A urethral caruncle is a protrusion of urethral mucosa from the urethral meatus and is almost exclusively a diagnosis in women. By definition, a urethral caruncle is an incomplete protrusion, usually confined to the posterior aspect of the urethral meatus, whereas a prolapse is a complete circumferential protrusion. Caruncles appear beefy red and friable, whereas a full prolapse appears bluish, mottled, and very dusky ( Fig. 88.1 ).
Caruncles are commonly found in older women and are rarely symptomatic or bothersome. In unusual cases, other pathologic conditions may present as a caruncle or prolapse, including urethral carcinoma. In rare cases, caruncles may develop after urethral intervention, such as after urethral bulking injection therapy. Caruncles may present with pain, bleeding and hematuria, or urinary symptoms, such as dysuria. In postmenopausal women, in whom these are most common, first-line treatment with topical estrogen is recommended and usually effective. When surgical intervention is warranted, the objective is resection of the prolapsed redundant mucosa and reconstitution of the normal urethral mucosal–vaginal relationship.
Preoperative Preparation and Planning
A history and genitourinary physical examination are paramount to a diagnosis of urethral caruncle. Imaging is rarely required for the evaluation and planning of surgical excision. However, if concern warrants imaging, a pelvic magnetic resonance imaging (MRI) is probably the best modality to evaluate soft structures of the urethra. A transvaginal ultrasound may also be considered. Preoperative cystoscopy may be considered, but not required in straightforward examples. In the cases of concomitant hematuria or other abnormality, a full evaluation, including cystoscopy and appropriate imaging, should be pursued regardless of the findings of caruncle. Prior to surgical treatment, a course of topical hormone should be prescribed as first-line therapy in appropriate patients. Surgical excision of urethral caruncles and prolapse can be performed under local, regional, or general anesthesia.
Patient Position and Surgical Incision
For surgical treatment, the female patient is positioned in dorsal lithotomy, with the legs well supported and padded in stirrups. The sterile field should include the vaginal introitus and external labia. A weighted vaginal speculum and retraction with suture, assistants or a self-retaining retractor can all aid in visualization. A urethral or bladder catheter is placed to help aid in dissection. The meatus is often hidden or displaced to the side of a caruncle and is located centrally in the middle of a prolapse. If a full prolapse is very edematous, the lumen may not be obvious. The surgical incision is generally a circumscribing incision around the edematous mucosal tissue.