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Urethral Hemangioma
Vol. 94, Nov. Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1965 by The Williams & Wilkins Co.
URETHRAL HEMANGIOMA H. MEL VIN RADMAN There is a tendency to consider a urethral tumor benign; 1- 3 however, it has been shown statistically that the majority of these tumors are malignant. 3 Because of this misconception and to demonstrate the relationship between urethral caruncle and malignancy, Marshall and associates reviewed a series of cases at the Squier Clinic of The Presbyterian Hospital of New York. 3 From 1932 to 1958, a 26-year period, 394 women with urethral tmnors were seen. The true urethral caruncle was defined as localized swelling with varying degrees of inflammation, vascularity and fibrosis. They were not considered to be neoplastic since the true identity as such has been questioned. Of the 394 patients, there were 356 with caruncles, 16 with benign growths and 22 with malignant tumors. Numerous reports can be found in the literature in regard to urethral carcinoma;1- 5 on the other hand, non-malignant tumors have received little attention. The most common benign lesions are polyps and papilloma while the most rare are myoma, fibromyoma and hemangioma. 4 • 6 In 1 woman, treated for 10 years for unexplained hematuria, a urethral hemangioma was discovered and removed. Since the literature is sparse and few authenticated examples have been recorded,7 the case presented herein might prove valuable. Opinion is divided whether hemangiomas are more frequent in men or in women.1· 2 • 5 Scholl and Braasch believed that the condition appeared more often in middle-aged women. 5 The causative factors have not been determined but are thought to be the result of chronic irritation. 6 A more Accepted for publication February 23, 1965. 1 Graves, R. C. and Guiss, L. W.: Tumors of the urethra. J. Urol., 46: 925, 1941. 2 Lowsley, 0. S. and Kirwin, T. J.: A clinical and pathological study of congenital obstruction of the urethra. J. Urol., 31: 497, 1934. 3 Marshall, F. C., Uson, A. C. and Melicow, M. M.: Neoplasms and caruncles of the female urethra. Surg., Gynec. & Obst., 110: 723, 1960. 4 McCrea, L.: Tumors of the urethra. In: Gynecological Urology, edited by A. F. Youssef. Springfield: Charles C Thomas, 1960, p. 596. 5 Scholl, A. J. and Braasch, W. F.: Primary tumors of the urethra. Ann. Surg., 76: 246, 1922. 6 Herbut, P. A.: Urological Pathology. Philadelphia: Lea & Febiger, vol. 1, 1952, p. 95. 7 Everett, H. S.: Personal communication. 580
plausible explanation is that they represent varicosities of the urethral vessels. CASE REPORT
Mrs. S. P., a 56-year-old woman, had been observed for 13 years. In 1953, total abdominal hysterectomy and bilateral salpingo-oophorectomy were done because of a large fibromyoma associated with profuse bleeding at the time of the menstrual periods. The patient had a rapid convalescence. Approximately a year later she complained of urinary frequency and lower abdominal pain which radiated to the groin. She had no fever or chills. Urinalysis showed a few pus cells but no bacteria. After the symptoms had subsided, an excretory urogram showed a double ureter and kidney on the left side. No other abnormalities were noted. Shortly the patient noticed some blood in the urine and an inspection of the genital tract failed to reveal the cause. On retrograde cystoscopy and excretory urography, no apparent source of bleeding could be determined. Hematuria occurred at irregular intervals; a thorough investigation failed to reveal the source. In November 1964 the patient had pneumonitis and was treated by an intensive course of antibiotic therapy. Subsequently she complained of itching, burning and the protrusion of a mass in the genital area and was referred for gynecologic consultation. An inspection of the meatal area revealed a 5 by 5 by 2 cm. tumor protruding through the n1.eatus, attached by a moderately thin pedicle. The mass was removed under local anesthesia. Microscopic sections of the tissues showed papillary hypertrophy of the squamous epithelium overlying loose, myxomatous-like stroma. There were large vessels and channels filled with blood and thrombus. The diagnosis was benign cavernous hemangioma of the urethra. DISCUSSION
Recently the study and treatment of urological diseases in women have been transferred, to a great extent, from the gynecologist's domain. Aside from stress incontinence and urinary tract fistula, other maladies of the urethra, bladder,
URETHRAL HEMANGIOMA
ureters and kidneys are now usually treated by urologists. Because of a sharp division of specialties, training in urology for the gynecologic house officer has been neglected. As a result, the intimacy of the urinary and reproductive systems from the embryologic, anatomic, physiologic and functional standpoints has not been emphasized to the young gynecologist. The basic concepts of gynecologic disease demand a thorough knowledge of the anatomy, physiology and pathology of the urinary tract. The awareness of the proximity of the urinary organs to the genitalia and their interchangeable influences is essential during operation. 8 Also, in the postoperative period, the care of the urethra, bladder, ureters and kidneys is of major concern. Operations for cysto-rectocele, enterocele, prolapse of the uterus, cervical and endometrial carcinoma, large uterine ovarian and parovarian tumors, endometriosis and pelvic inflammatory disease have urinary tract connotations. Failure to investigate each patient completely prior to surgery results in improper treatment or operation, morbidity, and mortality. Similarly, study of chronic urinary tract infection in the child or 8 Wharton, L. R.: Gynecology, With a Section on Female Urology. Philadelphia: W. B. Saunders
Co., 1943, p. 770.
581
adult patient has been rewarded by the discovery of lesions heretofore unsuspected. Therefore, the gynecologist must become thoroughly familiar with diseases of the female urinary tract. In addition, he must be prepared to perform and evaluate the various diagnostic procedures since they are paramount for adequate treatment. While excretory urography has proved to be an invaluable aid in regard to kidney function and diagnosis, retrograde cystoscopy and pyelography' as well as panendoscopy are integral parts of an investigation. One of the most frequently ignored areas of the urinary tract is the urethra. Neoplasms of this organ supposedly are not found in early stages because the patient is reluctant to expose this area. However, in the gynecologic patient, a systema~ tic pelvic examination includes meticulous in~ spection of the urethral meatus and urethra. When diagnostic cystoscopic procedures are done, panendoscopy should be routine. In the case presented it must be assumed that the persistent hematuria was caused by the urethral hemangioma. Although there was extensive examination of the urinary tract, panendoscopy was not done. The course of events accentuates the necessity of a complete urologic investigation. Esplanade Apartments, Baltimore, Maryland
THE JOURNAL OF UROLOGY
Copyright © 1965 by The Williams & Wilkins Co.
URETHRAL HEMANGIOMA H. MEL VIN RADMAN There is a tendency to consider a urethral tumor benign; 1- 3 however, it has been shown statistically that the majority of these tumors are malignant. 3 Because of this misconception and to demonstrate the relationship between urethral caruncle and malignancy, Marshall and associates reviewed a series of cases at the Squier Clinic of The Presbyterian Hospital of New York. 3 From 1932 to 1958, a 26-year period, 394 women with urethral tmnors were seen. The true urethral caruncle was defined as localized swelling with varying degrees of inflammation, vascularity and fibrosis. They were not considered to be neoplastic since the true identity as such has been questioned. Of the 394 patients, there were 356 with caruncles, 16 with benign growths and 22 with malignant tumors. Numerous reports can be found in the literature in regard to urethral carcinoma;1- 5 on the other hand, non-malignant tumors have received little attention. The most common benign lesions are polyps and papilloma while the most rare are myoma, fibromyoma and hemangioma. 4 • 6 In 1 woman, treated for 10 years for unexplained hematuria, a urethral hemangioma was discovered and removed. Since the literature is sparse and few authenticated examples have been recorded,7 the case presented herein might prove valuable. Opinion is divided whether hemangiomas are more frequent in men or in women.1· 2 • 5 Scholl and Braasch believed that the condition appeared more often in middle-aged women. 5 The causative factors have not been determined but are thought to be the result of chronic irritation. 6 A more Accepted for publication February 23, 1965. 1 Graves, R. C. and Guiss, L. W.: Tumors of the urethra. J. Urol., 46: 925, 1941. 2 Lowsley, 0. S. and Kirwin, T. J.: A clinical and pathological study of congenital obstruction of the urethra. J. Urol., 31: 497, 1934. 3 Marshall, F. C., Uson, A. C. and Melicow, M. M.: Neoplasms and caruncles of the female urethra. Surg., Gynec. & Obst., 110: 723, 1960. 4 McCrea, L.: Tumors of the urethra. In: Gynecological Urology, edited by A. F. Youssef. Springfield: Charles C Thomas, 1960, p. 596. 5 Scholl, A. J. and Braasch, W. F.: Primary tumors of the urethra. Ann. Surg., 76: 246, 1922. 6 Herbut, P. A.: Urological Pathology. Philadelphia: Lea & Febiger, vol. 1, 1952, p. 95. 7 Everett, H. S.: Personal communication. 580
plausible explanation is that they represent varicosities of the urethral vessels. CASE REPORT
Mrs. S. P., a 56-year-old woman, had been observed for 13 years. In 1953, total abdominal hysterectomy and bilateral salpingo-oophorectomy were done because of a large fibromyoma associated with profuse bleeding at the time of the menstrual periods. The patient had a rapid convalescence. Approximately a year later she complained of urinary frequency and lower abdominal pain which radiated to the groin. She had no fever or chills. Urinalysis showed a few pus cells but no bacteria. After the symptoms had subsided, an excretory urogram showed a double ureter and kidney on the left side. No other abnormalities were noted. Shortly the patient noticed some blood in the urine and an inspection of the genital tract failed to reveal the cause. On retrograde cystoscopy and excretory urography, no apparent source of bleeding could be determined. Hematuria occurred at irregular intervals; a thorough investigation failed to reveal the source. In November 1964 the patient had pneumonitis and was treated by an intensive course of antibiotic therapy. Subsequently she complained of itching, burning and the protrusion of a mass in the genital area and was referred for gynecologic consultation. An inspection of the meatal area revealed a 5 by 5 by 2 cm. tumor protruding through the n1.eatus, attached by a moderately thin pedicle. The mass was removed under local anesthesia. Microscopic sections of the tissues showed papillary hypertrophy of the squamous epithelium overlying loose, myxomatous-like stroma. There were large vessels and channels filled with blood and thrombus. The diagnosis was benign cavernous hemangioma of the urethra. DISCUSSION
Recently the study and treatment of urological diseases in women have been transferred, to a great extent, from the gynecologist's domain. Aside from stress incontinence and urinary tract fistula, other maladies of the urethra, bladder,
URETHRAL HEMANGIOMA
ureters and kidneys are now usually treated by urologists. Because of a sharp division of specialties, training in urology for the gynecologic house officer has been neglected. As a result, the intimacy of the urinary and reproductive systems from the embryologic, anatomic, physiologic and functional standpoints has not been emphasized to the young gynecologist. The basic concepts of gynecologic disease demand a thorough knowledge of the anatomy, physiology and pathology of the urinary tract. The awareness of the proximity of the urinary organs to the genitalia and their interchangeable influences is essential during operation. 8 Also, in the postoperative period, the care of the urethra, bladder, ureters and kidneys is of major concern. Operations for cysto-rectocele, enterocele, prolapse of the uterus, cervical and endometrial carcinoma, large uterine ovarian and parovarian tumors, endometriosis and pelvic inflammatory disease have urinary tract connotations. Failure to investigate each patient completely prior to surgery results in improper treatment or operation, morbidity, and mortality. Similarly, study of chronic urinary tract infection in the child or 8 Wharton, L. R.: Gynecology, With a Section on Female Urology. Philadelphia: W. B. Saunders
Co., 1943, p. 770.
581
adult patient has been rewarded by the discovery of lesions heretofore unsuspected. Therefore, the gynecologist must become thoroughly familiar with diseases of the female urinary tract. In addition, he must be prepared to perform and evaluate the various diagnostic procedures since they are paramount for adequate treatment. While excretory urography has proved to be an invaluable aid in regard to kidney function and diagnosis, retrograde cystoscopy and pyelography' as well as panendoscopy are integral parts of an investigation. One of the most frequently ignored areas of the urinary tract is the urethra. Neoplasms of this organ supposedly are not found in early stages because the patient is reluctant to expose this area. However, in the gynecologic patient, a systema~ tic pelvic examination includes meticulous in~ spection of the urethral meatus and urethra. When diagnostic cystoscopic procedures are done, panendoscopy should be routine. In the case presented it must be assumed that the persistent hematuria was caused by the urethral hemangioma. Although there was extensive examination of the urinary tract, panendoscopy was not done. The course of events accentuates the necessity of a complete urologic investigation. Esplanade Apartments, Baltimore, Maryland