems. Caruncle urethrae in genital prolapse]. Ned Tijdschr Gene- eskd. 2002;146:1984. 1843 Case Report