儲精囊結石引起反覆性血精: 經前列腺囊儲精囊鏡案例分享
柯旭承¹、莊毓峰¹、許兆畬¹、歐宴泉¹、童敏哲¹

童綜合醫療社團法人童綜合醫院 外科部 泌尿科

Refractory Hematospermia caused by seminal vesicle calculi: a case sharing of transutricular seminal vesiculoscopy
Hsu-Cheng Ko¹、Yu-Feng Chuang¹、 Chao-Yu Hsu¹、Yen-Chuan Ou¹、Min-Che Tung¹

¹Division of Urology, Department of Surgery, Tungs' Taichung MetroHarbor Hospital, Taichung City, Taiwan

Introduction:

Hematospermia is an uncommon clinical presentation with an incidence rate of 73.6 per 100,000, and it can exert significant psychological pressure on male patients, potentially leading to anxiety, sexual dysfunction, and even impotence.^{1 3} With the advancement of endoscopic technology, transurethral seminal vesiculoscopy (TUSV) has become a feasible and safe tool for both diagnosis and treatment. Therefore, we present a male patient who experienced recurrent hematospermia due to urolithiasis of the seminal vesicle (SV).

Case presentation:

This 55-year-old male has a history of hypertension and coronary artery disease and has been using aspirin for an extended period. He first reported experiencing hematospermia three years ago. Other accompanying symptoms included perineal pain and discomfort during initial urination. At first, under the impression of epididymitis, we prescribed antibiotics as a conservative treatment, but hematospermia persisted. The patient was lost to follow-up for a period of two years.

This April, he experienced recurrent hematospermia and sought assistance by visiting our Urology outpatient department. Soon after, magnetic resonance imaging (MRI) was scheduled. The axial view of MRI revealed high intensity on T1-weighted images (Figure 1) and low intensity on T2-weighted images (Figure 2) in the left SV, indicating recent bleeding. TUSV guided by a safety guidewire was performed. After entering the lumen of the verumontanum, one translucent membranous area was identified on the wall of the utricle. We made a puncture in the translucent membrane with a 0.032 inch safety guidewire. (Figure 3) The bilateral ejaculatory duct (ED) orifices were identified. (Figure 4) The left ED was filled with blood-tinged seminal fluid. (Figure 5) Total 3 c.c. bloody fluid was drained from the left ED. With assistance of safety guidewire, TUSV was injected with ease into the left SV. Hematoma and a 4x1x1 mm yellowish stone were identified and removed using a grasper. (Figure 6) We passed through the right ED with similar technique done in the left side to confirm the presence of any other possible lithiasis. Normal ejaculatory fluid flew in the right SV. There was no stone or hematoma noticed. In the end, we irrigated and observed the left SV, the seminal vesiculoscope was then withdrawn from the left SV. After the procedure, there was no postoperative fever or symptoms of epididymitis recorded. During the outpatient department follow-up two weeks later, hematospermia also resolved.

Discussion

Hematospermia defined as the appearance of blood in the seminal fluid is a relatively uncommon condition, with an incidence rate of 56.6 per 100,000 in 2010, which increased to 73.6 per 100,000 in 2018.¹ Polito et al. reported that hematospermia accounted for 1% of all symptoms in genitourinary system diseases.² The etiology of hematospermia can be broadly categorized into ten groups: lithiasis, infectious, inflammatory, cystic, obstructive, tumoral, vascular, traumatic, iatrogenic, and systemic origin.³  Patients who consistently observe the presence of blood in their ejaculatory fluid may undergo feelings of anxiety, diminished sexual activity, and potentially even erectile dysfunction.⁴  While hematospermia is benign and self-limiting in most cases, further evaluation should be considered for patients experiencing persistent or refractory hematospermia, as it could be indicative of more significant underlying organic pathological changes.

Transrectal ultrasound (TRUS), computed tomography (CT), and magnetic resonance imaging (MRI) are the most used tool for diagnosis.⁵ Among them, MRI is the gold standard for imaging examinations of hematospermia. Three-dimensional imaging of MRI provides great resolution and can differentiate soft tissue structures while revealing hemorrhagic characteristics within the seminal vesicles.⁶ Patterns of recent bleeding typically exhibit high signal intensity on T1-weighted image and low signal intensity on T2-weighted images, whereas older blood clots tend to show high signal intensity on both T1- and T2-weighted image.⁷ Obstructive, inflammatory, and lithiasis origins can exacerbate each other, leading to the pathological basis of refractory hematospermia. In such cases, conservative treatment often has a limited effect, and surgical intervention to relieve obstruction and remove the stone is usually necessary.⁸

With advancements in endoscopy technology, transurethral seminal vesiculoscopy (TUSV) has been utilized as a diagnostic tool since 2002.⁹ Mei et al. recently reported a success rate of 94.7% for unilateral TUSV in their study, with only 2 out of 48 patients experiencing postoperative complications, specifically epididymitis. Despite TUSV having a high success rate and low complication rate, there is a recurrence rate of hematospermia of 33.3% during a follow-up period of 40.1 months.¹⁰ Based on their findings and other studies, we can conclude that TUSV is a safe and viable tool for diagnosing and treating persistent hematospermia.^{11 12}

Conclusions:

For patients with recurrent hematospermia, MRI is considered the gold standard for imaging examinations due to its superior resolution in distinguishing soft tissue structures. Thanks to the progress in endoscopy techniques, TUSV plays a dual role in both the diagnosis and treatment of hematospermia. Additionally, TUSV offers a high level of safety and a low rate of postoperative complications. Nevertheless, the recurrence rate of hematospermia cannot be overlooked during long-term follow-up, highlighting the ongoing challenges for urologists in understanding the pathophysiology of recurrent hematospermia.