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 seminal vesicles, via the urethra. 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, prostate 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 prostatic urethra 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 Æ SD age was 35.3 Æ 5.8 years in the prostatic utricle. In some cases, the (range 22–54 years). The mean Æ SD dis- openings were located at a position lateral to ease duration was 9.0 Æ 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 ejaculatory duct 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