(Pics attached below; open with caution)
Have you ever heard of a urethral caruncle? This may a finding on your ano-genital exam but is not related to sexual assault injury. This is a non-traumatic variant. It is a benign fleshy outgrowth at the urethral meatus and can be soft pink or red, measuring 1-2cm. They are often asymptomatic, but could have light bleeding and dysuria.
You may hear people use the terms urethral caruncle and urethral prolapse interchangeably. They look similar. The slight difference is that in a urethral prolapse, the urethra protrudes out on all edges. (This usually looks like a tiny pink donut.) With a urethral caruncle, the urethra only protrudes out on one edge. Both of them involve protrusion of urethral tissue.
You can also see them in pre-menopausal girls too, although more common in post menopause. I actually saw an 11 year old with one once. Her mom saw blood in her underwear and brought her to us for a FNE exam, thinking her daughter had been sexually assaulted. There was no abuse disclosure and she had not yet started menses. When I performed the ano-genital exam, I noted the urethral caruncle with scant red blood. The patient adamantly denied any form of sexual abuse or consensual sexual contact but did endorse dysuria. There were no genital findings concerning for acute injury or any other findings that could have been the source of bleeding, and the patient was verbal and able to give a history, in which she denied any sexual penetration or contact of any kind. We ultimately discharged her home after a urology consult, and our concern for SA was very low.
The treatment is usually estrogen cream (which is what we do for lichens sclerosis too). Sitz baths, anti-inflammatories, and/or antibiotics may also be prescribed.
If you think about what estrogen does to genital tissues, you know it increases elasticity and pliability and well as increases tissue thickness and lubrication. When estrogen is low (such as in pre or post menopause), the tissue is thin, dry, and inflexible, resulting in tissue that tears easily, making it easier for the urethra to protrude outward. So by using topical estrogen cream, it allows the tissues to become more elastic and pliable so the mass will be able to find its way back home, haha. Most courses of treatment take 2-4 weeks of estrogen cream, and in rare cases where it is too large or doesn’t respond to aforementioned treatments, excision may be necessary. I have attached some pics below, from google.
