@UrologyQuiz Quiz5 Answer: Hyper-Granulation Tissue (aka overgranulation)

(Hypergranulation [or overgranulation] is an excess of granulation tissue beyond the amount required to replace the tissue deficit incurred as a result of skin injury or wound1)

Differential Diagnosis -Infection -Skin excoriation/trauma -Dermatoses -Cancer (SCC, Urothelial carcinoma etc.) Suprapubic (SPC) Catheter exit Sites are a common course of concern but are RARELY INFECTED and RARELY cancer (SCC or TCC growing out of tract) Next step in treatment History- recurrent or first time, change in catheter type or size, trauma, dressing etc. as precipitants Is wound swab for microscopy/culture and sensitivities necessary? Although often done discharge in the form of urine, mucous and debris is quite normal with a SPC site- as is hypergranulation so unless the site is newly tender with erythema and other evidence of infection the answer is no- organisms will go and potentially be inappropriately treated with antibiotics Is a biopsy needed? If progressive and not responding to normal measures or suspect-YES Treatment: - Often NO treatment is required if it is stable and asymptomatic Remove irritant (e.g. make catheter more secure to stop rubbing, change of dressing if used) Silver nitrate: Seen in picture left (comes as impregnated sticks) - be careful as excessive use may burn skin (cover normal skin with protecting barrier). Repeat applications may be required. Excision etc. is to be avoided. Topical steroids have been used. Any means of removing tissue (including silver nitrate) may cause more inflammation and so is argued against by some1 For those keen- very comprehensive document: http://www.wcauk.org/downloads/booklet_overgranulation.pdf Teaching Points: 1) Hypergranulation tissue is common and rarely a cause of concern as it may be easily treated with removal of irritant, change of dressing and regular cleaning with gentle agents 2) Use of topical agents such as silver nitrate (or surgical removal) may be argued against due to causing more inflammation on essentially a new wound but are often used 3) In rare instances swab and treatment with antibiotics (topical or systemic) may be required for bona fide cellulitis of an SPC exit site and rarely a biopsy of a lesion may be required to exclude cancercareful monitoring will allow triage to those requiring further investigation
References 1. Vuolo J, 2010 Br J Nurs. 2010 Mar 25-Apr 7;19(6):S4, S6-8.Hypergranulation: exploring possible management options http://uhra.herts.ac.uk/bitstream/handle/2299/7006/904021.pdf?sequence=2

By @lawrentschuk Editor-in-Chief @UrologyQuiz Assoc. Professor Nathan Lawrentschuk, University of Melbourne AUSTRALIA