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Urethral caruncle
URETHRAL EDWARD Instructor,
Department
L.
CARUNCLE”
KICKHAM,
M.D.,
F.A.C.S.
of Gynecology, Tufts College MedicaI School; Obstetrical Service, Carney Hospital
Visiting
Surgeon,
Gynecologicat
and
BOSTON
U
caruncIe or vascuIar tumor of the meatus is the most common neopIasm of the urethra and was first described by SamueI Sharp in 1730, who said, “ SmaII excrescences may occasion vioIent disorders in so tender an organ as the urethra.” It is known by various other terms such as granuIoma, papilIoma, angioma and irritabIe caruncIe. RETHRAL
ETIOLOGY
ANATOMY
The growth practicaIIy aIways appears on the Iower haIf of the meatus, is florid or dusky red in coIor, and is attached to the urethra1 margin by either a pedicIe or a broad base which may extend into the cana1. The appearance varies from ffat and rugose and sIightIy eIevated to a narrow tumor with a pedicIe and a sharp crenated edge, standing out from the urethra and compressed by the nymphae. It is usuaIIy singIe, but occasionaIIy there may be two or more. HISTOLOGY
It is essentiaIIy a vascuIar growth and Skene, who made a specia1 study of urethra1 neopIasms, appIied the term papiIIary poIypoid angioma and described it as a “bunch of diIated capiIIaries set in moderateIy dense stroma of connective tissue, covered with mucous membrane which has the usua1 pavement epitheIium.” The presence of any unusua1 number of nerve fibres or unusua1 arrangement of nerve endings has not been satisfactoriIy demonstrated aIthough many beIieve they are we11 suppIied with nerve tissue which accounts in some measure for their extreme sensitiveness. * The Department
of GynecoIogy,
The exact cause is not known. It may occur at any age. It is most common just before, during or immediateIy after the menopause and it is more frequentIy seen in muItiparae. In young women gonorrhea1 urethritis is thought to be a causative factor, as is inflammation of Skene’s ducts. In oIder women chronic cystitis, cystoceIe and urethroceIe are thought to cause the condition. DIAGNOSIS
The diagnosis is usuaIIy made by inspection or examination and is obvious. OccasionaIIy the condition is so sensitive that compIete examination is not possibIe and this in itseIf is a point in favor of the presence of a caruncle. Urethra1 carDiferential Diagnosis. uncIe must be distinguished from severa conditions found in this region, aIthough the differentiation is usuaIIy not very diffIcult. Urethra1 poIypi which are usuaIIy much Iess sensitive and most often are attached higher in the urethra may at times be confused with caruncIe. ProIapse of the urethra is another condition which occurs in this region, but the principa1 point of difference is that the proIapse invoIves the entire circumference of the meatus whiIe the caruncIe is most aIways on the Iower haIf and a smaI1 part of that. Inffammation of Skene’s ducts usuaIIy does not cause painfu1 micturition which is an aImost constant symptom of caruncIe. AIso, the gIand openings can usuaIIy be seen and pus may be expressed from them. Cancer at this point is very rare, but patho-
Tufts CoIIege MedicaI SchooI and the GynecoIogicaI Carney HospitaI, Boston, Mass. 178
and Obstetrica
Service,
NEW
SERIES
VOL. XXXVI.
No. I
Kickham-Urethral
IogicaI examination of the excised tumor wiII assure the diagnosis and proper foIlow-up treatment may be instituted without any harm having been done either by trauma or deIay. CLINICAL
HISTORY
The principa1 symptom is pain. It may take the form of painfuI micturition, either sIight or severe. Dyspareunia is a common symptom, with consequent upset of the nervous system. Pressure on waIking or sitting and especiaIIy pressure from cIothing or sanitary pads are frequent compIaints. OccasionaIIy, retention of urine for long periods is noted and this is brought on graduaIIy by the individua1 in her attempt to avoid painfu1 micturition. Hemorrhages may occur when the vessels are near the surface and these may vary from sIight staining to bIeeding of aIarming proportions, especiaIIy when they are recurrent. In extreme cases the constant pain and discomfort may cause irritabIeness, despondency, Ioss of appetite, Ioss of weight, loss of sIeep and sometimes Ieads to severe nervous upsets, the cause of which is many times compIeteIy overIooked. Frequency of micturition without pain is found in the occasiona case but to be without pain is very rare. TREATMENT
Various forms of treatment have been used with varied success. One author advocates the remova of the tumor with a scissors and suturing the base. He contends that remova by cautery is unreIiabIe, causes unnecessary destruction of tissue and promotes the formation of uncontroIIabIe scar tissue. Another maintains that the procedure shouId be entireIy surgical, with free excision of the entire base and the wound cIosed with sutures. StiII another is of the opinion that simpIe excision is foIIowed by a Iarge percentage of recurrences and that remova by a smaI1 tip cautery is foIIowed by the Iargest proportion of permanent cures. KeIIy advises
Caruncle
American
Journal
of Surgery
179
compIete extirpation, preferabIy by electrodessication or eIectrocoaguIation of the base. The treatment we advise and have found to be uniformIy successfu1 in uncompIicated cases is a combination of both surgica1 excision and the cautery. Technique. Under surgica1 anesthesia a semicircuIar incision is made aIong the margin of the meatus about the tumor. We make sure that this incision is wide enough to incIude the base of the tumor and deep enough to incIude the fuI1 thickness of the mucous membrane. The growth is then excised and the base is coaguIated with a fine tip cautery. Very rareIy are sutures used in the entire procedure, aIthough they may be used at the angIes for approximation of the cut edges. Care must be exercised in the use of the cautery in order to avoid injuring the surface epitheIium thereby causing a troubIesome scar. If the cautery is confined to the base of the tumor which is beIow the mucous membrane, the surface pavement epitheIium wiI1 hea uneventfuIIy and recurrence is rare. PROGNOSIS
The prognosis is not aIways hopefu1, especiaIIy in recurrent cases. Many of these tumors are very stubborn and reformation is IikeIy to occur with the consequent deformity of the orifice by repeated partia1 operations. In primary cases, with compIete excision and cauterization of the base the cure is compIete in practicaIIy every case in our experience. SUMMARY
First, I wouId again caI1 attention to the frequency of the condition, especiaIIy in women of middIe age or oIder; SecondIy, to the necessity for inspection and examination of patients who compIain of urinary symptoms; and ThirdIy, to the importance of surgica1 treatment in the beginning, as the chance of cure with paIIiative treatment is sIight.
Department
L.
CARUNCLE”
KICKHAM,
M.D.,
F.A.C.S.
of Gynecology, Tufts College MedicaI School; Obstetrical Service, Carney Hospital
Visiting
Surgeon,
Gynecologicat
and
BOSTON
U
caruncIe or vascuIar tumor of the meatus is the most common neopIasm of the urethra and was first described by SamueI Sharp in 1730, who said, “ SmaII excrescences may occasion vioIent disorders in so tender an organ as the urethra.” It is known by various other terms such as granuIoma, papilIoma, angioma and irritabIe caruncIe. RETHRAL
ETIOLOGY
ANATOMY
The growth practicaIIy aIways appears on the Iower haIf of the meatus, is florid or dusky red in coIor, and is attached to the urethra1 margin by either a pedicIe or a broad base which may extend into the cana1. The appearance varies from ffat and rugose and sIightIy eIevated to a narrow tumor with a pedicIe and a sharp crenated edge, standing out from the urethra and compressed by the nymphae. It is usuaIIy singIe, but occasionaIIy there may be two or more. HISTOLOGY
It is essentiaIIy a vascuIar growth and Skene, who made a specia1 study of urethra1 neopIasms, appIied the term papiIIary poIypoid angioma and described it as a “bunch of diIated capiIIaries set in moderateIy dense stroma of connective tissue, covered with mucous membrane which has the usua1 pavement epitheIium.” The presence of any unusua1 number of nerve fibres or unusua1 arrangement of nerve endings has not been satisfactoriIy demonstrated aIthough many beIieve they are we11 suppIied with nerve tissue which accounts in some measure for their extreme sensitiveness. * The Department
of GynecoIogy,
The exact cause is not known. It may occur at any age. It is most common just before, during or immediateIy after the menopause and it is more frequentIy seen in muItiparae. In young women gonorrhea1 urethritis is thought to be a causative factor, as is inflammation of Skene’s ducts. In oIder women chronic cystitis, cystoceIe and urethroceIe are thought to cause the condition. DIAGNOSIS
The diagnosis is usuaIIy made by inspection or examination and is obvious. OccasionaIIy the condition is so sensitive that compIete examination is not possibIe and this in itseIf is a point in favor of the presence of a caruncle. Urethra1 carDiferential Diagnosis. uncIe must be distinguished from severa conditions found in this region, aIthough the differentiation is usuaIIy not very diffIcult. Urethra1 poIypi which are usuaIIy much Iess sensitive and most often are attached higher in the urethra may at times be confused with caruncIe. ProIapse of the urethra is another condition which occurs in this region, but the principa1 point of difference is that the proIapse invoIves the entire circumference of the meatus whiIe the caruncIe is most aIways on the Iower haIf and a smaI1 part of that. Inffammation of Skene’s ducts usuaIIy does not cause painfu1 micturition which is an aImost constant symptom of caruncIe. AIso, the gIand openings can usuaIIy be seen and pus may be expressed from them. Cancer at this point is very rare, but patho-
Tufts CoIIege MedicaI SchooI and the GynecoIogicaI Carney HospitaI, Boston, Mass. 178
and Obstetrica
Service,
NEW
SERIES
VOL. XXXVI.
No. I
Kickham-Urethral
IogicaI examination of the excised tumor wiII assure the diagnosis and proper foIlow-up treatment may be instituted without any harm having been done either by trauma or deIay. CLINICAL
HISTORY
The principa1 symptom is pain. It may take the form of painfuI micturition, either sIight or severe. Dyspareunia is a common symptom, with consequent upset of the nervous system. Pressure on waIking or sitting and especiaIIy pressure from cIothing or sanitary pads are frequent compIaints. OccasionaIIy, retention of urine for long periods is noted and this is brought on graduaIIy by the individua1 in her attempt to avoid painfu1 micturition. Hemorrhages may occur when the vessels are near the surface and these may vary from sIight staining to bIeeding of aIarming proportions, especiaIIy when they are recurrent. In extreme cases the constant pain and discomfort may cause irritabIeness, despondency, Ioss of appetite, Ioss of weight, loss of sIeep and sometimes Ieads to severe nervous upsets, the cause of which is many times compIeteIy overIooked. Frequency of micturition without pain is found in the occasiona case but to be without pain is very rare. TREATMENT
Various forms of treatment have been used with varied success. One author advocates the remova of the tumor with a scissors and suturing the base. He contends that remova by cautery is unreIiabIe, causes unnecessary destruction of tissue and promotes the formation of uncontroIIabIe scar tissue. Another maintains that the procedure shouId be entireIy surgical, with free excision of the entire base and the wound cIosed with sutures. StiII another is of the opinion that simpIe excision is foIIowed by a Iarge percentage of recurrences and that remova by a smaI1 tip cautery is foIIowed by the Iargest proportion of permanent cures. KeIIy advises
Caruncle
American
Journal
of Surgery
179
compIete extirpation, preferabIy by electrodessication or eIectrocoaguIation of the base. The treatment we advise and have found to be uniformIy successfu1 in uncompIicated cases is a combination of both surgica1 excision and the cautery. Technique. Under surgica1 anesthesia a semicircuIar incision is made aIong the margin of the meatus about the tumor. We make sure that this incision is wide enough to incIude the base of the tumor and deep enough to incIude the fuI1 thickness of the mucous membrane. The growth is then excised and the base is coaguIated with a fine tip cautery. Very rareIy are sutures used in the entire procedure, aIthough they may be used at the angIes for approximation of the cut edges. Care must be exercised in the use of the cautery in order to avoid injuring the surface epitheIium thereby causing a troubIesome scar. If the cautery is confined to the base of the tumor which is beIow the mucous membrane, the surface pavement epitheIium wiI1 hea uneventfuIIy and recurrence is rare. PROGNOSIS
The prognosis is not aIways hopefu1, especiaIIy in recurrent cases. Many of these tumors are very stubborn and reformation is IikeIy to occur with the consequent deformity of the orifice by repeated partia1 operations. In primary cases, with compIete excision and cauterization of the base the cure is compIete in practicaIIy every case in our experience. SUMMARY
First, I wouId again caI1 attention to the frequency of the condition, especiaIIy in women of middIe age or oIder; SecondIy, to the necessity for inspection and examination of patients who compIain of urinary symptoms; and ThirdIy, to the importance of surgica1 treatment in the beginning, as the chance of cure with paIIiative treatment is sIight.