This is an interesting case of persistent haematospermia which was managed conservatively.
Case presentation: A 65-year-old gentleman was referred to the urology one stop clinic with a 4-month history of haematospermia, flank ache radiating to testicle, and obstructive lower urinary tract symptoms. There was no risk of STIs or urinary tract infections and he had no other penile or scrotal symptoms.
Past medical history of only stable angina, with no relevant family history. Clinical examination of abdomen and external genitalia was normal. Digital rectal examination revealed a benign feeling prostate.
Investigations: Routine urinalysis, blood tests, and an ultrasound scan of the renal tract were normal. Prostate Specific Antigen (PSA) was 5.5 µg/L this was above the threshold as per NICE guidelines. Due to haematospermia and a raised PSA, a decision was made to perform Magnetic Resonance Imaging (MRI) scan. This showed a prostate volume of 50 ml, the seminal vesicles were well distended, and multiple small calculi were seen in the left seminal vesicle. The left seminal vesical showed T1 high signal which could be due to haemorrhage or inspissated secretions with high protein content.
No convincing focal lesion were seen in the peripheral or transitional zone. Mild degree of benign hyperplasia was noted.
T2W MRI Images showing left SV Calculi
T1W MRI Images showing left SV Calculi
Outcome and Follow up: Following confirmation of the diagnosis of left sided seminal vesicle calculi, a consultation took place with the patient, the repeat PSA has fallen into normal range at 3.0ug/L.
Urine microscopy was negative for any growth, the patient did not suffer from any symptoms apart from heamatospermia every 3-4 weeks.
All options were given to the patient including surgical treatment in the form of seminal vesiculospy . He opted for conservative management.
Discussion: First SV calculi was described in the literature by White in 1928.1 Calculi of the seminal vesicle, ejaculatory duct, and vas deferens are uncommon and rarely of clinical significance. Aetiology remains unclear but can follow inflammation, reflux of urine and infection.1,7
Symptoms presenting with SV stones include erectile dysfunction, graveluria, haematospermia, haematuria, infertility, low ejaculatory volume, and spermolithiasis. Normally associated with abdominal or perineal pain with lower urinary tract symptoms.1
Imaging is the conventional way of diagnosing stones present in the SVs. Modalities for diagnosis include vasoseminal vesiculography, MRI, CT, and TRUS. In children, a retrograde urethrogram or voiding cystourethrogram may be used to distinguish between SV and posterior urethral calculi.1,6
Prior to surgical intervention pre-operative sperm banking should be offered, to provide security and reassurance in the future.1
In recent years, transurethral seminal vesiculoscopy (TRU-SVS) has shown to be a safe, minimally invasive surgical procedure for the management of both SV and ejaculatory duct calculi. TRU-SVS has shown to be a more attractive option than TURED due to lower complications and having significant improvement in sperm counts and ejaculation volume, thus improving fertility. Furthermore, seminal vesiculography can be performed transrectally in patients who do not want to undergo a transurethral procedure.3,5
TRU-SVS was not performed in this case, a review of the literature showed a recommendation for conservative management as most of the calculi had disintegrated into sludge, with recommended follow in 6 months.4
Conclusions: SV calculi are a rare cause of haematospermia, Sound urologic principles of relieving the obstruction, eradicating infection, and providing unimpeded urinary drainage will usually prove successful in their treatment. Recent advances in and increased use of lower genitourinary tract imaging have identified calculi in the prostate, seminal vesicles, and ejaculatory ducts with increasing frequency.
Written by: Bashir Mohamed, Raghav Varma, & Wasim Mahmalji, Herford County Hospital, Wye Valley NHS Foundation Trust, United Kingdom
References:
- Zaidi, Sahera; Gandhi, Jasona,b; Seyam, Omara; Joshi, Gunjanc; Waltzer, Wayne C.e; Smith, Noel L.d; Khan, Sardar Alia,e. Etiology, Diagnosis, and Management of Seminal Vesicle Stones. Current Urology: May 2019 - Volume 12 - Issue 3 - p 113-120
- Williams, Sarah Anne; Christodoulidou, Michelle; Nigam, Raj (2017). Large bilateral seminal vesicle calculi presenting with spermolithiasis. BMJ Case Reports, (), bcr-2017-219630–. doi:10.1136/bcr-2017-219630
- Song L, Han H, Lei H, Cui Y, Feng S, Zhang X, Tian L. Successful treatment of seminal vesicle calculi and prostatic utricle calculi by transurethral seminal vesiculoscopy. Andrologia. 2020 Dec;52(11):e13804. doi: 10.1111/and.13804. Epub 2020 Aug 26. PMID: 32851699; PMCID: PMC7757201.
- Mahmood Vazirian-Zadeh, Adam Jones, Yih Chyn Phan & Wasim Mahmalji (2020) A case of persistent haematospermia secondary to seminal vesicle calculi in an ageing male, The Aging Male, 23:4, 297-299, DOI: 10.1080/13685538.2018.1563064
- Han CH, Liang Q, Dong BZ, Hao L, Fan T, Zhang JJ, Zhang WD, Chen B, Qiu XZ, Zhou XJ, Pei CS. The transurethral seminal vesiculoscopy in the diagnosis and treatment of the seminal vesicle disease. Cell Biochem Biophys. 2013 Jul;66(3):851-3. doi: 10.1007/s12013-013-9527-6. PMID: 23447051.
- Michelle Christodoulidou, Arie Parnham & Raj Nigam (2017) Diagnosis and management of symptomatic seminal vesicle calculi, Scandinavian Journal of Urology, 51:4, 237-244, DOI: 10.1080/21681805.2017.1295398
- Trivedi, J., Sutherland, T. & Page, M. Incidental findings in and around the prostate on prostate MRI: a pictorial review. Insights Imaging 12, 37 (2021). https://doi.org/10.1186/s13244-021-00979-7