Amyloidosis of the seminal vesicle and hematospermia

Identification of amyloidosis of the urinary tract and prostate: Opportunities for early diagnosis & intervention in systemic disease

OBJECTIVES

To determine the prevalence of different amyloid types and frequency of associated systemic amyloidosis in the urinary tract/prostate.

METHODS

We studied Congo red-positive prostate (n = 150) and urinary tract (n = 767) specimens typed by a proteomics-based method between 2008 and 2020. Clinical follow up was available for a subset (urinary tract, n = 111; prostate, n = 17). Amyloid types were correlated with various clinicopathologic features. For patients with clinical follow up, chart review was performed to establish localized versus systemic disease, frequency of initial diagnosis of amyloidosis on urinary tract/prostate specimens, presence of cardiac disease, and death from disease-related complications.

RESULTS

The most common amyloid types were AL/AH in urinary tract (479/767, 62 %) and localized ASem1 in prostate (64/150, 43 %). Urinary tract AL/AH amyloid was usually localized, but systemic AL amyloidosis occurred in both sites (urinary tract: 5/71, 7 %; prostate: 2/2, 100 %). ATTR amyloidosis was seen in over a third of cases (urinary tract: 286/767, 37 %; prostate: 55/150, 37 %). Urinary tract/prostate was the site of the initial ATTR amyloidosis diagnosis in 44/48 patients (92 %), and 38/48 (79 %) were subsequently found to have cardiac involvement. Seminal vesicle/ejaculatory duct involvement was pathognomonic for ASem1-type amyloidosis (39/39, 100 %).

CONCLUSIONS

Over 40 % of patients had systemic amyloidosis, with urinary tract/prostate often the first site in which amyloid was identified. Since early recognition of systemic amyloidosis is critical for optimal patient outcomes, there should be a low threshold to perform Congo red stain. Proteomics-based amyloid typing is recommended since treatment depends on correctly identifying the amyloid type.

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.

Amyloidosis of seminal vesicles and ejaculatory ducts: a histologic analysis of 21 cases among 447 prostatectomy specimens

To investigate the incidence of amyloidosis of seminal vesicles and ejaculatory system including ejaculatory ducts and vasa deferentia, we reviewed the whole mount sections of 447 radical prostatectomy specimens removed for prostatic cancer, including 273 cases from the United States and 174 cases from Korea. Of these, 21 cases (4.7%) showed amyloidosis in seminal vesicles, vasa deferentia, and in ejaculatory ducts. Ten of these (3.7%) cases were from the United States and 11 cases (6.3%) from Korea. The patients' age ranged from 51 to 79 years (mean, 66.1 years). Amyloid deposition was found in 5 patients in the sixth decade (3.4%), 9 patients in the seventh decade (4.7%), and 7 patients in the eighth decade (9.3%). At the seventh decade of life, the Korean patients showed a higher incidence (8.3%) than American patients (2.5%), but other age groups showed no difference. All cases showed bilateral involvement of the seminal vesicles and ejaculatory systems. The deposits of amyloid tended to be nodular and affected the subepithelial region of seminal vesicles, vasa deferentia, and ejaculatory ducts. There was no amyloid deposit around blood vessels or in the prostatic parenchyma. Localized amyloidosis of the ejaculatory system involves not only the seminal vesicles but also the vasa deferentia and the ejaculatory ducts. The vessels or prostatic stroma are not part of this process. Amyloidosis develops subepithelially spreading to include the wall of these organs and appears to be related to advanced age. The incidence of amyloidosis of the ejaculatory system in Korean patients was higher than in US patients.

CHARACTERIZATION OF LOCALIZED SEMINAL VESICLE AMYLOIDOSIS CAUSING HEMOSPERMIA: AN ANALYSIS USING IMMUNOHISTOCHEMISTRY AND MAGNETIC RESONANCE IMAGING

PURPOSE

We evaluated the characteristics of seminal vesicle amyloidosis (SVA) associated with hemospermia by immunohistochemistry and magnetic resonance imaging (MRI) as well as the clinical course of hemospermia.

MATERIALS AND METHODS

Of 56 patients with hemospermia 12 underwent transperineal biopsy of the seminal vesicle under transrectal ultrasound monitoring. SVA was proved in 4 men 48 to 59 years old by histological and immunohistochemical examinations of specimens obtained by biopsy. Two men presented with the first episode of hemospermia and 2 presented with recurrent hemospermia. MRI at 1.5 Tesla was performed while hemospermia persisted and after its resolution. Patients were followed for 10 to 86 months with regard to the duration of hemospermia, the time of its resolution and its recurrence.

RESULTS

Amyloid deposits in the subepithelial tissue of the seminal vesicles were permanganate sensitive, and positive for lactoferrin and the amyloid P component but negative for amyloid A protein, lambda and kappa chains, and beta2-microglobulin. The seminal vesicles with obvious intravesicular hemorrhage on needle puncture were hyperintense on T1-weighted images. After hemospermia resolution T1-weighted images became diffusely hypointense. T2-weighted images were of low intensity, representing amyloid deposits. Hemospermia resolved spontaneously in all patients in an average of 14 months. Although disease recurred in 1 patient after 8 months of resolution, it disappeared after 11 months of recurrence.

CONCLUSIONS

Localized SVA with hemospermia shows hypointensity on T2-weighted MRI. Hemospermia is spontaneously resolved with the transition from hyperintense to hypointense T1-weighted MRI.