pelvic organ prolapsesurgery Thrombosed urethral carunclefollowing LETTER TO EDITOR ScienceDirect

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Progrèsenurologie(2019)29,391—392

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LETTER TO EDITOR

Thrombosed urethral caruncle following pelvic organ prolapse surgery

Une caroncule urétrale thrombosée après chirurgie d’unprolapsusgénital

Keyword Urethralcaruncle Motclé Caronculeurétrale Totheeditor,

The authors wouldlike toshare thecase of a urethral caruncle(UC)(orthrombosedurethralhaemorrhoid?)after pelvicorganprolapse(POP)surgery.

A 72-year-old patient suffered fromPOP with stageIII uterineprolapse, stageII cystocele andstage II rectocele presenting with symptoms of vaginal bulging, associated withurgency andbladderoutletobstruction. Preoperative urodynamicﬁndingswerenormal,includingnormalvoiding functiononuroﬂowmetry.Sheunderwentsurgicalcorrection ofprolapsewithvaginalhysterectomyandbilateraladnex- ectomy,sacrospinoushysteropexyandanteriorandposterior midlinefascialplicationunderspinalanaesthesia.

Eleven days after surgery, she presented to the emer- gency room for perineum pain, urethral bleeding and bladderoutletobstruction.Physicalexaminationshoweda softreddishpolypoid massofabout 2cm,protrudingfrom theurethra(Fig.1) andnoPOP.Following failureof topi- caltreatment,sheunderwenttheremovalofthemassbya four-quadrantexcisional technique.Pathological examina- tionpointedtoUCwithnosignofmalignancy.Thepatient wasasymptomaticafterexcisionofthelesionandtheclin- icalexamat6weeksshowedonlyasmallurethralmucosal prolapse.

UCisacommonbenignpolypoidtumouroftheurethra whichpresentsasaredﬂeshyandfriablepedunculatedor sessilenoduleprotrudingfromthemeatus.Itcanalsoappear ulcerated,velvetyorhaemorrhagic.Itisusuallylocatedon the lower half of the posterior lip of the urethra. It can beasymptomatic or canbe associatedwithvarioussymp- tomsandsignssuchaspain,vaginalbleeding, haematuria andbladderoutletobstruction[1].Itoftenaffectswomen afterthemenopause,butsomecaseshavealsobeenseen inprepubertalgirlsandmen.

UC and urethral prolapse are similar diseases except urethral prolapse is circumferencialwhereas UCdoes not

Figure1. Thrombosedurethralcaruncle/hemorrhoid.

encircletheentireurethralmucosa[2].Theiraetiopathol- ogyisnotwellunderstood.Oestrogendeficiency,irritation or trauma of the urethra and conditions associated with chronicallyincreased intra-abdominal pressurehave been suspected[1].An hypothesis isthat theirpathophysiology issimilartothe oneof anal hemorrhoids.Venousconges- tion of the urethral submucous vascular complex due to increasedabdominalpressureandoestrogendeficiencymay leadtourethralvarices[3].Anotherhypothesisisthatlack of oestrogenscauses defects of attachment between lay- ersofurethralsmoothmuscleleadingtotheprotrusionof themucosa[2].Inthecurrent case, thecauseofUCmay bethemodificationofvenousdrainageaftersurgeryorthe placementofaurinarycatheterduringsurgery.

The medical treatment is based on topical oestrogen, anti-inﬂammatoryandveinotonicagents.Surgical excision

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392 Lettertoeditor (bythefour-quadrantexcisionaltechnique,excisionofthe

mucosa over a Foley catheter or ligation at the base of thecaruncle)may be needed ifthe medicaltreatment is ineffective.Therecurrencerateisabout12.5%[2].

Histologically, UC is composed of an epithelial lining of hyperplasic benign urothelium and squamous epithe- liumoverlyingasubmucosalcongestion,lymphoplasmacytic inﬂammatoryinﬁltrateanddilatedbloodvesselswithinthe laminapropiawhichcancontainthrombus(asinourcase) [1].

Pathologicalexaminationisrequiredtoconﬁrmthediag- nosis because UC can be mistaken for a wide range of benignormalignanturethrallesions:ﬁbroepithelial polyp, urethralleiomyoma,primaryurethral carcinoma,urethral melanoma and lymphoma [1]. In case of suspicious or atypicalmass,investigationsshouldbeledsuchasurethro- cystoscopy(whichenablesassessmentoftheextensionand biopsyifnecessary)andradiologicimaging(magneticreso- nanceimagingorcomputedtomographyurography).

AppendixA. Supplementarydata

Supplementary data associated with this article can be found, in the online version, at https://doi.org/

10.1016/j.purol.2019.04.010.

Disclosureofinterest

Theauthorsdeclarethattheyhavenocompetinginterest.

References

[1]Conces MR, Williamson SR, Montironi R, Lopez-Beltran A, ScarpelliM,ChengL.Urethralcaruncle:clinicopathologicfea- turesof41cases.HumPathol2012;43(9):1400—4.

[2]HallME,OyesanyaT,CameronAP.Resultsofsurgicalexcision ofurethralprolapseinsymptomaticpatients.NeurourolUrodyn 2017;36(8):2049—55.

[3]ArnoldSJ,GoodeR,GinsburgA.Photostudiesofurethralvarices

‘‘hemorrhoids’’:aforgottenlesion.Urology1978;11(1):19—27.

C.Armengaudâ,J.F.Hermieu^b,X.Deffieuxâ^,∗

aServicedegynécologie-obstétriqueetmédecine delareproduction,hôpitalAntoineBéclère, AP—HP,GHUSud,157,ruedelaPortedeTrivaux, 92140Clamart,France

bServiced’urologie,hôpitalBichat,AP—HP,46, rueHenriHuchard,75018Paris,France

∗Correspondingauthor.

E-mailaddress:xavier.defﬁ[email protected] (X.Defﬁeux) Availableonline23May2019

https://doi.org/10.1016/j.purol.2019.04.010