Clinical Note Journal of International Medical Research 2014, Vol. 42(1) 236–242 Transurethral seminal ! The Author(s) 2014 Reprints and permissions: vesiculoscopy in the sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0300060513509472 diagnosis and treatment of imr.sagepub.com intractable seminal vesiculitis

Bianjiang Liu, Jie Li, Pengchao Li, Jiexiu Zhang, Ninghong Song, Zengjun Wang and Changjun Yin

Abstract Objective: To investigate the efficacy and safety of transurethral seminal vesiculoscopy in the diagnosis and treatment of intractable seminal vesiculitis. Methods: This prospective observational study enrolled patients with intractable seminal vesiculitis. The transurethral seminal vesiculoscope was inserted into the bilateral ejaculatory ducts and , via the . The ejaculatory ducts and seminal vesicles were visualized to confirm the diagnosis of seminal vesiculitis and to determine the cause of the disease. The seminal vesicles were washed repeatedly using 0.90% (w/v) sodium chloride before a 0.50% (w/v) levofloxacin solution was injected into the seminal vesicles. Results: A total of 114 patients participated in the study and 106 patients underwent bilateral seminal vesiculoscopy. Six patients with postoperative painful ejaculation were treated successfully with oral antibiotics and a-blockers. Two patients with postoperative epididymitis were treated successfully with a 1-week course of antibiotics. Haematospermia was alleviated in 94 of 106 patients (89%), and their pain and discomfort had either disappeared or had been obviously relieved, following treatment. Conclusion: Transurethral seminal vesiculoscopy is effective for diagnosing and treating intractable seminal vesiculitis.

Keywords Seminal vesiculoscopy, seminal vesiculitis, efficacy, safety, minimally invasive

Date received: 17 September 2013; accepted: 28 September 2013

Corresponding author: Dr Zengjun Wang, State Key Laboratory of Reproductive State Key Laboratory of Reproductive Medicine and Medicine and Department of Urology, The First Affiliated Department of Urology, The First Affiliated Hospital of Hospital of Nanjing Medical University, 300 Guangzhou Nanjing Medical University, Nanjing, Jiangsu Province, Road, Nanjing 210029, Jiangsu Province, China. China Email: [email protected] Liu et al. 237

Introduction Patients and methods Seminal vesiculitis is frequently encountered Patient population by urologists and andrologists. This prospective observational study Haematospermia and lower abdominal (or enrolled consecutive patients who had perineal) pain and discomfort are the most recurrent haematospermia with lower common clinical manifestations. A variety abdominal or perineal pain and discomfort of pathological causes can result in haema- between December 2007 and September tospermia.1 Seminal vesiculitis is one of the 2012 in the Department of Urology, The most common causes, especially in patients First Affiliated Hospital of Nanjing under 40 years old.1,2 Although seminal Medical University, Nanjing, Jiangsu vesiculitis is a benign and self-limiting dis- Province, China. None of the patients had ease, recurrent episodes lead to anxiety, fear, a history of poorly controlled hypertension, erectile dysfunction and even male infertil- abnormal liver function, coagulation ity.2 Lesions in the male urogenital tract abnormalities, or a history of trauma to (urethra, and seminal vesicle) can or tumours in the urogenital tract. cause haematospermia, and lower abdom- Urinalysis and prostatic fluid examinations inal or perineal pain and discomfort. prior to enrolment had been normal. Systemic diseases, such as serious hyperten- Routine semen analysis had demonstrated sion and bleeding tendency, can occasionally normal semen volume (>2 ml) and red lead to haematospermia. In addition, the blood cells (RBC; rated from þ to þþ anatomical position of the seminal vesicles is þþ[most serious haematospermia]), based complex and concealed. For these reasons, on the quantity of RBCs present in the the diagnosis of seminal vesiculitis relies semen. Preoperative TRUS and MRI mainly on the typical clinical manifestations, examinations had not revealed any con- which means that sometimes it is difficult to genital abnormalities or tumours in the distinguish seminal vesiculitis from prosta- urogenital tract. Before admission, patients titis. Transrectal ultrasonography (TRUS) had received standard regimens of systemic and pelvic magnetic resonance imaging antibiotics and local physiotherapy for 3–6 (MRI) are helpful for the diagnosis by months. However, the symptoms in the excluding congenital abnormalities or patients had been persistent or recurrent tumours in the urogenital tract.3–6 The and the patients were therefore considered main treatments for seminal vesiculitis are to have intractable seminal vesiculitis on systemic antibiotics and local physiother- study enrolment. apy. However, long-term medication use Approval for this study was granted by and a high recurrence rate are the major the Ethics Committee of Nanjing Medical problems associated with intractable sem- University, Nanjing, Jiangsu Province, inal vesiculitis. Transperineal puncture for China and written informed consent was direct drug injection into the seminal vesicles obtained from all study participants. may cause damage to the rectum or bladder, bleeding, and infection:7 a more effective and safer treatment method is needed for Transurethral seminal vesiculoscopy intractable seminal vesiculitis. The present Patients were placed under general anaes- study summarizes the clinical outcomes fol- thesia in the dorsal lithotomy position. lowing the use of transurethral seminal Transurethral seminal vesiculoscopy was vesiculoscopy to diagnose and treat patients performed using a Wolf F7 rigid uretero- with intractable seminal vesiculitis. scope (Henke-Sass, Wolf, Tuttlingen, 238 Journal of International Medical Research 42(1)

Germany). First, the ureteroscope was inserted into the for pre- Results liminary visualization of the verumontanum A total of 114 patients were considered to (the anatomical landmark near the entrance have intractable seminal vesiculitis and of the seminal vesicles). The bilateral ejacu- were eligible for inclusion in the study. latory duct openings were usually identified The mean SD age was 35.3 5.8 years in the . In some cases, the (range 22–54 years). The mean SD dis- openings were located at a position lateral to ease duration was 9.0 2.7 months (range the verumontanum. Under the guidance of a 5–18 months). Laser lithotripsy was per- zebra guidewire (UROVISION, formed for seminal vesicle stones in 12 Achenmu¨hle, Germany) in the lumen, the patients. ureteroscope was inserted into the ejacula- Postoperative outcomes are shown in tory ducts and seminal vesicles with the Table 1. Of the 114 patients, 106 successfully assistance of hand-controlled intermittent underwent bilateral transurethral seminal perfusion dilatation, using 0.90% (w/v) vesiculoscopy. During the procedure, the sodium chloride (normal saline) (Figure openings were found to be 1A). Then the bilateral ejaculatory ducts covered with white membranous tissues in and seminal vesicles were observed on the 39% of patients (41/106). Valve-like tissues endoscopic monitor. The seminal vesicles existed in the ejaculatory duct openings of contained a honeycomb-like structure, con- 4% of patients (four of 106). The mean gested walls and a milky, yellow or pink operative time was 32 min (range 20– seminal vesicle fluid filled with flocculent 50 min). The mean length of hospitalization turbidity and dark blood clots (Figure 1B). was 3 days. The mean duration of follow-up No congenital abnormalities or tumours was 10 months. Six patients with post- were observed in the ejaculatory ducts and operative painful ejaculation were treated seminal vesicles. The seminal vesicles were successfully by the administration of stand- washed repeatedly using normal saline ard regimens of oral antibiotics and through the endoscopic working channel a-blockers. Two cases of postoperative until the seminal vesicle fluid became clear epididymitis were treated successfully with (Figure 1C). Then a 0.50% (w/v) levofloxa- a 1-week standard course of antibiotics. cin solution was injected into the seminal There were no severe complications (such vesicles. For those patients who had seminal as retrograde ejaculation, rectal injury or vesicle stones, laser lithotripsy was per- urethral sphincter damage). In 94 of 106 formed using a SlimLineTM 200 micron (89%) patients, macroscopic haematosper- Holmium Laser Fibre (LumenisÕ, San mia had disappeared 1 month after the Jose, CA, USA) (Figure 1D). Small and operation; at this timepoint pain and dis- crushed stones were washed out or removed comfort had either disappeared or had been using stone forceps or a stone basket. obviously relieved. No RBCs were found Incomplete obstructions or stenosis of the during postoperative microscopic semen ejaculatory ducts were incised and dilated by analysis in 95% of these patients (89/94); the Holmium Laser Fibre and endoscope. in the remaining five patients, microscopic After the operation, a urethral Foley cath- examination of the semen revealed RBCs eter (Bard, Murray Hill, NJ, USA) was (þ). In eight of the 94 patients in whom retained in place overnight. All patients were symptoms disappeared, haematospermia required to refrain from ejaculation for 2 was recurrent during the follow-up period. weeks and were followed up on a monthly Six patients still reported lower abdominal basis for 6–12 months. or perineal pain and discomfort. Liu et al. 239

Figure 1. Representative images showing the stages of transurethral seminal vesiculoscopy that were used to clean the seminal vesicles, in a study of men with intractable seminal vesiculitis. (A) The endoscope was inserted into the ejaculatory duct openings under the guidance of a zebra guidewire. (B) Representative image of seminal vesiculitis with turbid seminal fluid. (C) Representative image of a seminal vesicle, washed repeatedly with 0.90% (w/v) sodium chloride. (D) Laser lithotripsy was performed to remove seminal vesicle stones. The colour version of this figure is available at: http://imr.sagepub.com.

Haematospermia and pain coexisted in two unilateral ejaculatory duct opening and a patients at follow-up. homolateral seminal vesicle were observed Eight patients failed to receive bilateral and treated. The bilateral ejaculatory duct transurethral seminal vesiculoscopy. The openings could not be found using the clinical outcomes of these eight patients are ureteroscope in the remaining five cases. shown in Table 1. In three cases, only a Surgical separation of the 240 Journal of International Medical Research 42(1)

Table 1. Clinical outcomes following transurethral seminal vesiculoscopy, undertaken to clean the seminal vesicles of men with intractable seminal vesiculitis (n ¼ 114)a.

Postoperative symptom Postoperative complication

Lower abdominal or perineal pain Painful Procedure Nn Haematospermia and discomfort ejaculation Epididymitis

Transurethral seminal 94 94 # 60 vesiculoscopy 12 6 þ# 00 4 þ 01 2 þþ 01 Vas deferens puncture 8 3b þ# 00 4c # 00 1c þþ 00

Data presented as n of patients for postoperative complications. aAfter 6 months’ follow-up. bUnilateral vas deferens puncture. cBilateral vas deferens puncture. , symptom disappeared; þ, symptom persisted; #, symptom disappeared or was obviously relieved. through a small scrotal incision and further The present study investigated the use of vasoseminal vesiculography through the transurethral seminal vesiculoscopy to ana- puncture-exposed vas deferens demon- lyse the cause of the seminal vesiculitis in 114 strated dysplasia of the ejaculatory duct patients with an intractable form of the openings. A 0.50% (w/v) levofloxacin solu- disease. To our knowledge, this is the largest tion was then injected into the vas deferens study undertaken to date in this research and seminal vesicles. area. The present study also reports the postoperative symptoms and complications following successful transurethral seminal Discussion vesiculoscopy. For those patients who were Endoscopy was first applied by Shimada unable to undergo this novel procedure, and Yoshida8 to observe the internal struc- details of their diagnoses and alternative tures of an excised seminal vesicle from a treatments are provided. cystoprostatectomy specimen. This was fol- Transurethral seminal vesiculoscopy can lowed by the first successful endoscopic directly observe the urethra, prostate, ejacu- examination of the seminal vesicles in a latory ducts and seminal vesicles to identify patient, in 1998.9 Yang et al.10 reported the some of the anatomical causes of seminal first use of an ureteroscope being inserted vesiculitis. In the present study, ejaculatory through the ejaculatory duct openings to duct openings were covered with white diagnose seminal vesicle disease. To date, membranous tissues or valve-like tissues. few studies have focused on seminal vesicu- These abnormal anatomical factors could loscopy in diagnosing and treating seminal lead to poor drainage of the seminal vesicle vesiculitis.11–15 The overall cure rate was fluid and consequently result in seminal reported as 78.6–97.6%, with the recurrence vesiculitis. For the administration of ther- rate being <10%.11–15 No severe complica- apy, transurethral seminal vesiculoscopy tions were observed in these studies.11–15 can directly wash the pathological seminal Liu et al. 241 vesicles and inject therapeutic solutions into intractable seminal vesiculitis would lead them. Coexistent stones, obstructions or to the enrolment of different patients, stenoses can be treated simultaneously. which might result in different clinical The results of the present study demon- outcomes. It should be acknowledged that strated that transurethral seminal vesiculo- this present study only assessed short-term scopy was effective for the diagnosis and complications, which precludes the identi- treatment of intractable seminal vesiculitis; fication of longer term complications that its use was associated with a good safety might be theoretically related to the trans- profile. This simple procedure is minimally urethral seminal vesiculoscopic process, invasive as it is performed via the urogenital such as seminal tract stenosis. Therefore, tract. No additional pieces of equipment or longer follow-up or the implementation of expertise are required. more diagnostic evaluation methods may It is worth noting that not all of the be beneficial to determine the efficacy and patients with intractable seminal vesiculitis safety of transurethral seminal vesiculo- in this present study were cured by trans- scopy. A previous small-scale study that urethral seminal vesiculoscopy. This was investigated the antimicrobial susceptibility due to the numerous and complex causes of chronic and recurrent seminal vesiculitis of this disease. For example, eight patients found that quinolones were the most sen- were not suitable for transurethral seminal sitive drugs,16 therefore a levofloxacin solu- vesiculoscopy due to dysplasia of the ejacu- tion was used in the present study. Future latory duct openings. Future research will research will focus on the infectious aeti- investigate the clinical characteristics of ology of intractable seminal vesiculitis in a patients for whom transurethral seminal larger number of patients, with a view to vesiculoscopy is not applicable. Of the 106 providing more targeted and individual patients who underwent transurethral sem- drug choice. inal vesiculoscopy, 12 had recurrent symp- In conclusion, transurethral seminal toms during the follow-up period. The vesiculoscopy is a simple, minimally inva- postoperative recurrence of obstruction or sive procedure that is performed via the stenosis might lead to recurrent symptoms. urogenital tract. Its use can avoid damage Understanding the causes of the poor out- to the urethra, prostate and rectum, but the comes in these 12 patients requires further operating space is small. Therefore, careful research. and cautious operating procedures are This present study had a number of essential to avoid bleeding and subsequent limitations. The definition for intractable poor visibility. The positions of the ejacu- seminal vesiculitis remains unclear. The latory duct openings are not anatomically present study recruited patients according fixed and sometimes membranous or valve- to the following criteria: (i) persistent, like tissues cover the openings, which can typical haematospermia and lower abdom- make transurethral seminal vesiculoscopy inal or perineal pain and discomfort; (ii) difficult to perform. Increasing the velocity normal urinalysis and prostatic fluid exam- of the normal saline perfusion and using a ination; (iii) persistent or recurrent symp- zebra guidewire for guidance are helpful toms after systemic antibiotic therapy and for finding the openings. In some patients local physiotherapy for 3–6 months. The with anatomical abnormalities or dysplasia study excluded patients with congenital of the ejaculatory ducts, vas deferens punc- abnormalities or tumours in the urogenital ture and injection of methylene blue, tract as determined by preoperative TRUS combined with transurethral endoscopy, and MRI. Using different criteria for can help with the observations of the 242 Journal of International Medical Research 42(1) ejaculatory duct openings. Vasoseminal patients with hemospermia. Urology 2008; vesiculography and drug injection are the 72: 838–842. alternative diagnostic and therapeutic 7. Fuse H, Sumiya H, Ishii H, et al. Treatment methods if transurethral seminal vesiculo- of hemospermia caused by dilated seminal scopy is not possible. In addition, partial vesicles by direct drug injection guided by ultrasonography. J Urol 1998; 140: 991–992. resection of the verumontanum tissues is 8. Shimada M and Yoshida H. Ex vivo ultra- beneficial in cases with severe distal thin endoscopy of the seminal vesicles. J Urol obstruction of the ejaculatory duct, which 1996; 156: 1388–1390. 17 was reported in our previous study. 9. Okubo K, Maekawa S, Aoki Y, et al. In vivo endoscopy of the seminal vesicle. J Urol 1998; 159: 2069–2070. Declaration of conflicting interest 10. 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