Une caroncule urétrale thrombosée après chirurgie d’un prolapsus génital

25 juillet 2019

Auteurs : C. Armengaud, J.F. Hermieu, X. Deffieux
Référence : Prog Urol, 2019, 7, 29, 391-392




 


To the editor,

The authors would like to share the case of a urethral caruncle (UC) (or thrombosed urethral haemorrhoid?) after pelvic organ prolapse (POP) surgery.


A 72-year-old patient suffered from POP with stage III uterine prolapse, stage II cystocele and stage II rectocele presenting with symptoms of vaginal bulging, associated with urgency and bladder outlet obstruction. Preoperative urodynamic findings were normal, including normal voiding function on uroflowmetry. She underwent surgical correction of prolapse with vaginal hysterectomy and bilateral adnexectomy, sacrospinous hysteropexy and anterior and posterior midline fascial plication under spinal anaesthesia.


Eleven days after surgery, she presented to the emergency room for perineum pain, urethral bleeding and bladder outlet obstruction. Physical examination showed a soft reddish polypoid mass of about 2cm, protruding from the urethra (Figure 1) and no POP. Following failure of topical treatment, she underwent the removal of the mass by a four-quadrant excisional technique. Pathological examination pointed to UC with no sign of malignancy. The patient was asymptomatic after excision of the lesion and the clinical exam at 6 weeks showed only a small urethral mucosal prolapse.


Figure 1
Figure 1. 

Thrombosed urethral caruncle/hemorrhoid.




UC is a common benign polypoid tumour of the urethra which presents as a red fleshy and friable pedunculated or sessile nodule protruding from the meatus. It can also appear ulcerated, velvety or haemorrhagic. It is usually located on the lower half of the posterior lip of the urethra. It can be asymptomatic or can be associated with various symptoms and signs such as pain, vaginal bleeding, haematuria and bladder outlet obstruction [1]. It often affects women after the menopause, but some cases have also been seen in prepubertal girls and men.


UC and urethral prolapse are similar diseases except urethral prolapse is circumferencial whereas UC does not encircle the entire urethral mucosa [2]. Their aetiopathology is not well understood. Oestrogen deficiency, irritation or trauma of the urethra and conditions associated with chronically increased intra-abdominal pressure have been suspected [1]. An hypothesis is that their pathophysiology is similar to the one of anal hemorrhoids. Venous congestion of the urethral submucous vascular complex due to increased abdominal pressure and oestrogen deficiency may lead to urethral varices [3]. Another hypothesis is that lack of oestrogens causes defects of attachment between layers of urethral smooth muscle leading to the protrusion of the mucosa [2]. In the current case, the cause of UC may be the modification of venous drainage after surgery or the placement of a urinary catheter during surgery.


The medical treatment is based on topical oestrogen, anti-inflammatory and veinotonic agents. Surgical excision (by the four-quadrant excisional technique, excision of the mucosa over a Foley catheter or ligation at the base of the caruncle) may be needed if the medical treatment is ineffective. The recurrence rate is about 12.5% [2].


Histologically, UC is composed of an epithelial lining of hyperplasic benign urothelium and squamous epithelium overlying a submucosal congestion, lymphoplasmacytic inflammatory infiltrate and dilated blood vessels within the lamina propia which can contain thrombus (as in our case) [1].


Pathological examination is required to confirm the diagnosis because UC can be mistaken for a wide range of benign or malignant urethral lesions: fibroepithelial polyp, urethral leiomyoma, primary urethral carcinoma, urethral melanoma and lymphoma [1]. In case of suspicious or atypical mass, investigations should be led such as urethrocystoscopy (which enables assessment of the extension and biopsy if necessary) and radiologic imaging (magnetic resonance imaging or computed tomography urography).


Disclosure of interest


The authors declare that they have no competing interest.



Appendix A. Supplementary data


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References



Conces M.R., Williamson S.R., Montironi R., Lopez-Beltran A., Scarpelli M., Cheng L. Urethral caruncle: clinicopathologic features of 41 cases Hum Pathol 2012 ;  43 (9) : 1400-1404 [cross-ref]
Hall M.E., Oyesanya T., Cameron A.P. Results of surgical excision of urethral prolapse in symptomatic patients Neurourol Urodyn 2017 ;  36 (8) : 2049-2055 [cross-ref]
Arnold S.J., Goode R., Ginsburg A. Photostudies of urethral varices "hemorrhoids": a forgotten lesion Urology 1978 ;  11 (1) : 19-27 [cross-ref]






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