Urethral caruncle is a benign neoplasm of the urethra consisting of vascular–rich elastic connective tissue. It usually has a short leg and a wide base. It is manifested by dysuria (burning sensation and soreness during urination), frequent cystitis and urethritis, bloody discharge (urethrorrhagia) and hematuria. Diagnosis is made by gynecological examination, urethroscopy, biopsy with histological examination of the tissues of the formation, urography. With a small tumor size, treatment is not required, in case of urodynamic disorders, surgical removal, cryodestruction, laser vaporization are performed.
Meaning
Urethral caruncle is currently considered a type of urethral polyp. This neoplasm is registered only in women, most often in post-menopausal age (older than 45-50 years). The exact occurrence of pathology is unknown, since the disease is sometimes not accompanied by obvious symptoms and does not cause complaints in the patient. The back wall of the distal part of the canal is considered a favorite localization. Often the caruncle is combined with prolapse or prolapse of the urethra, which indicates a possible general etiology of these diseases. Sometimes polyp malignancy occurs with the development of squamous cell carcinoma.
Causes
The etiology of the urethral caruncle is complex, due to both external factors and internal changes in the woman’s body. It is assumed that it is the combined effect of several disorders that leads to the proliferation of connective tissue in the walls of the urethra. The main conditions contributing to the formation of a caruncle are:
- Hormonal changes. A decrease in the level of estrogens during menopause leads to a weakening and partial degradation of the tissues of the urinary system. As a result, the prolapse of the urethra develops more easily, the resistance of its mucosa to infection decreases, conditions are created for the occurrence of neoplastic processes, including the formation of polyps.
- Chronic infections. Inflammatory lesions of the urinary tract, especially of a chronic nature, increase the likelihood of developing a urethral caruncle. The reason is the irritation of tissues by pathogenic microorganisms and their toxins.
- Traumatization of the urethra. In women, damage to the urethra of varying severity can occur due to urolithiasis, during sexual intercourse or childbirth. Injuries stimulate the growth of connective tissue, which sometimes ends with the appearance of a polyp.
- Systemic diseases. Diabetes mellitus, hormonal disruptions, and some autoimmune pathologies facilitate the development of a caruncle. This is due to many factors – more frequent infections, metabolic disorders and changes in the state of the urinary system.
Pathogenesis
The process of formation of the urethral caruncle is preceded by damage to the walls of the urethra. Traumatic factors are infections, mechanical damage, deformation of the lower urinary tract due to age-related changes in the vagina or prolapse. All of the above leads to stimulation of the growth of connective tissue forming the submucosal layer of the urethra.
In some patients, these processes cause the development of a small neoplasm with an expansive growth pattern, which takes the form of a polyp on a short, wide leg. The caruncle protrudes into the lumen of the canal, so it is easily injured, which, in turn, triggers the growth of fibrous elements again. When a benign tumor reaches a certain size, it can make it difficult to pass urine, bleed or facilitate infection of the urethra, contributing to the development of chronic urethritis and cystitis.
Symptoms
The disease may not manifest itself for a long time and can only be detected during diagnostic studies (for example, cystourethroscopy). However, over time, an increasing neoplasm creates an obstacle to the flow of urine, which leads to pronounced symptoms of dysuria. Patients complain of pain, burning sensation during urination and after its completion, splashing of urine, frequent urges.
Urine becomes cloudy, often with an admixture of blood, when the caruncle is located close to the external opening of the urethra, urethrorrhagia is possible – the discharge of blood from the urethra. Sometimes a neoplasm can be probed independently due to its superficial localization. The size of the tumor is usually several millimeters, in some cases it reaches 1-1.5 centimeters. Inflammatory diseases of the urinary tract are often registered in patients with urethral caruncle.
Urethritis and cystitis are characterized by a long and severe course, they easily turn into chronic forms. In some cases, women with this pathology are forced to give up sexual intercourse because of their soreness, sometimes even wearing tight underwear causes unpleasant sensations. A sharp increase in pain, increased bleeding neoplasms are formidable symptoms indicating possible malignancy.
Complications
Urethral caruncle rarely provokes the formation of severe or dangerous complications. With prolonged presence of the formation and its bleeding, chronic iron deficiency anemia may occur. Due to pathology, inflammation of the urinary tract sometimes turns into a purulent form with intoxication of the body, chills, high fever. A caruncle of considerable size can greatly limit the outflow of urine, lead to its delay – ischuria, often taking a chronic character. The most dangerous consequence of the disease is malignancy with the development of urethral cancer.
Diagnostics
The diagnosis of urethral caruncle is carried out by a gynecologist, who often identifies asymptomatic forms of pathology as part of a preventive examination. It is recommended to consult a urologist, and in the presence of endocrine disorders – an endocrinologist. Diagnostic measures are used to confirm the benign nature of the neoplasm, to identify possible complications (bleeding, suppuration). The following studies are most often used:
- Gynecological examination. Due to the location of the caruncle in the distal part of the urethra, it is relatively easy to determine during a traditional examination on a chair. It is a dense spherical formation up to 1 centimeter in size, sometimes capable of “falling out” through the external opening of the urethra. It is often combined with signs of vulvar kraurosis or prolapse.
- Endocrinological studies. A large role in the pathogenesis of the disease is played by a drop in the level of estrogens, therefore, as part of the differential diagnosis of the caruncle, the level of these hormones in the blood is determined.
- Endoscopic techniques. Cystourethroscopy is used with a deep location of the polyp and the need for its more detailed study. Also, within the framework of this diagnostic technique, a tumor biopsy is taken in controversial cases, and some therapeutic manipulations are performed.
- Histological examination. Tissue sampling and its examination under a microscope is prescribed to exclude a malignant process. Histologically, the urethral caruncle is a connective tissue structure rich in blood vessels.
General clinical tests (blood and urine tests) are used to detect complications, for example, purulent urethritis, cystitis, periurethral abscesses. For the same purpose, transvaginal ultrasound of the pelvic organs is sometimes performed. Differential diagnosis of the disease is carried out with cancer of the urethra, papillomas and condylomas, some forms of urethral diverticula. Sometimes vascular neoplasms are distinguished with a caruncle – varicose veins of the labia majora, hemangiomas.
Treatment
Therapeutic measures can be conservative and radical (surgical). In clinical urology and gynecology, the use of only drug treatment of a neoplasm is justified with an asymptomatic course or if there are contraindications to the removal of the neoplasm. The main goal of therapy is to slow down the growth of the caruncle, prevent its malignancy and other complications.
Conservative treatment
Conservative methods include warm salt baths and the use of the following drugs:
- Hormonal agents. With a decrease in the level of estrogens, an endocrinologist can develop hormone replacement therapy (HRT). Apply gels and ointments for local use, containing estrogen-like compounds. Correction of the hormonal background dramatically slows down the development of a benign tumor of the urethra.
- Anti-inflammatory drugs. Most often, local remedies are used to reduce soreness and other symptoms of the disease. Anti-inflammatory therapy is also prescribed during the preparation of the patient for surgery.
- Antibiotics. Antimicrobials are recommended for infectious and inflammatory complications of the caruncle – cystitis, urethritis and other lesions of the urinary tract. The choice of medication depends on the clinical picture and the results of laboratory tests (for example, urine back-up).
Surgical treatment
It is possible to completely eliminate the neoplasm only operationally. This method is used in cases when the tumor becomes the cause of severe dysuria, frequent inflammatory diseases or manifests itself with severe soreness. The significant size of the polyp, even in the absence of pronounced symptoms, is also an indication for its removal, since the risk of malignancy increases. Removal of the urethral caruncle is performed using the following techniques:
- Surgical excision. It is used for formations of considerable size, produced both under local and general anesthesia. It has high efficiency and a low percentage of relapses, but it is quite invasive, can lead to complications (bleeding, urethral perforation, stricture development).
- Laser vaporization. With small tumors, the entire volume of the altered tissues is cauterized, in other cases, only the vessels feeding the caruncle coagulate. An effective technique that has a number of advantages, practically has no contraindications and complications.
- Cryodestruction. Exposure to low temperatures destroys the structure of the neoplasm, followed by scarring. At the same time, the risk of infectious complications in the form of purulent urethritis increases slightly.
Less often, removal is carried out by dressing the polyp leg or cauterization – cauterization with solutions of aggressive chemical compounds. Relapses are extremely rare, especially with full concomitant treatment – the elimination of inflammatory pathologies, prolapse, hormonal imbalance.
Prognosis and prevention
Severe complications for the urethral caruncle are uncharacteristic. With properly selected conservative therapy, a long-term asymptomatic course is possible. Removal is performed at the request of the patient, regular monitoring by a urologist is required. After surgical removal of the neoplasm, complete recovery usually occurs, in 0.1-0.5% of cases, the formation of urethral strictures is observed. Prevention of caruncle includes timely treatment of infectious and inflammatory lesions of the urinary tract, avoiding hypothermia of the lumbar region and perineum. An important role is played by periodic examination by a gynecologist, who can detect the disease at an early stage.