- Email: [email protected]
Massive Hemospermia: A New Etiology and Simplified Treatment
0022-5347/82/1281-0151$02.00/0 Vol. 128,
THE JOURNAL OF UROLOGY
Printed in
Copyright© 1982 by The Williams & Wilkins Co.
MASSIVE HEMOSPERMIA: A NEW ETIOLOGY AND SIMPLIFIED TREATMENT EUGENE V. CATTOLICA From the Departments of Urology, Kaiser-Permanente Medical Center, Oakland and University of California Medical Center, San Francisco, California
ABSTRACT
Hemospermia is a common urologic symptom that is usually benign and self-limited, and requires no clinical investigation. Massive hemospermia causing hematuria, with clot formation and occasional urinary retention, occurs in a subset of patients. Three patients are reported in whom cystourethroscopy demonstrated nonvaricose abnormal posterior urethral vessels. Treatment consisted of fulguration of the vessels. One patient was cured, 1 had no symptoms for 3 years and 1 improved slightly. Endoscopically, this is a safe simple outpatient surgical procedure that is recommended for massive hemospermia due to abnormal posterior urethral vessels. Hemospermia is a common urologic symptom. Although it may be caused by a variety of pathologic entities usually no clear etiology is discovered. Because hemospermia is intermittent, benign and self-limited, no clinical investigation is warranted. Reassurance, which may be combined with short-term diethylstilbestrol therapy, usually allays the acute anxiety that often accompanies this symptom. A few cases are persistent and require more thorough clinical investigation. 1' 2 Massive hemospermia appears to affect a subset of patients whose sexual life-style is altered by the degree of hemospermia. In the first of the 3 patients reported on herein, serendipitous discovery of abnormal posterior urethral vessels that were not varicose led to early cystourethroscopy in the next 2 cases of massive hemospermia. Fulguration of these vessels is warranted. CASE REPORTS
Case 1. A 31-year-old man described recurrent hemospermia with post-coital gross hematuria, clot formation and urinary retention, sometimes requiring urethral catheterization. The disability was so predictable and severe that he engaged in sexual intercourse only on Friday night or Saturday morning so that he could devote the remainder of the weekend to allowing the clots to be passed and the hematuria to resolve. In the event of acute urinary retention the patient was catheterized after which the condition cleared by the time he returned to work on Monday morning. During a urologic consultation 6 years previously, physical examination, excretory urography (IVP) and cystourethroscopy were normal. The diagnosis was seminal vesiculitis and he was told that a blood vessel might rupture with coitus. The patient was advised that seminal vesiculectomy or transurethral prostatectomy could cure the condition but that fertility would be compromised. Infrequent coitus was recommended. At our institution cystourethroscopy, bilateral seminal vesiculograms and a pelvic angiogram were normal. The patient was treated empirically with diethylstilbestrol, which was unsuccessful. Repeated cystoscopy with seminal vesicle and prostate massage under vision showed normal expressate and no blood. After informed consent was obtained, transvesical, bilateral seminal vesiculectomy and excision of the ampullae of the vas deferens bilaterally were performed. Postoperatively, massive hemospermia continued upon sexual arousal even without intercourse. At repeat cystourethroscopy 7 weeks postoperaAccepted for publication October 30, 1981. Read at annual meeting of Western Section, American Urological Association, Salt Lake City, Utah, June 28-July 2, 1981. 151
tively erection occurred. Immediately after detumescence urethroscopy revealed engorged vessels extending alongside the verumontanum to the membranous urethra. Fulguration of these vessels 2 months after transvesical seminal vesiculectomy cured the massive hemospermia. Case 2. A 32-year-old man who noticed blood in the condom after coitus had total gross painless hematuria with clot formation and marked difficulty voiding that nearly caused urinary retention. He had had 2 similar episodes previously. A physical examination was normal and interval microscopic urinary sediment showed occasional red blood cells per high power field. An IVP demonstrated a normal horseshoe kidney. Cystourethroscopy revealed prominent veins in the area of the posterior urethra adjacent to the verumontanum. The patient returned 8 months later with the same symptoms. He was treated empirically with diethylstilbestrol but symptoms recurred 11 months later. These episodes were each followed by abstinence for several weeks because of fear of complete urinary retention. The posterior urethral veins were electrofulgurated. The hemospermia recurred 3 years later, at which time another vein was discovered and fulgurated. DISCUSSION
Hemospermia has been described in patients between 16 and 74 years old, indicating only that there is no predilection for age but only for sexually active men. Leary and Aguilo reported that 85 per cent of their 150 patients had episodes of hemospermia separated by weeks to years,2 and Yu and associates reported a 55 per cent recurrence rate. 2 Hemospermia is usually unaccompanied by other symptoms, although dysuria occurred in 21.5 per cent of the patients reported on by Yu and associates. 2 Rectal examination is usually normal as is urinalysis. Urologic investigation may lead to the diagnosis of diverse pathologic conditions that may be neither etiologic nor serious. 1 Intraductal adenocarcinoma of the prostate presented with hemospermia in l case,3 although in large series the majority of patients have no apparent cause for the symptom. Since benign or no disease is discovered by thorough urologic investigation, it seems reasonable that no studies be pursued in routine cases of hemospermia. In the large series there has been no mention of the massive hemospermia and hematuria reported herein, although Yu and associates reported that 12.3 per cent of their patients had hematuria. Pelouse believed that hemospermia was not often the result of disease of the seminal vesicle but was due to rupture of engorged veins in or just under the epithelium of the
152
CATTOLICA
posterior urethra. 4 Ross mentioned that "granulations in the vicinity of the verumontanum" may be seen on posterior urethroscopy.5 Prostatic varicositis, noted in 8 of 174 patients in the series of Leary and Aguilo, 1 represented a fixed dilated vein. In the cases reported herein the vessels coarsing along the side of the verumontanum were not impressive when the penis was flaccid but could be interpreted as granulations. The discovery in case 1 that these were extremely engorged as detumescence occurred invited the postulation that perhaps their rupture could be the cause of the massive hemospermia. Fulguration of these vessels in the first patient, who had no seminal vesicles, with complete cessation of massive hemospermia and hematuria appears to substantiate that hypothesis. The second patient was vastly improved by discovery and fulguration of these abnormal vessels. In a third patient treated by fulguration the response was less dramatic.
Because of this experience, it is recommended that cases of massive hemospermia be investigated cystoscopically to look specifically for vessels alongside the verumontanum. Their discovery and fulguration may be the simple, safe solution to the treatment of a subset of patients whose symptom significantly interferes with a normal life-style. REFERENCES 1. Leary, F. J. and Aguilo, J. J .: Clinical significance of hematospermia.
Mayo Clin. Proc., 49: 815, 1974. 2. Yu, H. H. Y., Wong, K. K., Lim, T. K. and Leong, C. H.: Clinical study of hemospermia. Urology, 10: 562, 1977. 3. Stein, A. J., Prioleau, P. G. and Catalana, W. J.: Adenomatous polyps of the prostatic urethra: a cause of hematospermia. J. Urol., 124: 298, 1980. 4. Pelouse, P. S.: Office Urology. Cited by Ross. 5 5. Ross, J.C.: Haemospermia. Practitioner, 203: 59, 1969.
THE JOURNAL OF UROLOGY
Printed in
Copyright© 1982 by The Williams & Wilkins Co.
MASSIVE HEMOSPERMIA: A NEW ETIOLOGY AND SIMPLIFIED TREATMENT EUGENE V. CATTOLICA From the Departments of Urology, Kaiser-Permanente Medical Center, Oakland and University of California Medical Center, San Francisco, California
ABSTRACT
Hemospermia is a common urologic symptom that is usually benign and self-limited, and requires no clinical investigation. Massive hemospermia causing hematuria, with clot formation and occasional urinary retention, occurs in a subset of patients. Three patients are reported in whom cystourethroscopy demonstrated nonvaricose abnormal posterior urethral vessels. Treatment consisted of fulguration of the vessels. One patient was cured, 1 had no symptoms for 3 years and 1 improved slightly. Endoscopically, this is a safe simple outpatient surgical procedure that is recommended for massive hemospermia due to abnormal posterior urethral vessels. Hemospermia is a common urologic symptom. Although it may be caused by a variety of pathologic entities usually no clear etiology is discovered. Because hemospermia is intermittent, benign and self-limited, no clinical investigation is warranted. Reassurance, which may be combined with short-term diethylstilbestrol therapy, usually allays the acute anxiety that often accompanies this symptom. A few cases are persistent and require more thorough clinical investigation. 1' 2 Massive hemospermia appears to affect a subset of patients whose sexual life-style is altered by the degree of hemospermia. In the first of the 3 patients reported on herein, serendipitous discovery of abnormal posterior urethral vessels that were not varicose led to early cystourethroscopy in the next 2 cases of massive hemospermia. Fulguration of these vessels is warranted. CASE REPORTS
Case 1. A 31-year-old man described recurrent hemospermia with post-coital gross hematuria, clot formation and urinary retention, sometimes requiring urethral catheterization. The disability was so predictable and severe that he engaged in sexual intercourse only on Friday night or Saturday morning so that he could devote the remainder of the weekend to allowing the clots to be passed and the hematuria to resolve. In the event of acute urinary retention the patient was catheterized after which the condition cleared by the time he returned to work on Monday morning. During a urologic consultation 6 years previously, physical examination, excretory urography (IVP) and cystourethroscopy were normal. The diagnosis was seminal vesiculitis and he was told that a blood vessel might rupture with coitus. The patient was advised that seminal vesiculectomy or transurethral prostatectomy could cure the condition but that fertility would be compromised. Infrequent coitus was recommended. At our institution cystourethroscopy, bilateral seminal vesiculograms and a pelvic angiogram were normal. The patient was treated empirically with diethylstilbestrol, which was unsuccessful. Repeated cystoscopy with seminal vesicle and prostate massage under vision showed normal expressate and no blood. After informed consent was obtained, transvesical, bilateral seminal vesiculectomy and excision of the ampullae of the vas deferens bilaterally were performed. Postoperatively, massive hemospermia continued upon sexual arousal even without intercourse. At repeat cystourethroscopy 7 weeks postoperaAccepted for publication October 30, 1981. Read at annual meeting of Western Section, American Urological Association, Salt Lake City, Utah, June 28-July 2, 1981. 151
tively erection occurred. Immediately after detumescence urethroscopy revealed engorged vessels extending alongside the verumontanum to the membranous urethra. Fulguration of these vessels 2 months after transvesical seminal vesiculectomy cured the massive hemospermia. Case 2. A 32-year-old man who noticed blood in the condom after coitus had total gross painless hematuria with clot formation and marked difficulty voiding that nearly caused urinary retention. He had had 2 similar episodes previously. A physical examination was normal and interval microscopic urinary sediment showed occasional red blood cells per high power field. An IVP demonstrated a normal horseshoe kidney. Cystourethroscopy revealed prominent veins in the area of the posterior urethra adjacent to the verumontanum. The patient returned 8 months later with the same symptoms. He was treated empirically with diethylstilbestrol but symptoms recurred 11 months later. These episodes were each followed by abstinence for several weeks because of fear of complete urinary retention. The posterior urethral veins were electrofulgurated. The hemospermia recurred 3 years later, at which time another vein was discovered and fulgurated. DISCUSSION
Hemospermia has been described in patients between 16 and 74 years old, indicating only that there is no predilection for age but only for sexually active men. Leary and Aguilo reported that 85 per cent of their 150 patients had episodes of hemospermia separated by weeks to years,2 and Yu and associates reported a 55 per cent recurrence rate. 2 Hemospermia is usually unaccompanied by other symptoms, although dysuria occurred in 21.5 per cent of the patients reported on by Yu and associates. 2 Rectal examination is usually normal as is urinalysis. Urologic investigation may lead to the diagnosis of diverse pathologic conditions that may be neither etiologic nor serious. 1 Intraductal adenocarcinoma of the prostate presented with hemospermia in l case,3 although in large series the majority of patients have no apparent cause for the symptom. Since benign or no disease is discovered by thorough urologic investigation, it seems reasonable that no studies be pursued in routine cases of hemospermia. In the large series there has been no mention of the massive hemospermia and hematuria reported herein, although Yu and associates reported that 12.3 per cent of their patients had hematuria. Pelouse believed that hemospermia was not often the result of disease of the seminal vesicle but was due to rupture of engorged veins in or just under the epithelium of the
152
CATTOLICA
posterior urethra. 4 Ross mentioned that "granulations in the vicinity of the verumontanum" may be seen on posterior urethroscopy.5 Prostatic varicositis, noted in 8 of 174 patients in the series of Leary and Aguilo, 1 represented a fixed dilated vein. In the cases reported herein the vessels coarsing along the side of the verumontanum were not impressive when the penis was flaccid but could be interpreted as granulations. The discovery in case 1 that these were extremely engorged as detumescence occurred invited the postulation that perhaps their rupture could be the cause of the massive hemospermia. Fulguration of these vessels in the first patient, who had no seminal vesicles, with complete cessation of massive hemospermia and hematuria appears to substantiate that hypothesis. The second patient was vastly improved by discovery and fulguration of these abnormal vessels. In a third patient treated by fulguration the response was less dramatic.
Because of this experience, it is recommended that cases of massive hemospermia be investigated cystoscopically to look specifically for vessels alongside the verumontanum. Their discovery and fulguration may be the simple, safe solution to the treatment of a subset of patients whose symptom significantly interferes with a normal life-style. REFERENCES 1. Leary, F. J. and Aguilo, J. J .: Clinical significance of hematospermia.
Mayo Clin. Proc., 49: 815, 1974. 2. Yu, H. H. Y., Wong, K. K., Lim, T. K. and Leong, C. H.: Clinical study of hemospermia. Urology, 10: 562, 1977. 3. Stein, A. J., Prioleau, P. G. and Catalana, W. J.: Adenomatous polyps of the prostatic urethra: a cause of hematospermia. J. Urol., 124: 298, 1980. 4. Pelouse, P. S.: Office Urology. Cited by Ross. 5 5. Ross, J.C.: Haemospermia. Practitioner, 203: 59, 1969.