Article

Urethral caruncle: clinicopathologic features of 41 cases

Department of Pathology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
Human pathology (Impact Factor: 2.77). 03/2012; 43(9):1400-4. DOI: 10.1016/j.humpath.2011.10.015
Source: PubMed

ABSTRACT

Urethral caruncle is a benign polypoid mass of the urethral meatus in primarily postmenopausal women. Although a conclusive association with malignancy, urologic disorder, or systemic disease has not been established, often the lesion carries a challenging clinical differential diagnosis that includes malignancy. Conversely, unexpected malignancy is identified in some cases resembling caruncle clinically. We examined clinical and histopathologic characteristics in 41 patients. Medical records were assessed for presentation, clinical diagnosis, associated urothelial carcinoma, radiation treatment, tobacco use, immunologic/urologic disorder, and treatment strategy/outcome. Average patient age was 68 years (range, 28-87 years). Presenting symptoms were pain (37%), hematuria (27%), and dysuria (20%), in contrast to asymptomatic (32%). Clinical diagnosis favored malignancy in 10% of cases. Concurrent or subsequent urothelial carcinoma was present for 5 patients (12%), although none developed urethral carcinoma. Histologic features included mixed hyperplastic urothelial and squamous lining, overlying a variably fibrotic, edematous, inflamed, and vascular stroma. Invaginations of urothelium extending into the stroma were common (68%), showing rounded nests with cystic or glandular luminal spaces, similar to urethritis cystica/glandularis, without intestinal metaplasia. Two lesions included an organizing thrombus, 1 with intravascular papillary endothelial hyperplasia. Twenty patients were treated with topical medications without resolution. Three lesions recurred (7%) after excision. A subset of patients had history of smoking or previous pelvic irradiation. Urethral caruncle is an uncommon lesion that may clinically mimic benign and malignant conditions. Awareness of the spectrum of clinical and histologic differential diagnoses is important in dealing with this unusual disease.

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    ABSTRACT: Urethral bleeding is a relatively common reported event. Different etiologies characterize this symptom in males and females. In the male patient, urethral bleeding may suggest a urethral injury requiring urgent hospital referral. Other common causes of male urethral bleeding are linked to sexually transmitted diseases such as urethritis and condylomata of the urethral meatus. In a significant proportion of patients, the etiology of urethral bleeding will remain unknown, yet a urological referral is advisable to rule out the rare possibility of urethral neoplasms. In the female patient, it is usually more difficult to ascertain the urethral origin of bleeding because of possible confusion with an underlying gynecological -(vulvovaginal or uterine) disease. Urethral examination usually helps to rule out benign conditions such as caruncles and diverticula as well as the rare occurrence of urethral neoplasms. In both sexes, the presence of urinary incontinence makes the differential diagnosis with hematuria difficult; hence, patients should be investigated accordingly. Unusual sexual practices that involve transurethral insertion of traumatic foreign bodies should always be kept in mind when considering urethral bleeding. A practical algorithm is provided to help the general practitioner in making decisions about female and male urethral bleeding.
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    ABSTRACT: Aims Urethral caruncle is a benign, polypoid urethral mass that occurs almost exclusively in postmenopausal women. Despite that these lesions are routinely managed with topical medications or excision, their pathogenesis is not well understood. We investigated the possibilities of autoimmune, viral and inflammatory myofibroblastic proliferations as possible aetiologies. Methods In 38 patients with urethral caruncle, we utilised immunohistochemistry for immunoglobulin G (IgG) and IgG4 to assess for a potential autoimmune aetiology. Immunohistochemistry was performed in nine patients for Epstein–Barr virus, BK virus, human herpesvirus 8, human papillomavirus, adenovirus and anaplastic lymphoma kinase. Results Four patients (11%) showed infiltrates of ≥50 IgG4-positive plasma cells per high power field, of which all showed an IgG4 to IgG ratio greater than 40%. A statistically significant difference (p<0.01) was detected in the mean number of IgG4-positive cells (14.73 per high power field) compared with control benign urethral specimens (mean, 1.19). One patient with increased counts below this threshold had rheumatoid arthritis; none had documented autoimmune pancreatitis or other known manifestations of systemic IgG4-related sclerosing disease. All lesions showed negative reactions for the viral and inflammatory myofibroblastic markers. Conclusions Urethral caruncle is a benign inflammatory and fibrous polypoid urethral mass of unclear aetiology. It appears unrelated to viral infection and lacks the abnormal expression of anaplastic lymphoma kinase protein, as seen in inflammatory myofibroblastic tumours. Increased numbers of IgG4-positive plasma cells in a subset of lesions raise the possibility that some cases may be related to the autoimmune phenomena of IgG4-associated disease.
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