What are Benign Urethral Lesions in Adults?

Male Urinary Tract
Male Urinary Tract
Medical Illustration Copyright © 2015 Nucleus Medical Media, All rights reserved

The urethra is a vital part of the urinary tract. Its main job is to carry urine out of the body. In men, this channel also carries semen from the reproductive tract. Most people won't have problems with the urethra, but a few of us may suffer from benign (no cancer) urethral lesions.

What Happens under Normal Conditions?

The urethra is a tube-like organ that carries urine from the bladder out of the body. In males, the urethra starts at the bladder and runs through the prostate gland, perineum (the space between the scrotum and the anus), and the penis. In women, the urethra is much shorter: it runs from the bladder to just in front of the vagina and opens outside the body. Normal urine flow is painless and can be controlled. The stream is strong and the urine is clear with no visible blood.

Female Urinary Tract
Female Urinary Tract
Medical Illustration Copyright © 2015 Nucleus Medical Media, All rights reserved

A lesion is a damaged part of an organ or tissue. The defect keeps the organ from working the way it should.

Causes

Lesions can be caused by an accident, infection, or the way the organ grows.
Some causes are:

  • abscesses
  • pelvic breaks
  • straddle injuries
  • infections
  • injury caused by medical tools (such as catheters or cystoscopes)
  • rare health problems present at birth


What are Some Types of Benign Urethral Lesions?

Non-Cancerous Growths

Non-cancerous growths in men are linked to warts on the penis shaft. These lesions are often caused by the human papilloma virus (HPV). Your health care provider might suspect urethral wart-like growths if he/she sees a lesion on the urethra outlet. He/she may also suspect them if your urinary stream changes, or if you've had them before. There may also be blood in your urine and pain/burning when you pee.

Lichen Sclerosis (LS) or Balanitis Xerotica Obliterans (BXO)

Lichen sclerosis is a lasting skin problem of the penis end that doesn't have a known cause. LS is marked by pale, shiny, whitish skin around the outlet of the urethra. This skin can turn into a scar over time. This is thought to start in early childhood and progress through adulthood. The scar can make the urethra thinner (urethral stricture). This can make it harder to pee. Other symptoms are soreness, itching, and cracking skin, sometimes with ulcerations and bleeding. Uncircumcised men with this problem can have trouble pulling back the penis foreskin.

Urethral Stricture
Urethral Stricture

Urethral Stricture Disease

A urethral stricture is when part of the urethra narrows. This can be caused by scar tissue forming in the urethra. (This disease is described in the Urethral Stricture section on this website.) The symptoms of urethral stricture disease are:

Your urologist mostly finds urethral strictures by testing a urine sample, using an x-ray test (retrograde urethrography), and looking inside your body with a long, thin telescope with a light at the end (cystoscope).

Urethral Polyps

A urethral polyp is a rare, irregular growth that most often appears at birth. It's most common in females. This polyp is often made up of fibrous tissue. It may also include some smooth muscle, small cysts, or nerve tissue, all covered with a thin protective layer of tissue.

Some symptoms are:

  • lump in the vulva of the vagina
  • blood in the urine
  • urinary blockage

Urethral polyps are found with a cystoscope. A type of x-ray test called a voiding cystourethrogram (VCUG) is also used.

Paraurethral Cyst

Paraurethral cysts, also known as Skene's glands, are found in the wall of the vagina near the urethra in females. A paraurethral cyst appears as a glistening, tense, and bulging yellowish-white mass that narrows the urethral outlet.

Common symptoms are:

  • a lump that can be felt
  • misdirected urinary stream
  • urinary blockage
  • painful urination

Urethral Caruncle

Urethral caruncles are polypoid ("stalk-like") masses hanging from part of the urethral outlet. These are most often spotted during an exam for some other health problem. Urethral caruncles are more common in women who don't use hormone replacement therapy (HRT) after menopause. The main sign of this problem is a thin, reddish membrane sticking out from the urethral outlet.

Some symptoms are:

  • bleeding and pain when peeing
  • needing to pee often
  • sudden need to pee
  • outlet of the urethra is tender

Urethral Prolapse

Urethral prolapse is a rare problem of the female urethra. It's much more bothersome than other benign lesions. The urethra's membrane and the spongy tissue below poke out of the urethral outlet. This leads to pain and vaginal bleeding. Sometimes it can keep your body from getting rid of urine. Urethral prolapse occurs most often in young girls, but may happen at any age. It's most often found by physical exam.



Treatment

Foley Catheter
Foley Catheter
Blamb/Shutterstock.com

How a benign lesion is treated depends on the type and where it is. Abscesses, urethral injuries, and infections need to be treated quickly. Your urologist has many meds and methods to deal with these lesions.

Abscesses linked to gonococcal urethritis can be treated well with antibiotics. Your urologist may also need to surgically drain the abscess. You may need a catheter in the bladder (Foley catheter) or a tube in the bladder through the belly (suprapubic tube) to keep urine out of the urethra until it heals. After the urethra heals, you should be able to pee as usual.

Urethral Stricture Disease

To treat urethral stricture disease, your urologist needs to know where the scars are. This is done with an x-ray test called urethrography. A special dye is infused into the urethra through the tip of the penis. When an x-ray is taken, the dye will show where and how long the scars are. If these strictures are very dense or if they block the channel, a more detailed voiding study through a small cut above the pubic bone may be needed.

Suprapubic catheter
Suprapubic catheter
Blamb/Shutterstock.com

Urethral strictures are often treated by making the channel wider. This is done either through stretching (dilation) or surgery.

Dilation

Dilation is a way to stretch the narrow urethra back to its normal width. A tube slightly wider than the urethra is passed through its outlet into the bladder. The tube is taken out and slightly larger tubes are used until the opening is stretched to the right width. The procedure is done using anesthetic jelly on the skin. Your urologist may use a urethroscope to look into the urethra. Dilation may cause some discomfort, which may be worse with tighter, denser strictures. Your urologist may place a urethral catheter into the urethra for 24 hours or longer afterwards to drain the bladder. Dilation is often only useful for very short strictures. If you've had stricture dilation before, another isn't likely to permanently fix the problem. But the time it takes for a stricture to form again varies, so this treatment may still be useful for some patients.

Surgery

Urethrotomy. Direct vision internal urethrotomy (DVIU) may work well for short strictures (less than about ¾ inch). Using a cystoscope, the urologist feeds a small knife through a tube into the urethra and makes a deep cut through the stricture. Making a single cut through the scarred stricture exposes the healthy epithelial tissue below. This should allow the urethra to re-cover itself with more normal tissue. DVIU is most often done with the patient under general anesthesia. This procedure may need to be done again  if the stricture reforms.

Urethroplasty. Long strictures and scars in the urethra close to the penis outlet don't react as well to DVIU or dilation. Those scars--and completely destroyed urethras--can be dealt with by surgery to rebuild the urethra (urethroplasty), but results vary. Urethroplasty is done by making a cut in the penis or the perineum and taking out the scar tissue. The healthy tissues at the ends of the urethra are rejoined.

Sometimes a skin graft is sewn in to replace the urethra at the stricture. This skin is taken from inside the cheek or some other part of the body. A catheter is often needed for several weeks after this procedure.

Other Methods

Permanent metal stents have been implanted for bulbar urethral strictures, but aren't useful for most patients. Non-cancerous urethral growths can be hard to treat. Lasers can be used to destroy the lesions seen with genital warts (from HPV). Some health care providers suggest using skin creams. As of now, no technique reliably cures this health issue or keeps the virus from coming back.

Lichen Sclerosis (LS) or Balanitis Xerotica Obliterans (BXO)

LS and BXO are treated with agents that kill bacteria and reduce swelling. Circumcision may be needed. If scars block the urethra, more reconstructive surgery may be needed.

Urethral Polyps

Urethral polyps can be removed using cystourethroscopy. Your urologist can peer into the urethra with a small, flexible camera and use miniaturized tools to remove the growth.

Paraurethral Cyst

Paraurethral cysts don't need to be treated if there are no symptoms. Most often, these pop and shrink on their own. But if there's a block, infection, or if pain occurs, your urologist may pierce the cyst with a scalpel blade to drain it and ease the symptoms.

Urethral Caruncle

Urethral caruncle cysts don't need to be treated if there are no symptoms. Some urologists suggest using estrogen cream or HRT to make the caruncle go away. If the caruncle is large or causes problems, your urologist may remove it and burn its base.

Urethral Prolapse

Urethral prolapse is treated by surgically removing the prolapsed tissue. The membrane is then stitched in place to keep it from occurring again.



What Can I Expect after Treatment for Benign Urethral Lesions?

Benign lesions from HPV and gonorrhea are hard to get rid of. Antibiotics can often keep them under control. These urethral lesions often come back and need to be treated again.

Both dilation and internal urethrotomy treatment have a high chance of strictures coming back. This depends on the length of the stricture. Shorter strictures mostly do better than longer ones. Many studies suggest that daily, intermittent catheterization for up to 3 months after the treatment may help keep the stricture from forming again.

Problems with urethroplasty are:

  • stricture coming back
  • bleeding
  • infection
  • lower extremity problems due to longer surgery times (this is rare)

Before taking out the catheter after surgery, your urologist will likely order a voiding cystourethrogram. This x-ray study of the urethra will show if it's healing the right way.

Your urologist will often follow up any stricture procedure with repeat clinic visits, a physical exam, and questions. He/she might also do a test to check how fast your urine flows and the force of the urine stream. Repeat radiographic studies (retrograde urethrograms) are often done 3 and 12 months after a urethroplasty to see if the stricture has come back. While most strictures form again within a year of surgery, they've been known to show up as long as 10 years later.