A New Method of Chronic and Recurrent Seminal Vesiculitis Treatment

Introduction

C hronic and recurrent seminal vesiculitis is a rare entity that is encountered in urologic practice. Patients with this disorder may present with recurrent and persistent hemospermia, spermatocele, perineal pain, and male infertility. Currently, main management of chronic and recurrent seminal vesiculitis is antimicrobial treatment. Because of highly convoluted tubular glands of seminal vesicles and ejaculatory duct obstruction as a result of recurrent inflammation, the drainage of the inflammatory exudation in the seminal vesicles is poor. Moreover, the blood circulations of seminal vesicles are relatively poor, so the drug concentration at the local level is low. Based on these reasons, patients with seminal vesiculitis had a low bacteriologic cure rate even after three antibiotic courses. ¹

Therefore, alternative treatments are wanted. Few studies have reported surgical treatment for refractory seminal vesiculitis, especially with an endoscope. Shimada and Yoshida ² first reported ex vivo endoscopy of the seminal vesicles in 1996, and Okubo and associates ³ observed seminal vesicles through a cutaneous fistula. Moreover, Li and colleagues ⁴ reported direct observation of the distal seminal tracts in vivo.

Between February 2008 and February 2010, a novel treatment for chronic and recurrent seminal vesculitis was performed in the First Affiliated Hospital of Nanjing Medical University. In these patients, seminal vesicle endoscopy was conducted. With guidance from a Zebra^® nitinol guidewire, an F9 seminal vesicle endoscope was inserted through the ejaculatory duct to the seminal vesicles, and the seminal vesicles cavity was washed with metronidazole and gentamicin. After the treatment, the outcomes were satisfactory, as reported below.

Patients and Methods

Study design and treatment

All patients underwent the the surgical procedure of dilating the ejaculatory duct and flushing the seminal vesicle with an F9 seminal vesicle endoscope (9F×360 mm, Shenda, Supplementary Fig. S3; Supplementary Data are available online at www.liebertonline.com/end). The procedure was performed with the patients in the dorsal lithotomy position and under epidural anesthesia. First, we inserted the scope into the prostatic urethra and found the verumontanum. Then, we attempted to put the Zebra nitinol guidewire (0.035 in×150 cm, Boston Scientific, Supplementary Fig. S4; Supplementary Data are available online at www.liebertonline.com/end) into the ostia of the verumontanum. The F9 seminal vesicle scope was advanced along the guidewire. The ostia of the two ejaculatory ducts are located on both sides of the prostatic utricle, a müllerian duct remnant of endodermal origin at the verumontanum. The ejaculatory ducts opened anterolateral to the orfice of the utricle, and the orifices were usually covered by a thin, transparent membraniform substance (Fig. 1A). Sometimes the orifices were difficult to identify; to confirm them, the guidewire was used to explore the suspected orifices. After the ejaculatory duct ostia dilation (Fig. 1B), guided by the wire, the scope was put into the seminal vesicle (Fig. 1C). If we failed to find the ejaculatory duct ostia in patients with ejaculatory duct obstruction, they were treated by transurethral resection of the ejaculatory ducts. In the seminal vesicles with infection, blood clots, and prunosus jell plasma were present (Fig. 1D). Then the fluid in the seminal vesicles was suctioned for bacterial culture and drug sensitivity test. After that, seminal vesicles were washed continuously using 0.1% metronidazole and 0.1% gentamicin. A F18 aerocyst urethral catheter was left in the urethra for 2 to 3 days and intravenous antibiotic therapy was administered according to the results of the drug sensitivity test.

OPEN IN VIEWER

FIG. 1.

(A) The ejaculatory duct ostia covered by thin, transparent membraniform substance in a patient with chronic seminal vesiculitis. (B) The ejaculatory duct ostia after dilation of the ejaculatory duct by a F9 seminal vesicle scope in a patient with chronic seminal vesiculitis. (C) Guided by the Zebra wire, the F9 seminal vesicle scope was put into the seminal vesicle. (D) The seminal vesicle of a hemospermic patient; blood clots and prunosus jell-like plasma were present.

Results

In total, 26 patients were included in the analysis. In three patients with ejaculatory duct obstruction, we failed to find the ejaculatory duct ostia; they were treated by transurethral resection of the ejaculatory ducts. We found Escherichia coli in 15 cases, Staphylococcus epidermidis in 7 cases, Pseudomonas in 2 cases, Neisseria gonorrhoeae in 1, and Salmonella in 1 in the seminal vesicle fluids. The culture sensitivities in patients were amikacin, etimicin, cefoperazone, sulbactam, and gatifloxacin. After surgery, there were significant reductions in symptoms, signs, WBC and RBC counts in microscopic examination, seminal vesicles size and improvement of inner walls echo in TRUS, and semen culture positive rate. Moreover, in five patients with male infertility, the semen parameters of four patients were improved and sperm appeared in semen in one case. All patients were improved (Supplementary Table S1; Supplementary Data are available online at www.liebertonline.com/end).

Discussion

The traditional means to treat patients with chronic seminal vesiculitis are mainly antibacterial therapies. ⁵ It has been relatively difficult to cure the inflammation, however, and easy for it to recur. Obviously, it has been rather difficult to cure the refractory chronic seminal vesiculitis by antibacterial therapies alone. New methods for chronic seminal vesiculitis treatment are wanted.

Several endoscopic approaches to seminal vesicles have been reported. An endoscopic procedure for seminal vesicle stone removal was performed in 2005. And for patients with infertility, an antegrade dilation of the ejaculatory ducts via the seminal vesicles using a transrectal approach with ultrasonographic and fluoroscopic guidance was described by Lawler and coworkers. ⁶ To date, however, there has been no report of an endoscopic technique for transurethral management of chronic seminal vesiculitis.

In the present study, we described a new procedure using a seminal vesicle scope for treatment of patients with chronic seminal vesiculitis. One of the prominent achievements in the present study was that the procedure for dilating the ejaculatory duct and flushing the seminal vesculitis with an F9 seminal vesicle scope was much more effective. Moreover, we collected fluids in seminal vesicles for bacterial cultures and drug sensitivity analyses and found E coli in 15 cases, S epidermidis in 7 cases, Pseudomonas in 2 cases, N gonorrhoeae in 1, and Salmonella in 1. With the results of drug sensitive analysis, more sensitivity drugs were used individually, which also improved the cure rate. More importantly, ejaculatory duct orifice stenosis or even obstruction was observed in almost all chronic seminal vesiculitis patients with recurrent hematospermia, and we found that when the ejaculatory duct was dilated to a normal size, the seminal vesicle fluid could be drained more easily.

In most cases, the etiology of hemospermia is nonspecific inflammation of the prostate or seminal vesicles. ⁷ In a small percentage of patients, it may be a manifestation of genitourinary malignancies. ⁸ Usually, imaging is not sufficient for diagnosis. In this situation, a laparoscopic procedure or even open surgery might be necessary, either of which is more invasive and may also have several complications, such as retrograde ejaculation, epididymitis, rectal injury, and secondary infertility. ⁹ With a lower risk of complications, however, transurethral endoscopy can also help urologists to confirm the diagnoses. In these patients, the ejaculatory duct and seminal vesicles are usually expansionary, so the scope is easy to pass through the ejaculatory duct to the distal seminal vesicle, flush the fluid, and identify the organizational structure.

Caution should be taken with the procedure, however. Because of the limited space in seminal tracts, the procedure should be conducted under low-pressure saline irrigation. Great care must be taken to avoid damage to normal seminal tracts, prostate, and rectum. At a follow-up of 3 months to 1 year, of 26 patients who received the surgical procedure in the present study, only 2 patients experienced perineal pain occasionally, which was relieved after symptomatic treatment. Other complications described above were not encountered.

Conclusion

The present study provides a new and effective transurethral seminal tract endoscopic technique with use of a seminal vesicle scope through the normal anatomic tract to treat patients with chronic and recurrent seminal vesiculitis. It has proved to be easily conducted with minimal complications. Further investigations are needed to confirm our results.