A case of persistent haematospermia secondary to seminal vesicle calculi in an ageing male

Abstract

Seminal Vesicle (SV) calculi are a rare pathology. Clinical presentation usually consists of nonspecific perineal pain and haematospermia. Adjuncts to aid diagnosis include US, MRI, and Vesiculography. This rare condition can be treated conservatively, however, surgical options are becoming more advanced with Vesiculoscopy now being the gold standard. Here, we present a case of a SV calculi treated conservatively.

Keywords:

• Seminal vesicle
• haematospermia
• calculi
• vesiculography
• vesiculoscopy

Introduction

Seminal vesicle (SV) calculi are a rare pathology, particularly when associated with multiple stones. They commonly present with haematospermia, infertility, non-specific perineal/testicular pain, and painful ejaculation. Diagnosis usually requires transrectal ultra-sonography (TRUS), however, other more sophisticated imaging modalities can also be utilised such as MRI and Vesiculography. Treatment is removal of the calculus, traditionally via open technique, however, laparoscopic technique is now being utilised more commonly and has now become the standard [1]. Here, we present a case of SV calculi treated conservatively.

Case report

A 44 year-old-man presented to the urology clinic with an 8-month history of persistent haematospermia and non-specific perineal pain which was exacerbated by ejaculation. He was otherwise fit and well with no additional co-morbidities or relevant family history. Physical examination of his external genitalia and prostate was unremarkable. Initial baseline investigations with routine blood, urine, and semen culture were negative, and his prostate-specific antigen (PSA) was 1.2 μg/L. The patient was further investigated with flexible cystoscopy during the same consultation, which was normal with no congenital anomalies discovered. Due to the patient’s long-term persistent haematospermia, non-specific perineal pain and unremarkable preliminary investigations a magnetic resonance image (MRI) of the prostate was arranged. The MRI revealed multiple calculi in the left SV (Figures 1 and 2). The patient was re-assured that no cancer was identified but given the reduction of quality of life (QoL) from his symptomology the patient was keen to have his SV calculi removed, and was referred to a tertiary centre for potential vesiculoscopy. Following his consultation with the andrologist, it was decided that conservative management would be more appropriate in this case as some of the stones had disintegrated into sludge. A follow-up appointment was arranged and the sludge had not resolved in the following year, a washout of the SVs was offered to the patient.

Figure 1. A case of persistent haematospermia secondary to seminal vesicle calculi in an ageing male.

Figure 2. The MRI revealed multiple calculi in the left seminal vesicle.

Discussion

Haematospermia can be a concerning and distressful symptom for sexually active patients and their partners. There are many common causes for haematospermia such as malignancy in the male genitourinary tract, infection, and trauma [2]. In addition to these more common causes for haematospermia, more rare pathology has been reported in the literature. These include an interesting case of persistent haematospermia secondary to a SV bleed as reported by Phan and Mahmalji [2]. Furthermore Yang et al. [3] reported that SV calculi were present in 16.2% of haemospermic patients in their review. SV calculi are extremely rare, and to our knowledge, there are few cases reported in published literature.

SV calculi can present with haematospermia, perineal/testicular pain and painful ejaculation [4], however, it should also be considered in cases of infertility of unknown aetiology [5]. Furthermore, SV calculi are associated with azoospermia, in which a patient has the absence of sperm in the ejaculate. This condition is present in around 10% of infertile men. More specifically associated with SV calculi is obstructive azoospermia (OA), which is characterised by an occlusion or partial absence of the reproductive tract with the presence of normal spermatogenesis [6].

The pathophysiology of SV stone formation remains debatable with some hypothesis proposed by various studies. Namjoshi et al. [7] suggest that a possible cause for stone formation is urinary tract obstruction. However, other studies propose that infection anomalies and urinary reflux into the ejaculatory ducts predispose to stone formation [8,9]. Moreover, the exact pathogenesis is difficult to establish, however, analysing the exact stone composition may give some clues in way of exact aetiology. Review of the literature reveals that majority of stones consist of proteinaceous material, in addition, carbonate apatite, calcium oxalate, and calcium fluorophosphate stones have also been reported. Henceforth, the current hypotheses for the pathogenesis of SV stones include: Infectious/inflammatory in the form of seminal vesiculitis and anatomical abnormalities of the SV predisposing to stasis and urinary reflux into the ejaculatory ducts [10–12]. In the current case, there was no significant past medical history hence the exact aetiology remains unknown.

The most useful preliminary diagnostic method for patients presenting with suspected SV calculi is TRUS [13]. However, as this patient had undergone a flexible-cystoscopy at the initial presentation, an MRI scan was opted to evaluate the prostate [9]. Moreover, the clinician must consider the limits of these techniques in the diagnosis of pelvic neoplasms, and therefore direct visualisation of the organ is now preferred [14,15].

Treatment requires removal of the calculus. Traditionally, SV calculi were treated with open seminal vesiculectomy or seminal vesiculotomy [10]; however, this technique is associated with high morbidity including organ dysfunction. This is in part due to anatomical consideration, given that the SV is located deep in the pelvis and an open approach will require substantial dissection which is associated with long operative time, intraperitoneal rupture, and haemorrhage [2]. As laparoscopic surgery has developed and now utilised routinely, laparoscopic seminal vesiculectomy is now possible as reported by Yun et al. [11]. Mello et al. [16] have published a step-by-step procedure on how a laparoscopic vesiculectomy could be performed. With advances in optics, seminal vesiculoscopy is now possible. Ozgök et al. [1] performed the world’s first ever seminal vesiculoscopy in 2005. In this case, the patient was treated by means of transurethral seminal vesiculoscopy (TRU-SVS). This is a highly specialised technique that utilises a 6 F endoscope to gain access and directly visualise the SVs and extract the calculi. It is also worth mentioning that this technique has also been utilised in some cases for the investigation of persistent haematospermia or ejaculatory duct obstruction [17].

Subsequently, various authors have reported the use of seminal TRU-SVS to treat SV calculi. Song et al. [18] have successfully treated 12 patients with seminal vesiculoscopy in their centre and they have concluded that seminal vesiculoscopy is safe and effective method in treating SV calculi. Similarly, Han et al. [19] have also reported good outcomes with seminal TRU-SVS for SV calculi. In their study, they also found that four infertile patients had a significant increase in sperm count and ejaculation volume following treatment. It is interesting to note that seminal TRU-SVS is also an effective diagnostic tool and treatment for intractable seminal vesiculitis as reported by Liu et al. [20].

Conclusions

In conclusion, SV calculi remain a rare cause for haematospermia, with only a few case reports in the literature. Treatment options are dependent on the size and exact location of the stones, however, a laparoscopic approach is now preferred and offered at tertiary centres. TRU-SVS was not conducted in this case, as upon consultation in a tertiary centre most of the calculi had disintegrated into sludge. Henceforth a conservative approach was taken with 6-month follow up. Should the patient’s symptomology have not resolved, then a vesiculoscopy and washout would be offered to the patient with successful procedure being defined as complete stone clearance of both SVs.

Disclosure statement

No potential conflict of interest was reported by the authors.