Transrectal ultrasound-guided transperineal and transrectal management of seminal vesicle abscesses

European Journal of Radiology 52 (2004) 329–334

Transrectal ultrasound-guided transperineal and transrectal management of seminal vesicle abscesses夽 Mutlu Sa˘glam a,∗ , Sahin ¸ U˘gurel a , Mete Kilciler b , a ˙ Mustafa Ta¸sar , Ibrahim Somuncu a , Taner Üçöz a a

Department of Radiology, Gülhane Military Medical Academy, 06018 Etlik-Ankara, Turkey Department of Urology, Gülhane Military Medical Academy, 06018 Etlik-Ankara, Turkey

b

Received 29 November 2001; received in revised form 4 February 2002; accepted 5 February 2002

Abstract Objective: The treatment of seminal vesicle abscesses (SVA) by transrectal ultrasound-guided transrectal and transperineal approaches were evaluated in this study. Materials and methods: Six SVA cases were diagnosed among 2350 patients admitted to our ultrasound unit with prostate and seminal vesicle symptoms during the last 6 years. Four out of six cases had bilateral, and two had unilateral SVA. Transperineal puncture and aspiration was done in four patients with bilateral abscesses and transrectal approach was preferred in two patients with unilateral abscesses. Results: For both approaches, the aspiration was successfully done without any complication. The mean durations of intervention were 64 and 13 min, and the durations of hospitalization were 2 and 3 days for the transperineal and transrectal approaches, respectively. Conclusion: Transrectal ultrasound examination allows simultaneous evaluation of the gland and the guidance for a needle puncture and aspiration. Furthermore, rapid pain relief, regression of other symptoms, minimally invasive technique and shorter hospitalization seem to be important features as compared with conservative and surgical treatment modalities. © 2003 Elsevier Ireland Ltd. All rights reserved. Keywords: Seminal vesicle; Abscess; Aspiration; Transrectal ultrasonography (TRUS)

1. Introduction Seminal vesicle abscess (SVA) is rarely encountered in urologic practice [1]. The first case of SVA was reported in 1978 [2]. Since that time, 26 cases have been added to the literature. SVA probably occurs more frequently than documented in the literature due to clinical ambiguity and lack of sensitive diagnostic tests [3]. Due to the anatomic location, abscesses in this area may not be palpable. With the development of transrectal ultrasound probes, SVA can now be readily recognized [4,5]. SVA may be managed using either surgical or needle drainage, or medical treatment. Transvesical, retrovesical or perineal surgery may have significant associated morbidity such as bleeding, fistulization, and contamination of neighboring tissues [4]. Long-term use of antibiotics is needed for medical treatment. In this study, 夽

doi of original article: 10.1016/S1571-4675(03)00017-8. Corresponding author. Present address: GATA Lojmanları, Serter Apt. No. 9, Basınevleri, 06120 Ankara, Turkey. Tel.: +90-312-3043071. E-mail address: [email protected] (M. Sa˘glam). ∗

we present six cases drained with needle aspiration, and discuss the advantages and the disadvantages of transrectal ultrasound-guided transperineal and transrectal drainage methods that seem to be efficient alternatives to surgical drainage of SVA.

2. Materials and methods During 1996 and 2001, 2350 patients with prostate and seminal vesicle symptoms were admitted to our ultrasound section at the GATA School of Medicine. Six cases were diagnosed as SVA by transrectal ultrasonography (TRUS). The age of the patients ranged between 18 and 47 years (median 33 years). Four out of six patients had bilateral and two had unilateral SVA. All six patients had cardiology and internal medicine consultations and signed informed consent before the intervention. We obtained approval of the institutional review board. Four patients who had bilateral SVA were started on intravenous cefoxitin, 1 g, bid, 2 days before the treatment. A

0720-048X/$ – see front matter © 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrad.2003.11.006

330

M. Sa˘glam et al. / European Journal of Radiology 52 (2004) 329–334

Table 1 Laboratory and digital rectal examination findings of six patients whose transrectal sonography revealed unilateral or bilateral SVA Case number

Age (years)

CBC

Urinalysis

Urine culture

DRE

TRUS

1

18

Leukocytosis

Hematuria, leukocyturia

E. coli

Bilateral SVA

2

26

Leukocytosis

Leukocyturia

E. coli

3

30

Leukocytosis

Leukocyturia

E. coli

4

32

Leukocytosis

Leukocyturia

E. coli

5

45

Leukocytosis

Hematuria, leukocyturia

E. coli

6

47

Leukocytosis

Leukocyturia

E. coli

Rectal discomfort, tender-swelling of prostate and seminal vesicles Rectal discomfort, tender-swelling of seminal vesicles Rectal discomfort, tender-swelling of prostate and seminal vesicles Rectal discomfort, tender-swelling of seminal vesicles Rectal discomfort, tender-swelling of seminal vesicle Rectal discomfort, tender-swelling of seminal vesicle, rectal recurrent tumor (postoperative)

Bilateral SVA Bilateral SVA Bilateral SVA Unilateral SVA Unilateral SVA

CBC, complete blood count; DRE, digital rectal examination; TRUS, transrectal ultrasonography; SVA, seminal vesicle abscess.

rectal enema was used 2 h before the intervention and 2 ml of an anesthetic gel (Instillagel, Farco-Pharma GMBH, Köln) was installed for local anesthesia before the probe is inserted through the anus. The patient was placed in the lithotomy position and TRUS was performed using a 7.5 MHz, mono-plane, linear endorectal probe (Acuson 128 XP/10, Mountain View, CA, USA) for delineating the localization of SVA for puncture and aspiration. After the sterilization of the perineal region, local perineal anesthesia was established by using 15 ml of lignocaine injection and transrectal ultrasound-guided stylet needle (Chiba 18G, 20 cm) was introduced. A 20 ml syringe was used for aspiration of the seminal vesicle contents. Complete drainage of the abscess cavity was ascertained both visually and with comparison of sonographicaly measured approximate abscess volume to drained aspirate volume. After the aspiration was completed, the needle was extruded and the area was closed with sterile dressings. The aspirate was then sent for culture. These four patients were maintained on intravenous cefoxitin, 1 g per day, postoperatively for 7 days. The two patients who had unilateral SVA were started on intravenous cefoxitin, 1 g, bid, 2 days before the intervention and the rectal stump was disinfected with antiseptic solutions for 2 days. Before the rectal probe was introduced, local anesthesia was performed with the same anesthetic gel. The patient was placed in left lateral decubitus position and 7.5 MHz, end-fired, sector probe (GE Logiq 700 MR, Mil-

waukee, WI, USA) with sterile biopsy attachment was introduced into the rectum, and the stylet needle (Chiba 18G, 20 cm) was inserted into the abscess. After the aspiration of the abscess material with a 20 ml syringe, the material was sent for culture. The two patients were then treated with intravenous cefoxitin, 1 g per day, for 10 days. No drainage catheter was used in order to prevent infectious complications. We used two different techniques and equipment; lithotomy position and mono-plane linear probe were chosen for transperineal intervention, and left lateral decubitus position and end-fired sector probe were preferred for transrectal intervention in order to ease the intervention. Five out of six patients were evaluated with TRUS, 1 month after the procedure. We preferred magnetic resonance imaging (MRI; Magnetom Vision, Siemens, Erlangen, Germany) for the patient with recurrent cancer at the rectal stump. We used T1 (TR, 640; TE, 17) and T2 (TR, 2000; TE, 80) weighted (W) spin echo (SE), enhanced-T1 W SE, and enhanced-Half-Fourier Acquisition Single-Shot Turbo Spin-Echo (HASTE) (TR, 4.4; TE, 64; FA, 150) scans.

3. Results Fever, dysuria, chills, frequency and perineal pain in all of our six patients (100%), urinary retention in three patients

Table 2 SVA of six cases as well as the preferred approach site for puncture and aspiration, abscess morphology, aspirate culture results and durations of intervention and hospitalization are summarized Case number

Seminal vesicle involvement

Abscess morphology

Approach for puncture and aspiration

Culture of aspirate

Duration of intervention (min)

Duration of hospitalization (days)

1 2 3 4 5 6

Bilateral Bilateral Bilateral Bilateral Unilateral Unilateral

Uniloculated, multiloculated Multiloculated, multiloculated Uniloculated, multiloculated Uniloculated, uniloculated Uniloculated Uniloculated

Transperineal Transperineal Transperineal Transperineal Transrectal Transrectal

E. E. E. E. E. E.

20, 44, 24, 26, 10 16

2 2 2 2 3 3

coli coli coli coli coli coli

30 45 37 30

M. Sa˘glam et al. / European Journal of Radiology 52 (2004) 329–334

331

Fig. 1. TRUS image (longitudinal-linear plane). Uniloculated cyst, with thin walls and internal echogenities, involving the left seminal vesicle (black arrows) and ejaculatory duct (black arrowheads) is seen.

(50%), and painful defecation in four patients (67%) were the symptoms encountered prior to the intervention. The findings of complete blood count, urinalysis, urine culture, digital rectal examination and TRUS are presented in Table 1. Properties of the SVA and their management results were summarized in Table 2. TRUS revealed 20–50 mm (mean 40 mm)-sized, thick-walled (3.5–5 mm; mean 4 mm), uniloculated (Fig. 1), and multiloculated (Fig. 2) SVA with internal echogenities. Four out of six patients had bilateral (67%) and two had unilateral (33%) abscesses. One patient with bilateral SVA had an accompanying involvement of unilateral ejaculatory duct. Four patients who had bilateral seminal vesicles abscesses (eight SVA totally) have been managed successfully by transperineal abscess puncture and aspiration. The duration of aspiration ranged between 20 and 30 min for uniloculated abscess (mean 25 min) and 30–45 min for multiloculated abscess (mean 39 min). The mean duration of intervention

Fig. 2. TRUS image (longitudinal-linear plane). Multiloculated thickwalled abscess of right seminal vesicle is seen with internal echogenities (white arrows).

Fig. 3. TRUS (longitudinal-linear plane). Post-treatment normal appearing right (a) and left (b) seminal vesicles are seen (black arrows).

in four patients is 64 min. All patients were found to feel sudden pain relief after the treatment. No complications such as hemorrhage, fistulization, or disseminated infection were observed either during or after the intervention. The specimen cultures in these four patients demonstrated E. coli and with the use of intravenous cefoxitin, 1 g per day, treatment for 7 days, all were discharged without any sign of infection. The duration of hospitalization was 2 days for the transperineal approach. At follow-up after 1 month, seminal vesicles were normal in size in all patients under TRUS examination and they were free from abscess signs and symptoms (Fig. 3a and b). The two patients with unilateral seminal vesicles abscess had been operated for rectum cancer 1 year ago and had rectal stumps. One of the patients also had tumor recurrence in addition to SVA (Fig. 4a and b). Both patients had undergone abscess puncture and aspiration by transrectal ultrasound-guided transrectal approach. The intervention took about 10–16 min (mean 13 min) (Fig. 5a–d). After the treatment, both cases felt sudden pain relief and comfort and the aspirate were sent for culture both of which ultimately demonstrated E. coli. No complication was noted during and after the treatment. The patients were maintained on intravenous cefoxitin, 1 g per day, for 10 days after the intervention and discharged with no sign of infection. The duration

332

M. Sa˘glam et al. / European Journal of Radiology 52 (2004) 329–334

Fig. 4. Pelvic MRI. (a) T1-weighted SE post-GdDTPA sagittal section reveals a left SVA with thick enhancing walls and hypointense center (thick white arrows). Besides, a recurrent rectal tumor (white arrowheads) involving the bladder posterior wall and base (thin white arrows) as well as the rectal stump were evident in T1-weighted sequence as an enhancing thickening. (b) T2-weighted SE sagittal section shows hyperintense uniloculated abscess (white arrows) and slightly hyperintense heterogeneous mass in T2-weighted sequences (white arrowheads).

of hospitalization was 3 days for the transrectal approach. A month after the intervention, follow-up pelvic MRI in the patient with recurrent tumor (Fig. 6) and follow-up TRUS examination in the other patient were clear from SVA cavity. The patient with recurrent rectum cancer was also given radiotherapy 4 weeks after the drainage and due to the tumor recurrence radical perineal resection was performed 4 weeks after the radiotherapy.

4. Discussion The etiology of a SVA is unclear. Several predisposing factors are infected urine, diabetes, indwelling Foley catheter, urological instrumentation and anatomical abnormalities [4]. Although, our cases with unilateral abscesses

had been operated for rectum cancer approximately 1 year ago, bilateral SVA cases did not have any predisposing factor. The symptoms of SVA consist of fever, chills, and irritative urinary symptoms of urgency, frequency, dysuria, incontinence, hematuria and perineal pain. The anatomical position of the seminal vesicles (neighboring to the prostate, bladder base, ureters, rectum and peritoneum) may account for the wide variety of presenting symptoms seen with this condition [1,3,4,6–8]. Clinical examination results of our patients were consistent with the diagnosis of SVA. The diagnosis of a SVA may be difficult and several diagnostic modalities, including TRUS, computerized tomography (CT) and MRI, may be necessary [1,9–11]. We agree with Lee et al. [7] and other authors [6,7,10,11] that TRUS is probably superior to CT and MRI in localizing a SVA. The advantages of TRUS over CT and MRI in the diagnosis of a SVA are the real time image that can show the extent of the abscess cavity, the image capability into the longitudinal and axial planes, and the ability to perform a ultrasound-guided puncture of the lesion for diagnostic and therapeutic purposes. We preferred TRUS as a diagnostic, therapeutic and follow-up tool, owing to its advantages for close imaging of abscesses. Pelvic MRI was additionally utilized to show the extensions of the tumor in only the case with recurrent cancer. MRI was also the single method in this patient for the control of post-drainage seminal vesicles. Treatment modalities for SVA are limited. Antibiotics are always prescribed for needle or surgical drainage procedures [4]. The most invasive management of SVA is surgical incision and drainage [3]. In contrast to other abscess cavities, a SVA has an ejaculatory duct system that opens into the prostatic urethra. As long as this ejaculatory duct remains open, the abscess can be drained into the prostatic urethra. Conservative measures may thus help decrease inflammation and further open up a partially obstructed ejaculatory duct system [1]. One review and some other studies report totally conservative treatment in 8 of 26 patients (31%), surgical drainage in 10 of 26 patients (38%), transurethral, transvesical or retropubic percutaneous drainage in 7 of 26 patients (27%), and transrectal drainage in 1 of 26 patients (4%) [1,12–16]. SVA, if they do so, usually resolve with conservative treatment between 24 and 72 days [1]. In all of our patients’ transrectal ultrasound-guided transperineal and transrectal SVA puncture and aspiration were performed for quick relief of discomfort and pain that were responding to conservative management quite slowly. Another reason to prefer transrectal ultrasound-guided transrectal or transperineal puncture and aspiration to surgical approach or to other drainage approaches (such as transurethral, transvesical and retropubic) was their low morbidity. Before introducing the ultrasound probe, anesthetic gel application is essential to relieve pain. Transperineal approach allows multiple punctures and aspiration without any complication and avoiding rectal contamination

M. Sa˘glam et al. / European Journal of Radiology 52 (2004) 329–334

333

Fig. 5. TRUS (transverse-sector plane). (a) Iso- to hyperechoic recurrent tumor (white arrows) in the rectal stump and thick-walled abscess with internal echogenities (black arrowheads) in the left seminal vesicle. (b and c) Abscess and ultrasound-guided tract with needle tip is seen in the same plane. (d) Completely drained left seminal vesicle is seen.

Fig. 6. Pelvic MRI. Post-GdDTPA sagittal section (HASTE) shows normally appearing prostate and left seminal vesicle. Besides, non-enhancing thickening of the posterior bladder wall (black arrows) as well as the recurrent tumor (white arrowheads) anterior to air–fluid level at the rectal stump are evident.

risk. Therefore, it should be preferred in bilateral or multiloculated abscesses, as we did in our cases. Transperineal approach has the disadvantages of necessitating a good local anesthesia of the perineal penetration site and being more irritating compared with transrectal puncture and aspiration. Further, it is twice more time consuming. We preferred transrectal puncture and aspiration approach in cases with unilocular or unilateral SVA where single penetration for aspiration will be enough. Rectal contamination risk is therefore low, because of either lower number of penetrations or the presence of a rectal stump that can be eligible for relative disinfection. However, transrectal puncture and aspiration of seminal vesicles should be avoided in patients with normal rectum including those with bilateral SVA, because of high risk of peritoneal contamination. In fact, the main reason we preferred transrectal drainage to transperineal one in our two cases was not the unilaterality of their abscesses, but the presence of a rectal stump, which is eligible for disinfection by continual disinfecting washing enemas. In this study, we succeeded to treat SVA in 7–10 days and follow-up TRUS and pelvic MRI, 1 month after the

334

M. Sa˘glam et al. / European Journal of Radiology 52 (2004) 329–334

treatment indicated complete resolution. Six months after the intervention, there was no recurrence. Our findings suggest that it may be possible to manage SVA with both transrectal and transperineal approaches without any complications. Considering the high risk of rectal contamination in the transrectal intervention, IV antibiotherapy was continued for 10 days. In summary, we suggest TRUS as the imaging modality of choice during drainage of SVA, in which, simultaneous drainage can be done for relieving the severe perineal pain. Transrectal ultrasound-guided perineal approach in patients with anatomically intact rectum, and transrectal approach in patients with rectal stump may be preferred. Successful treatment results may be obtained quite rapidly without any complications.

References [1] Pandey P, Peters J, Shingleton B. Seminal vesicle abscess: a case report and review of literature. Scand J Nephrol 1995;29:521–4. [2] Rajfer J, Eggleston JC, Sanders RC, Walsh PC. Fever and prostatic mass in a young man. J Urol 1978;119:555–8. [3] Kennelly MJ, Oesterling JE. Conservative management of a seminal vesicle abscess. J Urol 1989;141:1432–3. [4] Fox CW, Vaccaro JA, Kiesling VJ, Belville WD. Seminal vesicle abscess: the use of computerized coaxial tomography for diagnosis and therapy. J Urol 1988;139:384–5.

[5] Rifkin MD, Kurtz AB. Ultrasound of the prostate. In: Sanders RC, Hill M, editors. Ultrasound annual. New York: Raven Press; 1983. p. 95–132. [6] Kore RN, McLoughlin J, Kabala J, Sibley GNA. Seminal vesicle abscess. Br J Urol 1994;73:331–2. [7] Lee SB, Lee F, Solomon MH, Kumasaka GH, Straub WH, McLeary RD. Seminal vesicle abscess: diagnosis by transrectal ultrasound. J Clin Ultrasound 1986;14:546–9. [8] Zagoria RJ, Papanicolaou N, Pfister RC, Stafford SA, Young II HH. Seminal vesicle abscess after vasectomy: evaluation by transrectal sonography and CT. Am J Roentgenol 1987;149:137–8. [9] Frye K, Loughlin K. Successful transurethral drainage of bilateral seminal vesicle abscesses. J Urol 1988;139:1323–4. ˙ TRUS, CT [10] Sa˘glam M, Ta¸sar M, Bulakba¸sı N, Tayfun C, Somuncu I. and MRI findings of hydatid disease of seminal vesicles. Eur Radiol 1988;8:993–5. [11] Doringer E, Chandra I, Sarica K, Frick J, Schmoller H. MRI of bilateral seminal vesicle abscesses. Eur J Radiol 1991;12(1): 60–2. [12] Hanus T. Seminal vesical abscess and ipsilateral agenesis of the kidney. Rozhl Chir 1997;76(10):528–9. [13] Smith ER, Trerotola SO, Foster RS. Percutaneous transvesical drainage of a seminal vesicle abscess. J Vasc Interv Radiol 1998;9(5): 743–5. [14] Kerbl K, Mitterhuber J, Pauer W, Zisch R. Transrectal puncture and drainage of seminal vesicle abscess. Technol Urol 1998;4(3):169– 71. [15] Eastham JA, Spires KS, Abreo F, Johnson JB, Venable DD. Seminal vesicle abscess due to tuberculosis: role of tissue culture in making the diagnosis. South Med J 1999;2(3):328–9. [16] Nielsen RG, Frimodt-Moller PC. Transurethral treatment of seminal vesicle abscess. Ugeskr Laeger 2000;162(33):4404–5.