Case report: recurrent hematuria and hematospermia due to prostatic telangiectasia in classic von Willebrand's disease

Vascular abnormalities in patients with von Willebrand disease: A scoping review

BACKGROUND

Qualitative or quantitative defects of von Willebrand factor (VWF) such as in von Willebrand disease (VWD) are associated with vascular abnormalities, especially in the gastrointestinal (GI) tract. However, the locations, extent, and natural history of vascular abnormalities in patients with VWD is not well understood. To summarize the existing literature on the topic, we conducted a scoping review of vascular abnormalities in patients with VWD.

METHODS

We searched MEDLINE and EMBASE from inception to September 1, 2020, for studies clinically describing vascular abnormalities in VWD patients. Screening and data extraction was completed independently and in duplicate and each abnormality was documented individually.

RESULTS

After screening, 54 studies that reported patient level data comprising 146 patients were included. Type 2A (39%) and type 3 (14.4%) were the most common VWD subtypes. The most common site of vascular malformation was the GI tract, occurring in 124 patients (84.9%), whereas 18 (12.3%) had non-GI vascular abnormalities and 4 (2.7%) had both GI and non-GI vascular abnormalities. With respect to outcomes, the clinical course was not specified in the majority (55.5%) of patients. Survey and population level data were reported in nine studies, demonstrating vascular abnormalities occurred at higher rates in VWD and that VWD patients are overrepresented among those with those abnormalities.

CONCLUSION

Vascular malformations in patients with VWD occur primarily in the gastrointestinal tract. Type 2A and type 3 VWD are the most common subtypes affected. The clinical treatment and natural history of these abnormalities remains understudied and further research is needed.

Abnormal angiogenesis in blood outgrowth endothelial cells derived from von Willebrand disease patients

: Bleeding associated with angiodysplasia is a common, often intractable complication in patients with von Willebrand disease (VWD). von Willebrand factor (VWF), the protein deficient or defective in VWD, is a negative regulator of angiogenesis, which may explain the pathologic blood vessel growth in VWD. This study explores the normal range of angiogenesis in blood outgrowth endothelial cells (BOECs) derived from healthy donors and compares this to angiogenesis in BOECs from VWD patients of all types and subtypes. BOECs were assessed for VWF and angiopoietin-2 (Ang-2) gene expression, secretion, and storage. To explore angiogenic potential, we characterized cellular proliferation, matrix protein adhesion, migration, and tubule formation. We found great angiogenic variability in VWD BOECs with respect to each of the angiogenesis parameters. However, type 1 and 3 VWD BOECs had higher Ang-2 secretion associated with impaired endothelial cell migration velocity and enhanced directionality. Type 2A and 2B BOECs were the most proliferative and multiple VWD BOECs had impaired tubule formation in Matrigel. This study highlights the angiogenic variability in BOECs derived from VWD patients. Abnormal cell proliferation, migration, and increased Ang-2 secretion are common features of VWD BOECs. Despite the many abnormalities of VWD BOECs, significant heterogeneity among individual VWD phenotypes precludes a simple description of relationship between VWD type and in vitro surrogates for angiodysplasia.

Etiologic classification, evaluation, and management of hematospermia

Hematospermia is defined by the presence of blood in the semen typically occurring in men younger than 40 years of age. Symptoms can occur due to a multitude of reasons, but are usually benign and self-limiting, requiring no additional treatment or evaluation. Despite this, the condition often impairs quality of life due to associated anxiety and must be taken seriously by the patient and the physician, particularly if recurrent, refractory, and painful. The etiology of hematospermia can be classified into inflammatory, infectious, lithiasis, cystic, obstructive, tumoral, vascular, traumatic, iatrogenic, and systemic origin. Alternatively, it can also be divided into subcategories based on anatomical origins such as prostate, bladder, spermatic cord, seminal vesicles, or epididymis. A complete history and physician examination, laboratory testing, and a variety of invasive and non-invasive imaging and instrumentation modalities can help to identify and treat the underlying pathology promptly.

Angiodysplasia in von Willebrand Disease: Understanding the Clinical and Basic Science

Severe and intractable gastrointestinal bleeding caused by angiodysplasia is a debilitating problem for up to 20% of patients with von Willebrand disease (VWD). Currently, the lack of an optimal treatment for this recurrent problem presents an ongoing challenge for many physicians in their management of affected patients. Over the past few years, studies have pointed to a regulatory role for the hemostatic protein, von Willebrand factor (VWF), in angiogenesis, providing a novel target for the modulation of vessel development. This article will review the clinical implications and molecular pathology of angiodysplasia in VWD.

Hematospermia Evaluation at MR Imaging

Hematospermia is a challenging and anxiety-provoking condition that can manifest as a single episode or recur over the course of weeks to months. It is usually a benign self-limiting condition in younger sexually active males without a history of risk factors such as cancer, urogenital malformations, bleeding disorders, and their associated symptoms. However, patients with recurrent, refractory and painful hematospermia with associated symptoms, such as fever, pain, or weight loss, require evaluation through clinical assessment and noninvasive investigations to rule out underlying pathologic conditions such as ejaculatory obstruction, infectious and inflammatory causes, malignancy, vascular malformations, and systemic disorders that increase the risk of bleeding, especially when presenting in older men. If these investigations are negative, the patient should be reassured and treated accordingly. In the recent past, magnetic resonance (MR) imaging has assumed a major role in the investigation of hematospermia due to its excellent soft-tissue contrast and multiplanar capabilities. In this review, we will discuss the potential causes of hematospermia and its diagnostic workup, including pathophysiology, anatomic considerations, the imaging appearance of associated pathologic conditions, and management. (©)RSNA, 2016.

Hematospermia: etiology, diagnosis, and treatment

Hematospermia is a relatively frequent, distressing, and frightening symptom for the majority of men. Although the differential diagnosis list is extensive, it is usually a benign, self-limiting disorder, including inflammatory and infective pathologies, resolving in several weeks. However, in some cases, hematospermia is the harbinger of more serious pathological lesions that should not be missed. In younger patients below 40 years of age, infection of the urogenital tract is the most common etiology. Simple routine laboratory studies should identify the pathological factors. In patients 40 years or older, or those with persistent or recurrent conditions or associated symptoms, it is necessary to exclude urogenital malignant disorders. Patients should also undergo medical history taking, physical examination including temperature and blood pressure assessment, digital rectal palpation, and laboratory blood, urine, and semen tests. If the diagnosis is still unclear, further investigations involve transrectal ultrasonography, magnetic resonance imaging, urethrocystoscopy, and histological confirmation by biopsy. Treatment for hematospermia depends on the underlying pathological lesions, but often involves only minimal examinations and simple reassurance in most cases. Hematospermia caused by genitourinary infections is effectively treated with appropriate antiviral, antibiotic, or antiparasitic agents. Hematospermia due to malignant disorders including prostate, testis, and seminal vesicle cancers resolves with definitive treatment of the primary lesions.

TRANSURETHRAL INCISION FOR HEMATOSPERMIA CAUSED BY EJACULATORY DUCT OBSTRUCTION

Hematospermia is supposed to be derived from pathological conditions in the seminal vesicle, prostate, testis, epididymis, or urethra. A recent advance in diagnostic procedures has demonstrated the seminal vesicle, the prostate, and midline cyst as potential sources of hematospermia. The authors describe a case of hematospermia caused by ejaculatory duct obstruction, in which a transurethral technique was successful. A 51-year-old male was referred to the authors' clinic with a chief complaint of hematospermia. Transurethral ultrasonography showed a cystic lesion surrounded with hyperechoic area in the middle of the prostate. Vasography demonstrated the distal dilation of the ejaculatory duct. Magnetic resonance imaging demonstrated a high signal intensity area in the middle of the prostate. Urethrocystoscopy showed an enlarged cystic lesion with an orifice at the prostatic urethra, which was incised endoscopically. There was no complication observed postoperatively. Seven months after the technique, hematospermia resolved completely. A midline cyst should be considered a cause of hematospermia and the incidence of such cysts may be higher than that previously recognized. The transurethral technique is expected to be a successful treatment approach.

Hematospermia: etiological and management considerations

BACKGROUND

Hematospermia, or blood in the ejaculate, usually follows a benign self-limiting course. However, it can be a source of considerable anxiety in patients. The purpose of this article is to provide the primary care physician an algorithm for the evaluation and management of hematospermia based on frequency of occurrence and patient age.

METHODS

We performed an English language MEDLINE (1966 to present) search for the terms hematospermia, hemospermia, management, prostate biopsy and combinations thereof. We then constructed a management algorithm based on available evidence.

RESULTS

Typically, patients present to their primary care physician after a single episode of hematospermia out of concern for malignancy or venereal disease. In men 40 years old or younger, it is most often due to inflammatory or infectious processes. In men over 40 years of age, however, an association exists between hematospermia and more serious underlying pathology. A significant number of cases remain idiopathic even after extensive investigation.

CONCLUSIONS

Hematospermia is an anxiety-provoking sign that is usually due to inflammatory or infectious causes. Recurrent or symptomatic hematospermia may herald more serious underlying pathology, especially in those patients over 40 years old. A thorough evaluation is warranted to both rule out more serious pathology and to adequately address patient anxiety. With modern imaging techniques, the number of "idiopathic" cases should be much lower than historically reported.

Hemospermia

PURPOSE

With current diagnostic modalities the proportion of patients diagnosed with idiopathic hemospermia has decreased dramatically. The dilemma now is how far to investigate these patients since in the majority it is a benign and self-limiting symptom.

MATERIALS AND METHODS

We reviewed the literature on hemospermia with particular emphasis on etiology, diagnosis and management. A Medline search of the literature for the last 40 years was done and all relevant articles were studied in full.

RESULTS

Etiological factors are often categorized into the various pathophysiological mechanisms. Most cases of hemospermia are the result of iatrogenic, inflammatory and infective pathologies. A literature review of the etiological studies of hemospermia identified a total of 33 tumors (25 prostatic) in 931 cases (3.5%). In patients younger than 40 years an infective cause in the urogenital tract is the most common etiological factor. Often only simple, tailored investigations and appropriate treatment are required. In patients older than 40 years with persistent hemospermia or associated symptoms such as hematuria it is essential to exclude urogenital malignancy. History, examination and simple investigation should also suffice in this group. If the diagnosis is still unclear, further investigation in the form of transrectal ultrasound, magnetic resonance imaging and cystoscopy is of proven benefit. Treatment for hemospermia depends on the underlying pathological condition. In most cases bleeding is slight and self-limited, and it may be managed expectantly.

CONCLUSIONS

The majority of patients can be treated with minimal investigations and simple reassurance. In older patients or those with persistent hemospermia or associated symptoms modern diagnostic techniques are of proven benefit.

Hematospermia: imaging findings

Hematospermia is an anxiety provoking but otherwise generally benign and self-limited condition that is infrequently associated with significant underlying pathology, and is most often considered to be idiopathic in nature. Management with routine clinical evaluation, watchful waiting, and reassurance generally suffice without further diagnostic workup or treatment. Noninvasive imaging may play an important role in the diagnostic workup of men with hematospermia, particularly in those who are >40 years old, have other associated symptoms or signs of disease, or have persistence of hematospermia. Many entities may be encountered in association with hematospermia at imaging, and specific therapeutic interventions may be used if certain treatable underlying pathologies are coincidentally detected. In this comprehensive review, we discuss the potential etiologies, diagnostic workup, imaging techniques, relevant male pelvic anatomy, imaging appearance of specific associated pathologies, and treatment for hematospermia.

Painless urethral bleeding: an unusual presentation of Von Willebrand disease

Von Willebrand disease (vWD) is the most common bleeding disorder, and usually presents with either easy bruising or mucus membrane bleeding. Many patients are also diagnosed as a result of abnormal pre-operative laboratory tests. In this report, we describe two patients presenting with painless, persistent urethral bleeding as their initial manifestation of vWD. The first patient began bleeding after a Foley catheter was placed during a hospital admission for status epilepticus. A urologic examination demonstrated a wound in the posterior urethra. Despite repeated attempts at controlling the bleeding with cautery, the bleeding persisted. The second patient presented with spontaneous urethral bleeding and a normal urologic examination. Due to persistent bleeding, both patients underwent a coagulation evaluation that demonstrated the presence of type 1 vWD. The first patient had resolution of his bleeding following 5 weeks of Alphanate, a von Willebrand factor containing factor VIII concentrate, and aminocaproic acid. The second patient initially responded to desmopressin, but subsequently required Humate-P to achieve complete resolution. These cases illustrate the importance of an evaluation for bleeding disorders in patients with persistent bleeding from any site.

[Hemospermia: diagnosis and therapeutic aspects. Seven case reports]

Hemospermia or hematospermia is a common benign condition, but its prevalence remains unknown and can result from several causes. The aetiology is idiopathic in about 30-70% of the cases. The hemospermia is first of inflammatory origin, in the young patients, where it is due to uretroprostatitis or orchi-epididymitis, but in the older, it is due to a benign of malignant prostatic tumors. Transrectal ultrasonography and magnetic resonance imaging can afforded the opportunity to best investigate the patients with hemospermia. Hemospermia is not an uncommon problem and in most instances has little clinical significance other than evoking much anxiety for the patient. In view of the literature, the authors discus the diagnostic and therapeutic approach of hemospermia through a series of seven cases.