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

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.

Localized amyloidosis of the epididymis: a previously unreported phenomenon

BACKGROUND

Localized amyloidosis has not been documented in the epididymis; we report this phenomenon for the first time.

CASE PRESENTATION

The first aim of this work is to report three cases of localized epididymal amyloidosis. Two cases were clinically detected as epididymal nodules, and a third after reviewing 120 epididymides obtained with neighbouring pathological processes. Amyloid deposits showed Congo red positivity, with yellow-green birefringence, and immunohistochemical expression for light chains kappa and lambda, transthyretin, amyloid P and cytokeratin AE1 AE3. No immunoreactivity for amyloid A was seen. Amyloid deposit location was intraluminal, with partial or total loss of the epididymal epithelium and subsequent passage to the interstitium, forming large masses. No amyloid deposits were observed around blood vessels. A secondary objective was to explore in normal epididymis the amyloid tested in epididymal amyloidosis. In normal epididymides, expression of amyloid P and transthyretin was detected in the apical surface of epithelial cells. Amyloid P also showed strong expression in spermatozoa.

CONCLUSION

We contribute the existence of localized epididymal amyloidosis, which presents a distinctive, initial intratubular location, where there is a unique proteome and where functional amyloids act during sperm maturation.

Biomarker, Molecular, and Technologic Advances in Urologic Pathology, Oncology, and Imaging

Urologic pathology is evolving rapidly. Emerging trends include the expanded diagnostic utility of biomarkers and molecular testing, as well as adapting to the plethora of technical advances occurring in genitourinary oncology, surgical practice, and imaging. We illustrate those trends by highlighting our approach to the diagnostic workup of a few selected disease entities that pathologists may encounter, including newly recognized subtypes of renal cell carcinoma, pheochromocytoma, and prostate cancer, some of which harbor a distinctive chromosomal translocation, gene loss, or mutation. We illustrate applications of immunohistochemistry for differential diagnosis of needle core renal biopsies, intraductal carcinoma of the prostate, and amyloidosis and cite encouraging results from early studies using targeted gene expression panels to predict recurrence after prostate cancer surgery. At our institution, pathologists are working closely with urologic surgeons and interventional radiologists to explore the use of intraoperative frozen sections for margins and nerve sparing during robotic prostatectomy, to pioneer minimally invasive videoscopic inguinal lymphadenectomy, and to refine image-guided needle core biopsies and cryotherapy of prostate cancer as well as blue-light/fluorescence cystoscopy. This collaborative, multidisciplinary approach enhances clinical management and research, and optimizes the care of patients with urologic disorders.

Seminal Tract Amyloidosis: Synchronous Amyloidosis of the Seminal Vesicles, Deferent Ducts and Ejaculatory Ducts

Senile Seminal Vesicle Amyloidosis (SSVA) increases with age. Involvement of the whole seminal tract, i.e. the seminal vesicles, ejaculatory and deferent ducts was first reported by us in the International Symposium on Amyloidosis 1998. Since then we encountered four more cases of SSVA. In all these cases the ejaculatory and deferent ducts were also involved by amyloid. The amyloid was located mostly sub-epithelially, stained positively with Congo red, gave green birefringence under polarized light and was permanganate sensitive, slightly positive for lactoferrin immunostaining and negative for all known amyloid types. In recent years the amyloid was found to be derived from Semenogelin I, a major constituent of the seminal fluid which is present in the epithelial cells of the seminal vesicle and vas deference. This would explain the deposition of amyloid not only in the seminal vesicles but also in the deferent an ejaculatory ducts which transport the seminal fluid. In a review of the literature we found three more articles on SSVA in which the amyloid was not limited to the seminal vesicles alone. We propose to designate this type of amyloid as "Senile seminal Tract Amyloidosis" (SSTA) instead of "Senile Seminal Vesicle Amyloidosis (SSVA)".

Natural history of hematospermia in 189 Japanese men

OBJECTIVES

To prospectively investigate the natural history of hematospermia.

METHODS

This study included 189 patients with hematospermia. All the patients underwent watchful waiting without any empirical treatment.

RESULTS

The median observation period was 52 months. Hematospermia resolved spontaneously in 168 (88.9%) of the 189 patients, and the median disease duration was 1.5 months. Kaplan-Meier analysis showed that the persistence rates of hematospermia were 57.7% at 1 month, 34.2% at 3 months, 23.3% at 6 months, 12.5% at 1 year and 7.6% at 2 years. Hematospermia reoccurred in 20 (13.5%) of the 148 patients who had adequate follow up. The recurrence-free rates were 96.6% at 3 months, 89.0% at 1 year, 84.8% at 5 years and 78.2% at 10 years. Multivariate analysis showed that seminal vesicle hemorrhage and a midline cyst of the prostate were significant factors to predict the duration of hematospermia until spontaneous resolution. The nine patients with persisting hematospermia for more than 1 year were treated with transurethral endoscopic surgery (unroofing of the midline cyst in six, and transurethral resection of the ejaculatory duct in three), and hematospermia resolved postoperatively in all these patients.

CONCLUSIONS

In patients with hematospermia without inflammation, infection or malignancy, it is important to provide information on the possibility that symptoms will resolve spontaneously and to implement measures to relieve their anxiety. Detection of seminal vesicle hemorrhage and a midline cyst of the prostate is important for prediction of the duration of hematospermia.

Lesions of the Seminal Vesicles and their MRI Characteristics

Over the past few decades, MRI of the prostate has made great strides in improving cancer detection and is being embraced by more clinicians each day. This article aims to review the imaging characteristics of common and uncommon, but consequential lesions involving the seminal vesicles (SV), as seen predominantly on MRI. Many of these findings are seen incidentally during imaging of the prostate. Anatomy and embryology of the SV will be described which will help illustrate the associations of abnormalities seen. Congenital, infectious, neoplastic, and tumor mimics will be explored in detail, with discussion on clinical presentation and treatment strategies.

Hemosepermia after transrectal ultrasound-guided prostatic biopsy: A prospective study

Objectives:

Trans-rectal ultrasound (TRUS) is a safe, cost-effective, radiation-free imaging modality for evaluation of prostate. But unfortunately, hemospermia is known to be associated with TRUS–guided prostate biopsy. The aim of this study is to measure the incidence and risk factors of hemospermia in patients undergoing TRUS.

Patients and Methods:

A prospective observational study involving patients undergoing TRUS for suspected prostate cancer has been conducted at Al-Hussein and Sayed Galal Hospitals. Forty patients were included in the study.

Results:

Most men (90% = 36 patient) undergoing TRUS-guided prostatic biopsy, who were able to ejaculate, experienced hemospermia, which was associated with some degree of anxiety. The mean duration of hemospermia was 4 (±1.4) weeks. The number of ejaculations before the complete resolution of hemospermia was 6 (±5.6). None of the clinical and pathological factors was a significant predictor of the duration of hemospermia.

Conclusion:

Patients should be adequately counseled before TRUS-guided prostatic biopsy to avoid anxiety and alterations in sexual activity.

Incidental seminal vesicle amyloidosis observed in diagnostic prostate biopsies--are routine investigations for systemic amyloidosis warranted?

Seminal vesicle (SV) amyloidosis is a well-documented histological entity, but it is observed infrequently. Its incidence is on the rise, which is probably related to the increasing use of prostate biopsies to investigate patients with elevated serum prostate-specific antigen levels. Here, we report seven cases of incidental SV amyloidosis over a 3-year period and consider their relationship to the previously suggested aetiological factors. Based on our series, we conclude that incidental localized SV amyloidosis observed in diagnostic prostate biopsies does not warrant formal investigations for systemic amyloidosis.

Prospective trial comparing transrectal ultrasonography and transurethral seminal vesiculoscopy for persistent hematospermia

OBJECTIVE

To compare the diagnostic yield of transrectal ultrasonography and transurethral seminal vesiculoscopy in patients with persistent hematospermia, and to determine the advantages and disadvantages of both modalities.

METHODS

We prospectively enrolled 106 patients with persistent hematospermia of mean duration 20.5 months. All patients were evaluated by both transrectal ultrasonography and transurethral seminal vesiculoscopy after excluding definite etiological lesions beyond the reproductive duct system. The diagnostic yield and other technical parameters of both modalities were compared.

RESULTS

Final diagnoses were made in 93 patients (87.7%), with transrectal ultrasonography and transurethral seminal vesiculoscopy showing overall diagnostic yields of 45.3% and 74.5%, respectively (P < 0.001). The diagnostic yield of combining transrectal ultrasonography and transurethral seminal vesiculoscopy was significantly higher than that of each modality alone (both P < 0.001). Of the 114 findings of diagnostic value, the most frequent was calculus (47.4%, n = 54), followed by obstruction/stricture (37.7%, n = 43), cyst (8.8%, n = 10), dysplasia (3.5%, n = 4), polyp (1.8%, n = 2) and benign mass (0.9%, n = 1). Transurethral seminal vesiculoscopy showed significant superiority in detecting calculi and obstruction/stricture. Hematospermia disappeared in 95.3% (101/106) of all patients and in 97.6% (83/85) of patients receiving transurethral seminal vesiculoscopy therapy during follow up. No major adverse effects occurred during and after examination.

CONCLUSIONS

The diagnostic yield of transurethral seminal vesiculoscopy for persistent hematospermia was significantly superior to that of transrectal ultrasonography, especially in lesions diagnosed with calculi and obstruction/stricture. Combining both modalities might provide extra benefits for patients with persistent hematospermia.

The pentraxin serum amyloid P component is found in the male genital tract and attached to spermatozoa

Serum amyloid P component (SAP) belongs to the pentraxin family of proteins, members of which are characterized by radial pentameric structure and calcium-dependent ligand binding. SAP is present in all types of amyloidosis and has been shown to bind to several ligands, but the physiological function of this protein has not been fully elucidated. The present study identified and characterized SAP in human semen and immunolocalized it to the male reproductive tract. SAP was also detected in seminal plasma by immunoblotting and purification by affinity chromatography followed by mass spectrometry. According to electroimmunoassay, the concentration of SAP in semen is approximately 2 mg/L, and flow cytometry revealed SAP attached to the surface of spermatozoa. Moreover, immunohistochemistry showed positive staining of spermatozoa, subsets of epithelial cells, and the stroma of accessory male genital glands and testis. Presence of mRNA supports local production of SAP, as shown with reverse transcription polymerase chain reaction. We identified SAP in a new setting - the human male reproductive system. SAP was detected on ejaculated spermatozoa, in seminal plasma and in tissue sections from the male reproductive tract. Further functional studies are needed to explain the role of SAP in human reproduction.

Magnetic resonance imaging is accurate to detect bleeding in the seminal vesicles in patients with hemospermia

OBJECTIVE

To confirm the presence of hemorrhage in the seminal vesicles by aspiration in patients with findings suspicious for hemorrhage on magnetic resonance imaging (MRI); and to investigate the relationship between findings on MRI and the freshness of hemorrhage.

METHODS

Twenty-six patients with hemospermia who showed high-intensity signals on T1-weighted images with or without low-intensity signals on T2-weighted images, suggesting seminal vesicle hemorrhage, were analyzed. Of the 26, 15 underwent transperineal aspiration of the seminal vesicles under transrectal ultrasound guidance to confirm the bleeding.

RESULTS

Bloody fluid was aspirated from all seminal vesicles showing a pattern suggestive of bleeding on MRI. The morphologic analysis of red blood cells in the fluid indicated relatively fresh hemorrhage in the seminal vesicles showing high-intensity signals on T1-weighted images and low-intensity signals on T2-weighted images (group A), but old hemorrhage in those showing high-intensity signal on T1-weighted images as well as T2-weighted images (group B). In 3 patients of group A who did not receive aspiration, repeated MRI during the follow-up showed that the signal intensity changed from low to high on T2-weighted images. On the other hand, in 2 patients of group B who received aspiration, repeated MRI performed 12 and 7 days after aspiration showed low signal intensity on T2-weighted images.

CONCLUSIONS

Hemorrhage is really present in the seminal vesicles if high signal intensity is observed on T1-weighted images. The patterns showing low and high signal intensities on T2-weighted images suggest relatively fresh and old bleeding, respectively.

Effects of the antiestrogen fulvestrant (ICI 182,780) on gene expression of the rat efferent ductules

The efferent ductules express the highest amount of estrogen receptors ESR1 (ERalpha) and ESR2 (ERbeta) within the male reproductive tract. Treatment of rats with the antiestrogen fulvestrant (ICI 182,780) causes inhibition of fluid reabsorption in the efferent ductules, leading to seminiferous tubule atrophy and infertility. To provide a more comprehensive knowledge about the molecular targets for estrogen in the rat efferent ductules, we investigated the effects of ICI 182,780 treatment on gene expression using a microarray approach. Treatment with ICI 182,780 increased or reduced at least 2-fold the expression of 263 and 98 genes, respectively. Not surprisingly, several genes that encode ion channels and macromolecule transporters were affected. Interestingly, treatment with ICI 182,780 markedly altered the expression of genes related to extracellular matrix organization. Matrix metalloproteinase 7 (Mmp7), osteopontin (Spp1), and neuronal pentraxin 1 (Nptx1) were among the most altered genes in this category. Upregulation of Mmp7 and Spp1 and downregulation of Nptx1 were validated by Northern blot. Increase in Mmp7 expression was further confirmed by immunohistochemistry and probably accounted for the decrease in collagen content observed in the efferent ductules of ICI 182,780-treated animals. Downregulation of Nptx1 probably contributed to the extracellular matrix changes and decreased amyloid deposition in the efferent ductules of ICI 182,780-treated animals. Identification of new molecular targets for estrogen action may help elucidate the regulatory role of this hormone in the male reproductive tract.

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.

[Haemospermia due to seminal vesicle amyloidosis. Treatment by laparoscopic vesiculectomy. A case report]

Amyloidosis of the seminal vesicles is a rare cause of haemospermia. The authors report the case of a 42-year-old patient with recurrent haemospermia over a period of 2 years and abnormalities of one seminal vesicle on ultrasonography and MRI, justifying laparoscopic resection. Histological examination demonstrated localized amyloidosis, secondary to inflammation. No recurrence was observed with a follow-up of one.

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.