Haemospermia, or haematospermia, is defined by the presence of blood in the semen [
1,
2]. Haemospermia has been considered as a benign and self-limiting symptom; however, it often invokes considerable anxiety and is frightening to the patient [
3,
4]. It is believed that inflammation, infection, lithiasis, cyst, and obstruction in the distal seminal tract could all cause haemospermia [
1,
5]. Ejaculatory duct obstruction (EDO) is a surgically correctable condition that occurs in some patients with infertility or haemospermia [
6,
7], which can be sub-classified into congenital or acquired EDO. The congenital type could be caused by atresia or stenosis of the ejaculatory ducts as well as utricular, Müllerian, and Wolffian duct cysts. Conversely, the acquired type may be secondary to inflammatory or traumatic origin, including stone or post-inflammatory scar tissue formation [
8,
9]. Previous studies have shown that EDO was common in patients with persistent or recurrent haemospermia [
3,
10,
11]. The relationship between obstruction, inflammation, and calculus formation is vicious and can eventually lead to persistent and recurrent haemospermia [
12].
Traditionally, EDO has been treated with transurethral resection of the ejaculatory duct [
13,
14]. However, this surgical procedure could not remove the blood clots and calculi in the seminal vesicle or prostatic utricle for patients with persistent or recurrent haemospermia. Transurethral seminal vesiculoscopy is a common treatment for seminal tract calculi and recurrent haemospermia [
15,
16]. Herein, we report our experience in using a combination of TURED and seminal vesiculoscopy to resolve persistent or recurrent haemospermia in patients with EDO.
Discussion
Haematospermia, or haemospermia, is usually regarded as a benign and self-limiting symptom, requiring no additional treatment or evaluation [
19,
20]. However, the condition is often associated with impaired quality of life owing to induced anxiety and must be taken seriously by both patients and physicians, particularly if it is recurrent and refractory and has co-existing pain [
1,
2]. In addition, patients present to their primary care physician after a single episode of haemospermia out of concern for malignancy or venereal disease [
20]. Evaluating the aetiology is the best approach to the initial management of hemospermia. In the present study, 103 patients with persistent or recurrent haemospermia and EDO were treated with TURED combined with seminal vesiculoscopy. These results indicate that TURED combined with seminal vesiculoscopy is a safe and effective technique for the management of patients with refractory haemospermia and EDO.
There are many possible causes of hemospermia, most of which are benign, and the risk of malignancy is low [
21,
22]. In 2013, Li analysed the pathogenesis of persistent and refractory hemospermia in 102 patients, of which 88 (86.3%) patients showed typical and characteristic changes in the ejaculatory duct area, and some degrees of EDO were found during their surgery [
5]. In the recent study conducted by Chen in 2018, transurethral seminal vesiculoscopy was performed in 419 patients with persistent haemospermia in Shanghai Changhai Hospital (Shanghai, China) from May 2007 to November 2015 [
11]. Ejaculatory duct stenosis or EDO, mucosal lesions in the seminal vesicle, and calculi in the seminal vesicle or verumontanum were observed in 312 (81.9%), 209 (54.9%), and 19 (5.0%) cases, respectively [
11]. In our study, we enrolled 103 patients with persistent haemospermia and EDO. Cysts of the lower male genitourinary tract were found in 79 patients; calculi in the seminal vesicle or prostate utricle in 32 patients; and blood clots in 63 patients during surgery. EDO is considered as the most common cause of refractory hemospermia, and the risk of EDO might be higher in patients with hemospermia. If EDO is not resolved, the blood clots and calculi in the seminal vesicle or ejaculatory duct cannot be effectively discharged, which may lead to persistent or recurrent haemospermia. Therefore, the key point to the treatment of persistent or recurrent haemospermia in patients with EDO is early diagnosis, timely drainage, and relief of obstruction.
TURED, considered as the standard procedure for the management of EDO, was initially described by Farley and Barnes in 1973 [
23]. Some studies have reported that TURED is a viable and minimally invasive option for treating EDO caused by ejaculatory disorders, including infertility and hemospermia [
10,
24,
25]. In 2008, Manohar et al. investigated 25 patients with ejaculatory disorders, including hemospermia, who underwent TURED between 1997 and 2005, and all patients complained of symptoms, including painful ejaculation and hemospermia; they observed complete remission of symptoms 3 months after surgery [
10]. Transurethral seminal vesiculoscopy is a new technique used for the diagnosis and treatment of seminal tract diseases. The first report of in vivo endoscopic evaluation of the seminal vesicles was provided by Yang in 2002 [
26]. Recently, several reports have described the endoscopic technique for the management of patients with seminal tract diseases [
16,
27]. Liu et al. investigated 72 patients with haemospermia who underwent transurethral seminal vesiculoscopy and treatment at Shanghai Changhai Hospital between 2006 and 2008 [
4]. Their analysis showed that definite diagnosis was made in 93.1% of patients, and 94.4% were cured or at least reported alleviation of their symptoms. Tang et al. evaluated 30 patients with persistent hemospermia who were treated with transurethral seminal vesiculoscopy between November 2013 and January 2016 in the First Affiliated Hospital of Fujian Medical University [
28]. Calculi in the ejaculatory duct or seminal vesicle were found in 20 patients, and inflammation or dark red jelly-like substances in the seminal vesicle were observed in all patients [29]. In our study, all patients were treated with TURED combined with seminal vesiculoscopy; of them, 32 had calculi in the seminal vesicle or prostate utricle, and 63 had blood clots. The symptoms of haemospermia disappeared in 96 of the 103 (93.20%) patients after surgery. In addition, the ejaculate volume and percent motility significantly increased. In patients with haemospermia and EDO, the vicious cycle of obstruction, inflammation, and calculus formation may eventually lead to recurrent and refractory hemospermia. TURED combined with transurethral seminal vesiculoscopy is a simple, minimally invasive procedure that is performed via the urogenital tract. Its use can remove obstructions, blood clots, and calculi, thereby relieving symptoms and reducing the risk of recurrence. However, although the surgical procedure is not very difficult, the potential risk of ejaculatory duct and seminal vesicle structural damage remains. Therefore, careful performance of surgical procedures is required, especially in unmarried men who plan to have children.
The present study had a number of limitations. The sample size was small owing to the low rates of persistent haemospermia with EDO. Additionally, the study was a single-arm, observational study without a control group; thus, the beneficial effects of the surgery might have been overestimated. A randomised controlled trial is required to provide reliable evidence in the future. The follow-up period in a proportion of the patients after the treatment may not be of sufficient duration; long-term follow-up results are required to clarify the efficacy and safety of this surgical procedure. Despite these limitations, to the best of our knowledge, this is the first study to show the efficacy and safety of TURED combined with seminal vesiculoscopy for the treatment of persistent or recurrent haemospermia in patients with EDO. Our analysis showed that 93.20% of the patients had completely relieved haemospermia symptoms, and the percent motility significantly increased after surgery; these results are comparable to the results of previous studies. The results of our study provide important preliminary information indicating that TURED combined with seminal vesiculoscopy could be an alternative treatment strategy for persistent or recurrent haemospermia in patients with EDO.
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