A menopausal woman consults for light bleeding upon contact with her underwear and discomfort while urinating. The examination reveals a small reddish mass at the urethral opening. This scenario, common in gynecology or urology consultations, corresponds in the vast majority of cases to a urethral caruncle, a benign growth that primarily affects women after menopause.
Imaging and cystoscopy: distinguishing benign caruncle from suspicious lesion
The first reflex when faced with a visible mass at the urethral opening is to question whether it is truly benign. Clinical examination often suffices for diagnosis, but certain situations complicate interpretation: lesion of unusual size, irregular surface, persistent bleeding despite local treatment.
The recommendations from the European Association of Urology (EAU), updated in 2023, describe the use of high-definition videouroscopy and high-frequency ultrasound imaging of the urethral opening. These techniques allow for the characterization of a budding lesion and differentiate it from a urethral tumor before deciding on surgical excision.
We are well aware of the symptoms and treatment of the urethral caruncle, but this imaging step remains underestimated in standard care pathways. Resorting to cystoscopy avoids unnecessary biopsies and reassures the patient when the lesion presents an atypical appearance.
Urethral caruncle and menopause: the hormonal link in practice
The decrease in estrogen levels after menopause causes thinning of the urogenital mucosa. This phenomenon, described under the term genitourinary syndrome of menopause (GSM), weakens the urethral wall and promotes the appearance of the caruncle.
Specifically, the urethral mucosa loses elasticity and vascularization. The tissue becomes more exposed to microtraumas related to friction, recurrent urinary infections, or chronic local irritation. The caruncle then forms as a localized prolapse of the posterior wall of the urethra.
Anticoagulants and amplified bleeding
In patients on anticoagulant therapy, bleeding related to the caruncle may be more abundant and frequent. A retrospective study published in the Journal of Geriatric Urology in 2022 documented this link between anticoagulation and exacerbated benign urogenital bleeding. This should be considered during clinical evaluation to avoid unnecessary alarm while monitoring the progression.
Symptoms of the urethral caruncle: what leads to consultation
The urethral caruncle is often asymptomatic. It is sometimes discovered incidentally during a gynecological examination. When symptoms do appear, they take several forms.
- Light bleeding upon contact (stained underwear, pink toilet paper), sometimes confused with post-menopausal vaginal bleeding
- Burning sensation or discomfort while urinating (dysuria), which often leads to consultation thinking of a urinary infection
- Visible mass, small, red or purplish, at the entrance of the urethra, sometimes tender to the touch
- Pain during sexual intercourse (dyspareunia), a symptom that remains underreported in consultation
Confusion with a urinary infection is common. When urine tests return negative and discomfort persists, a referral for examination of the urethral opening is made.
Treatment of the urethral caruncle: from topical to surgery
Management depends on the size of the lesion, symptoms, and the patient’s profile. It proceeds in stages.
Local hormonal treatment as first-line
The application of a cream based on estrogen to the urethral area is the first-line treatment. It aims to restore the thickness and flexibility of the mucosa. Responses vary on this point: some patients report a significant regression of the caruncle within weeks, while others observe relief of symptoms without complete disappearance of the lesion.
Sometimes an anti-inflammatory cream is added to reduce local irritation. This conservative treatment is sufficient in the majority of cases.
Surgical excision and diathermy
When the caruncle persists, enlarges, or causes recurrent bleeding, a surgical procedure is considered. Excision is performed under local anesthesia, in consultation or on an outpatient basis. Diathermy (electrical cauterization) is a common alternative.
The risk of recurrence after excision exists, especially if estrogen deficiency is not corrected simultaneously. It is therefore recommended to continue local application of estrogens after the procedure.
Fractional CO₂ laser: a recent option
Specialized centers in pelvic-perineology use the fractional CO₂ vulvo-vaginal laser in menopausal patients presenting with GSM. Prospective series published since 2021 report an improvement in mucosal trophicity and a reduction in caruncle recurrences. This technique is still reserved for centers equipped with the appropriate technology, and its accessibility varies by region.
Prevention and follow-up after treatment of the urethral caruncle
Preventing the appearance or recurrence of a caruncle primarily involves managing GSM. Regular local hydration, the use of appropriate lubricants, and periodic gynecological follow-up after menopause form the basis of this prevention.
- Maintain local estrogen treatment as prescribed, even in the absence of symptoms
- Report any unusual urethral bleeding, especially under anticoagulants
- Avoid local irritants (harsh soaps, inappropriate pads) that weaken the mucosa
Regular follow-up allows for early detection of any recurrence and adjustment of treatment. The urethral caruncle remains a benign lesion of the female urethra, but its daily discomfort justifies careful management tailored to each patient.