I. Overview of the disease
(A) Definition
The definition of spermatorrhea has a broad and narrow sense. The broad definition of seminal vesiculitis includes non-specific seminal vesiculitis and specific seminal vesiculitis. Non-specific vesiculitis is a general infection of the seminal vesicles. Common germs include Escherichia coli, Aspergillus and Staphylococcus. Specific seminal vesiculitis is an infection caused by bacteria and fungi other than the general infection germs. For example, tuberculosis of the seminal vesicles, gonococcal vesiculitis, etc. The narrow definition of seminal vesiculitis refers exclusively to non-specific seminal vesiculitis. The narrow definition is commonly used at present.
Spermatorrhea can be divided into two categories: acute and chronic.
(ii) Epidemiology
There is no convincing epidemiological investigation of vesiculitis. However, seminal vesiculitis occurs in sexually active young adults, and often coexists clinically with prostatitis, called prostatic vesiculitis.
(iii) Pathogenesis
There are several routes of spermatorrhea infection.
(1) Retrograde infection of the seminal vesicles by pathogenic bacteria via the ejaculatory ducts.
(ii) direct spread of infection from organs adjacent to the seminal vesicles.
(3) The pathogenic bacteria from other parts of the body cause seminal vesiculitis through blood circulation and lymphatic route. Acute vesiculitis is mainly caused by Gram-negative bacilli, mostly Escherichia coli (80%).
Chronic vesiculitis mostly evolves from acute vesiculitis that has not been healed, but can also have no clear etiology.
(iv) Clinicopathophysiology
The initial manifestations of acute vesiculitis are congestion and edema of the vesicle wall, infiltration of leukocytes, and swelling and shedding of the epithelial cells of the glandular ducts. When the inflammation develops, the congestion and edema increase, and even many small abscesses can be formed in the glandular ducts. In severe cases, the abscess spreads and fuses to form a seminal vesicle abscess. It can also spread into the surrounding tissues.
In chronic vesiculitis, the epithelial cells of the seminal vesicles are atrophied and shed, the submucosa is swollen, and the red blood cells exude from the capillaries and enter the glandular lumen; in addition, when sexual excitement occurs, the seminal vesicles contract and the blood-filled capillaries rupture, making hematospermia the main symptom of chronic vesiculitis. The secretion function of the glandular ducts is disrupted, resulting in changes in the quality and quantity of semen. Long-term chronic inflammation can lead to atrophy or fibrosis of the seminal vesicles, seriously affecting the reproductive function. Because of the anatomical structure and pathogenesis associated with the bladder and posterior urethra, seminal vesiculitis can cause urinary tract symptoms.
(v) Risk factors
A number of factors that can lead to congestion of the prostate and seminal vesicles and provide a good environment for invading pathogens to grow can trigger vesiculitis. For example: indulgence, long-term abstinence, alcoholism, smoking, sedentary, cycling and low body resistance.
Diagnosis
(A) Clinical manifestations
1. Acute vesiculitis
(1) Symptoms.
①Main symptoms: discomfort, distension or severe pain in the perineum, pain may radiate to the genitals, lumbosacral region, lower abdomen and groin.
(2) Systemic symptoms: often with chills, fever, headache, general malaise, etc.
③Seminal tract symptoms: During sexual intercourse, there is fleshy hematochezia with painful ejaculation, radiating to the perineum, lower abdomen, and testicles.
④Urinary tract symptoms: Because the posterior urethra is often involved at the same time, burning sensation in the urethra, urinary frequency, urinary urgency, urinary pain, terminal hematuria, and difficulty in urination may occur.
(2) Physical signs: rectal examination can reveal enlarged seminal vesicles with obvious tenderness. If a seminal vesicle abscess has been formed, it will be full to palpation and have fluctuating sensation. Note that massage and instrumental examination are prohibited during the acute period.
2. Chronic vesiculitis
(1) Symptoms.
①The most common symptom is hematospermia, which appears as pink, dark red or coffee-colored and can be present every time of sexual intercourse or at intervals of several days, months or even years.
②Symptoms of sexual dysfunction: such as premature ejaculation, seminal emission, and erectile dysfunction.
③Other: discomfort of lower abdomen and perineum, burning sensation of urination with frequent and urgent urination, male infertility, etc.
(2) Physical signs Rectal examination can reveal enlarged, irregular, hardened and painful seminal vesicles. The fluid massaged out is often coffee-colored or dark red.
(B) Auxiliary examination
1.Laboratory semen examination.
Prostate and seminal vesicle massage and instrumentation examination are prohibited during the acute stage. The semen contains blood or coffee-colored material, and red blood cells are found under the microscope. Positive bacterial culture. In chronic seminal vesiculitis, semen contains bloody or coffee-colored material and red blood cells are found under the microscope. The fructose content may be reduced (normal value is 0,87-3,95g/L). There is no bacteria in the prostate fluid culture but bacteria in the semen or the bacteria in the semen is different from the bacteria in the prostate fluid.
2.Imaging examination
(1) Ultrasonography: In acute vesiculitis, the shape of seminal vesicles is enlarged, full and slightly oval. The edges are hairy or the borders are unclear. After the formation of abscess, there may be fine dotted echogenicity in the vesicle. In anaerobic bacterial infections, strong echogenicity of gas is seen in the abscess cavity. In chronic vesiculitis, the enlargement of the seminal vesicles is not obvious and is pyknotic. The wall of the vesicle is thickened and rough, with enhanced internal echogenicity and poor sound transmission. The vas deferens is more widened, often exceeding 0.8 cm. four side-by-side tubular echogenic structures in cross-section are interlaced and crowded, and even “misaligned” signs appear.
(2) CT examination: In acute vesiculitis, the seminal vesicles are enlarged. In case of abscess, there is central hypodensity or multi-room lesion (0-20Hu) with contrast enhancement at the edge of the abscess. In case of anaerobic bacterial infection, bubbles are seen and the adjacent bladder wall is thickened. In chronic vesiculitis, the seminal vesicles are enlarged and heterogeneous, and cysts or diverticula may be formed.
(3) MRI examination: in acute seminal vesiculitis, the seminal vesicles are enlarged. isosignal or low signal on T1WI and higher signal on T2WI, often combined with hemorrhage. In the case of spermatophore abscess, T1-weighted image shows focal low signal with poorly smooth margins and T2-weighted image shows high signal, and the lesion can infiltrate into the adjacent perivaginal fat of the seminal vesicles.
(4) Seminography: it is contraindicated in acute vesiculitis. There are two types of seminomastoid imaging modalities commonly used for chronic vesiculitis.
(i) Incision of the skin followed by puncture or incision of the vas deferens for imaging.
② direct puncture of the vas deferens via the skin of the scrotum for imaging. The former is more invasive and has a high possibility of postoperative vas deferens stenosis. Therefore, the latter is commonly used at present. The main manifestations of sperm ductography are:
(1) cloudy changes in the vas deferens abdomen and inner lumen of the seminal vesicles, with blurred visualization.
(2) Stenosis of the lumen in the corresponding area caused by inflammation, with uniform dilatation or cystic dilatation of the proximal lumen.
(3) Chronic inflammatory atrophy of the abdomen, seminal vesicles and ejaculatory ducts, narrow lumen, stiff lumen wall, and occlusion of the lumen are not visualized in the above areas.
(iii) Differential diagnosis
1. Acute abdomen: Acute vesiculitis must be differentiated from acute appendicitis, urinary stones and other acute abdomen. Acute vesiculitis is painful mainly in the perineum and groin with hematemesis. In contrast, acute appendicitis has metastatic right lower abdominal pain, pressure and rebound pain in the right lower abdomen at the point of McDonald’s, and no hematospermia. Urinary stones are paroxysmal colic in the lower back or lower abdomen with hematuria, and ultrasound and KUB+IVP may reveal stone images without hematospermia. It is generally easy to identify.
2, prostatitis: simple prostatitis without hematospermia, routine examination of prostate fluid with reduced lecithin vesicles and increased leukocytes.
3, seminal vesicle tuberculosis: with symptoms of seminal vesicle inflammation, but mostly with a history of tuberculosis in other parts, especially the genitourinary system. Infiltrative nodules can be palpated in the seminal vesicles by rectal palpation. Mycobacterium tuberculosis can be detected in the prostate and seminal vesicle massage fluid.
4. Seminal vesicle tumor: it has the symptoms of seminal vesicle inflammation, but it is more likely to occur in middle-aged and elderly people over 40 years old. Ultrasound, CT, MRI can help to confirm the diagnosis, and filling defect can be found in seminal vesicle angiography.
5. Seminal vesicle stone: there may be hematospermia. Ultrasound, CT, MRI can help to confirm the diagnosis.
III. Treatment
(A) General supportive treatment
In acute vesiculitis, pay attention to rest and prohibit heavy physical activity and sexual life. In chronic vesiculitis, life should be regular, combining work and rest. Keep a moderate and regular normal sexual life, avoid prolonged sitting, standing and squatting. Avoid smoking, alcohol and spicy diet.
(II) Psychological treatment
Do a good job of explaining the condition and eliminate the patient’s mental burden.
(C) Local treatment
1.Physiotherapy: hot water sitz bath, 1-2 times a day. Or trans-perineal or rectal ion introduction, microwave therapy.
2, intra-seminal vesicle drug injection In chronic seminal vesiculitis, under the guidance of rectal ultrasound, transrectal, perineal seminal vesicle puncture or direct perineal skin puncture vas deferens retention catheter, injection drug flushing treatment.
(iv) Systemic treatment
1, the application of antimicrobial agents: the choice of fat-soluble antibiotics, combined with plasma proteins easily diffused to the seminal vesicle secretion. Commonly used are quinolones, erythromycin, sulfonamides, etc.
2.Hemostatic agents: for those with red color of hematosperm, hemostatic min and hemostatic aromatic acid can be used appropriately.
3, drugs to reduce congestion and edema of the seminal vesicle gland such as ethylene estradiol, 5-alpha reductase inhibitors, etc.
(V) Surgical treatment
In acute vesiculitis, if abscess is formed, puncture or incision and drainage are required. In chronic seminal vesiculitis, if the ejaculatory duct is narrowed, resulting in poor drainage of seminal fluid, the ejaculatory duct can be incised via the urethra.
Assessment of efficacy
The hemorrhagic semen disappears, and no bacterial growth in semen culture is considered to be cured.