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Transrectal ultrasonography-guided transperineal bilateral seminal vesicle puncture and continuous irrigation for the treatment of intractable hematospermia

ZHANG, Xin-ru; GU, Bao-jun; XU, Yue-min; CHEN, Rong; ZHANG, Jiong; QIAO, Yong

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Hematospermia is a rare condition, but often causes frustration. The reason for this frustration is that the exact incidence of hematospermia remains unknown and its cause is difficult to determine.1 Many reports in the past decades have focused on the etiology of hematospermia.2 Hematospermia is treated initially by administration of antibiotics, coagulants, and sex steroid hormones. However, some cases may prove resistant to this therapy and the condition may continue. For some intractable and agnogenic cases, the therapeutic strategy mentioned above is not very effective. Recently, we treated 63 such nonresponsive patients by direct continuous antibiotic irrigation into the bilateral seminal vesicles through puncture under transrectal ultrasonography (TRUS) guidance.

METHODS

From January 1996 to January 2006, 63 patients with hematospermia aged 19 to 69 years (mean, 33.7 years) were treated in our department by direct continuous antibiotic irrigation into the bilateral seminal vesicles through puncture under TRUS guidance. Disease duration ranged from 4 to 120 months. All patients had received systemic internal medical therapy (anti-inflammatory, anticoagulant, antihypertensive, etc) for at least 2 months before the treatment started. In 23 patients older than 40 years no malignancy of the bladder, urethra, prostate, or seminal vesicles was confirmed by routine examination. The probable causes of hematospermia were chronic prostatitis or seminal vesiculitis in 33 patients, ejaculatory duct obstruction in 7, and chronic prostatitis or seminal vesiculitis combined with ejaculatory duct obstruction in 14; no definite causes were found in 9 patients. Besides hematospermia, major complicating complaints included pain at perineum and peripheral penis in 23 patients (36.5%), post-pubis and lumbosacral area indisposition in 11 (17.5%), ejaculation pain in 5 (7.9%) and hematuria after ejaculation in 4 (6.3%).

TRUS was performed using an Aloka SSD-2000 ultrasound apparatus (Aloka, Japan) with a biplanar, high-resolution 7.5 MHz transrectal transducer. The patients were placed in the lithotomic position, and local anesthesia was administered. A 16G trocar with a silica gel cannula was inserted into the perineum under ultrasound guidance. The trocar was introduced into the seminal vesicle through the prostate gland, the needle was pulled out, and the silica gel cannula was left in the seminal vesicle. The seminal vesicle fluid drained was sent for bacteriological and cytological examination. 0.9% saline was used to aspirate the bilateral seminal vesicles until the fluid was clean. At the end of the procedure, both silica gel cannulas were fixed on the perineum skin for direct continuous antibiotic irrigation.

Once the puncture was finished, the patients had to remain in a flat position on the bed and antibiotic solution was continuously irrigated into the seminal vesicle through the fixed silica gel cannula. Broad-spectrum antibiotics were given and could be adjusted according to a drug sensitivity assay of the seminal vesicle fluid. The irrigation pressure was set at 100 cm height above the seminal vesicle level, the speed was at 500 ml per 24 hours, and the period of treatment was 5 to 7 days. After the treatment the patients were followed up for 6 to 60 months during which TRUS examination was repeated at 6 months and semen examinations were performed at the 3rd, 6th, and 9th months.

RESULTS

The 63 patients had 124 seminal vesicles punctured and irrigated; 2 seminal vesicles were too small to identify for puncturing. The color of the fluid aspirated from 63 seminal vesicles in 58 patients was hemorrhagic. In 53 patients (84.1%) just 1 side was hemorrhagic and in 5 (7.9%) both sides were hemorrhagic. In sonographic images, 13 (20.6%) patients were found to have thick seminal vesicle walls which were more than 1 mm thick. Among these patients, 2 (3.2%) were found to have excessive extension of the seminal vesicle gland, with the anteroposterior dimension of seminal vesicle being more than 15 mm. Eight (12.7%) patients were found to have cysts, with diameters ranging from 2 to 4 mm; 4 of these patients also had seminal vesicle wall thickening. The results of laboratory examinations are listed in Table 1.

Table 1
Table 1:
Outcomes of laboratory examinations

Seven patients were not able to maintain a flat position on the bed and irrigation was discontinued on the third or fourth day of the course. The other 56 patients were followed up from 9 to 60 months (mean, 35.7 months). Except for 10 patients who rejected undergoing repeated TRUS examination, 46 patients underwent TRUS examination at 6 months after irrigation. Seminal vesicle wall thickening was resolved in 9 of 11 patients, ejaculatory duct cysts disappeared in 6 of 7 patients. Macroscopic hematospermia reoccurred in only 2 patients by 6 months. The results of semen tests are shown in Table 2.

Table 2
Table 2:
The semen test results of 56 follow-up patients (n (%))

With regard to complications, perineum and peripheral penis pain resolved in 17 of 21 patients (80.1%), post-pubis and lumbosacral area indisposition resolved in 7 of 9 (77.7%), ejaculation pain and hematuria after ejaculation disappeared in all 9 patients.

DISCUSSION

Hematospermia is a benign, but alarming symptom for many men. Some clinical studies have demonstrated that most cases take a benign and self-limiting course.3–8 In a minority of individuals, hematospermia can become recurrent or chronic in nature. Although the differential diagnosis is extensive from bacterial inflammation, stones, and systemic diseases to malignant or benign tumors, most cases result from infections or other inflammatory processes.9 During the last decade, some progress was made in discovering the etiology of hematospermia. Furuya et al detected chlamydia in the seminal vesicle fluid of patients with acute epididymitis, indicating that chlamydial infection was a suspected cause of hematospermia.10 Another report showed that localized seminal vesicle amyoloidosis might cause hematospermia in old men.11 In our series, the results of expressed prostate secretions and semen testing before irrigation seemed to show that inflammation was not a major cause of intractable hematospermia, however, more than 70% of seminal vesicle fluid tests showed the signs of inflammatory reaction. Although positive results of seminal vesicle fluid bacteriological culture were found in less than 10% of cases, the leucocytes in the semen clearly decreased after continuous antibiotic irrigation. These findings indicated that infection was still a crucial cause for hematospermia, therefore, antibiotic treatment was still necessary.

Another interesting aspect is that ejaculatory duct obstruction was detected in more than 30% of patients (including the combination of patients with chronic prostatitis or seminal vesiculitis). The probable mechanisms include extrusion by hyperplastic prostate tissue, edema stimulated by local inflammation, and blockage by melicera semen. These mechanisms can obstruct the discharge of semen, resulting in cystoid dilation of the ejaculatory duct, thickening of the seminal vesicle wall, and increase in seminal vesicle volume. It may explain why patients remained in a hematospermia condition and did not benefit from systemic antibiotic drugs. Recently, Furuya et al mentioned that cystic dilatation of the utricle is a significant underlying lesion in hematospermia,12 which is the same as our hypothesis. Accordingly, ejaculatory duct obstruction is a possible reason for persistent hematospermia that should not to be ignored. Moreover, in our series hematospermia did not have a definite cause in 14.3% of cases, indicating that there are still some unknown factors which cause hematospermia. In a study by Papp et al, the cause of hematospermia was unknown in 18.5% of patients.2

Treatment of hematospermia is based on the causative factors. The treatment of various pathogens with modalities such as systemic and local anti-inflammatory therapy, uro-oncological surgical and radiological treatment, transurethral interventions, and internal medical therapy (antihypertensive and anticoagulant therapy and treatment of hematological disorders) may be taken into consideration.2 Some investigators have reported favorable effects of estrogens.3 However, some cases are incurable with aforementioned therapy. Hideki et al treated hematospermia by direct drug injection guided by ultrasonography and achieved resolution of hematospermia in 2 to 3 months.13 We developed this method from one-shot drug administration in the seminal vesicle to leaving the cannula for continuous antibiotics irrigation for one week. Excluding 7 discontinued cases, we resolved 48 of 49 cases of macroscopic hematospermia involving inflammation and/or ejaculatory duct obstruction during a mean of 35.7 months follow-up. Moreover, macroscopic hematospermia also disappeared in 6 of 7 cases with undetermined cause.

Although remaining in a flat position for 5 to 7 days is extremely difficult to tolerate, continuous antibiotic irrigation has three advantages for obtaining a treatment effect. First, the pressure of 100 cm height is higher than the seminal vesicle inner pressure, which establishes a pressure gradient from seminal vesicle to posterior urethra or bladder neck to keep the ejaculatory duct open and wash out the small obstructions. This can help with the recovery of thickening of the seminal vesicle wall and disappearance of ejaculatory duct cysts. Second, broad-spectrum antibiotics can get into the seminal vesicle directly, thereby maintaining an effective drug concentration in the seminal vesicle. The 5 to 7 days of continuous irrigation ensures sufficient time for therapeutic action. Moreover, continuous irrigation pressure keeps the antibiotic in contact with all of the epithelium of the seminal vesicle. The antibiotic can also be adjusted according to a sensitivity assay of seminal vesicle fluid, guaranteeing the drug effectiveness. Third, continuous saline solution irrigation can keep the pH value of the fluid in the seminal vesicle around 7, benefiting the rehabilitation of the pathological epithelium of the seminal vesicle. Maybe this is the reason why the patients with unknown cause also benefit from this therapy.

Although the long-term effect still needs to be confirmed in future studies, we suggest that TRUS-guided transperineal bilateral seminal vesicle puncture and continuous antibiotic irrigation should be an effective method for treating intractable hematospermia.

REFERENCES

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11. Furuya S, Masumori N, Furuya R, Tsukamoto T, Isomura H, Tamakawa M. Characterization of localized seminal vesicle amyoloidosis causing hemospermia: an analysis using immunohistochemistry and magnetic resonance imaging. J Urol 2005; 173: 1273–1277.
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13. Fuse H, Sumiya H, Ishii H, Shimazaki J. Treatment of hemospermia caused by dilated seminal vesicles by direct drug injection guided by ultrasonography. J Urol 1988; 140: 991–992.
Keywords:

hematospermia; transrectal high intensity focused ultrasound; drug instillation

© 2008 Chinese Medical Association