Male Sexual Dysfunction Hyperuricemia: A Possible Cause of Hemospermia Adel Kurkar, Ahmad A. Elderwy, Sara M. Awad, Sherief Abulsorour, Hassan A. Aboul-Ella, and Ahmed Altaher OBJECTIVE PATIENTS AND METHODS
RESULTS
CONCLUSION
To report our experience with hemospermia and its relation to hyperuricemia. Between July 2005 and July 2012, 143 patients with hemospermia presented to the outpatient clinic in our hospital. History, examination, workup, treatment outcomes, and long-term followup were reported in a prospective database. Patients were followed up monthly by semen examination till disappearance of hemospermia, then every 3 months for 1 year. We identified 43 patients, who had 4-12 hemospermia attacks for 2-10 months before presentation with no identifiable cause for hemospermia. Of them, 22 had hyperuricemia. The association between hemospermia and hyperuricemia was examined by comparing such 22 hyperuricemic hemospermic patients with the other 21 idiopathic hemospermic patients. The commonest 5 findings identified as possible causes of hemospermia were bilharziasis (21.6%), hyperuricemia (15.4%), idiopathic (14.7%), tuberculosis (8.4%), and chronic prostatitis (8.4%). Hyperuricemic hemospermic patients were significantly of younger age (median of 31.5 vs 45 years), complaining of more painful ejaculation (68.2% vs 9.5%), and had higher serum uric acid (median, 9.3 vs 4.5 mg/dL) compared with those of idiopathic hemospermia. Hemospermia disappeared completely in all patients of the hyperuricemia group vs only 25% of the idiopathic group (P 7 mg/dL in adults.12 Gout is a rheumatic disease characterized by deposition of monosodium urate monohydrate microcrystals or uric acid mainly in joints.13 Uric acid has been suggested to play a role in different disorders such as obesity, metabolic syndrome, hypertension, coronary artery disease, and renal disease.14 The prevalence of hyperuricemia is variable worldwide, ranging from 35.2% of men in Seychelles15 to 8% of men in Saudi Arabia.16 However, the prevalence of hyperuricemia in our country has not been studied on epidemiologic basis. A link of uric acid to prostatic inflammation has been suggested in previous studies, introducing a role of high urate concentration in the etiology of nonbacterial prostatitis.17-19 Our aim is to investigate the possible causes of hemospermia and their frequency in our group of patients, as well as to detect the contribution of hyperuricemia as a new possible cause of hemospermia. http://dx.doi.org/10.1016/j.urology.2014.05.018 0090-4295/14
609
Table 1. Investigations of hemospermia in our patient population
Table 2. Possible detected causes of hemospermia in the 143 patients included in the study
Initial investigations (for all patients) Semen analysis and semen culture for specific and nonspecific infections Urinalysis and urine culture for specific and nonspecific infections Examination and culture of EPS Bleeding profile, complete blood count, liver function tests Serum uric acid Abdominal ultrasonography Plain x-ray of the urinary tract Extended evaluation (for those with recurrent hemospermia/aged >40 years) Serum PSA level TRUS with or without biopsy Pelvic CT/MRI Urethrocystoscopy
Cause
CT, computed tomography; EPS, expressed prostatic secretion; MRI, magnetic resonance imaging; PSA, prostate-specific antigen; TRUS, transrectal ultrasonography.
PATIENTS AND METHODS This is a prospective observational study that was conducted in outpatient clinics of our hospital during the period from July 2005 to July 2012. A total of 143 patients complaining of hemospermia of at least 2-month duration were included. Age range was 20-62 years (median 38). All the patients have undergone a thorough clinical history, as well as general and genitourinary examination. Semen analysis was initially done to confirm the diagnosis. Investigations were directed according to history and clinical findings ranging from simple investigations to invasive ones (Table 1). Patients were followed up monthly by semen examination till disappearance of hemospermia then every 3 months for 1 year. All findings were reported in a prospective database. Of the study population; 43 of 143 patients (30.1%) had no identifiable cause of hemospermia. Among those, 22 patients (15.4%) had a common finding of hyperuricemia and the other 21 patients were categorized as idiopathic hemospermia. For confirmation of our postulation; clinical, laboratory, imaging data of both groups as well as their therapeutic outcome were compared. A therapeutic trial was planned to the hyperuricemic patients. This was in the form of reassurance, dietary restriction of purine rich food, abundant water intake, and allopurinol 300-mg tablets given twice daily for 8 weeks followed by a maintenance dose of 1 tablet daily thereafter. For idiopathic hemospermia, reassurance was done together with the use of an antifibrinolytic drug (finasteride 5 mg once daily for 3 months and then on demand during any recurrence of hemospermic episode). Statistical analysis was performed using intercooled Stata, version 9.2. A univariate analysis was done to compare the 2 treatment groups. Analysis included the chi square test or Fisher exact test for comparison of the categorical data and the MannWhitney U test (values expressed as median, interquartile range) to compare the noncategorical data.
RESULTS The possible causes of hemospermia as reported on individual basis are shown in Table 2. 610
%
Inflammatory and infections Bilharziasis Chronic prostatitis Tuberculosis Chronic epididymitis Systemic factors Hypertension Anticoagulants/bleeding tendency Ductal obstruction/tumors/vascular abnormalities Ejaculatory duct cysts Prostate cancer Ejaculatory duct stones Posterior urethral vessels Excessive masturbation Hyperuricemia Idiopathic
21.6 8.4 8.4 5.6 4.9 4.9 3.5 3.5 2.8 2.8 3.5 15.4 14.7
The characteristics at presentation of hyperuricemic and idiopathic hemospermia were summarized in Table 3. Hyperuricemia patients were significantly of younger age, complaining of more painful ejaculation and had higher serum uric acid compared with those of idiopathic hemospermia. Urate crystals were seen in semen or expressed prostatic secretion (EPS) in the hyperuricemia group only (7 of 22 patients [31.8%]). Urine, EPS, and semen cultures (both specific and nonspecific) showed absence of infection in all patients. Plain x-ray of the urinary tract and abdominal ultrasonography were normal in all patients. In either group, prostate-specific antigen level measurement was done for patients aged >40 years, including 8 of 22 (36.4%) of the hyperuricemia group and 15 of 21 (71.4%) of the idiopathic group, with normal values (
RESULTS
CONCLUSION
To report our experience with hemospermia and its relation to hyperuricemia. Between July 2005 and July 2012, 143 patients with hemospermia presented to the outpatient clinic in our hospital. History, examination, workup, treatment outcomes, and long-term followup were reported in a prospective database. Patients were followed up monthly by semen examination till disappearance of hemospermia, then every 3 months for 1 year. We identified 43 patients, who had 4-12 hemospermia attacks for 2-10 months before presentation with no identifiable cause for hemospermia. Of them, 22 had hyperuricemia. The association between hemospermia and hyperuricemia was examined by comparing such 22 hyperuricemic hemospermic patients with the other 21 idiopathic hemospermic patients. The commonest 5 findings identified as possible causes of hemospermia were bilharziasis (21.6%), hyperuricemia (15.4%), idiopathic (14.7%), tuberculosis (8.4%), and chronic prostatitis (8.4%). Hyperuricemic hemospermic patients were significantly of younger age (median of 31.5 vs 45 years), complaining of more painful ejaculation (68.2% vs 9.5%), and had higher serum uric acid (median, 9.3 vs 4.5 mg/dL) compared with those of idiopathic hemospermia. Hemospermia disappeared completely in all patients of the hyperuricemia group vs only 25% of the idiopathic group (P 7 mg/dL in adults.12 Gout is a rheumatic disease characterized by deposition of monosodium urate monohydrate microcrystals or uric acid mainly in joints.13 Uric acid has been suggested to play a role in different disorders such as obesity, metabolic syndrome, hypertension, coronary artery disease, and renal disease.14 The prevalence of hyperuricemia is variable worldwide, ranging from 35.2% of men in Seychelles15 to 8% of men in Saudi Arabia.16 However, the prevalence of hyperuricemia in our country has not been studied on epidemiologic basis. A link of uric acid to prostatic inflammation has been suggested in previous studies, introducing a role of high urate concentration in the etiology of nonbacterial prostatitis.17-19 Our aim is to investigate the possible causes of hemospermia and their frequency in our group of patients, as well as to detect the contribution of hyperuricemia as a new possible cause of hemospermia. http://dx.doi.org/10.1016/j.urology.2014.05.018 0090-4295/14
609
Table 1. Investigations of hemospermia in our patient population
Table 2. Possible detected causes of hemospermia in the 143 patients included in the study
Initial investigations (for all patients) Semen analysis and semen culture for specific and nonspecific infections Urinalysis and urine culture for specific and nonspecific infections Examination and culture of EPS Bleeding profile, complete blood count, liver function tests Serum uric acid Abdominal ultrasonography Plain x-ray of the urinary tract Extended evaluation (for those with recurrent hemospermia/aged >40 years) Serum PSA level TRUS with or without biopsy Pelvic CT/MRI Urethrocystoscopy
Cause
CT, computed tomography; EPS, expressed prostatic secretion; MRI, magnetic resonance imaging; PSA, prostate-specific antigen; TRUS, transrectal ultrasonography.
PATIENTS AND METHODS This is a prospective observational study that was conducted in outpatient clinics of our hospital during the period from July 2005 to July 2012. A total of 143 patients complaining of hemospermia of at least 2-month duration were included. Age range was 20-62 years (median 38). All the patients have undergone a thorough clinical history, as well as general and genitourinary examination. Semen analysis was initially done to confirm the diagnosis. Investigations were directed according to history and clinical findings ranging from simple investigations to invasive ones (Table 1). Patients were followed up monthly by semen examination till disappearance of hemospermia then every 3 months for 1 year. All findings were reported in a prospective database. Of the study population; 43 of 143 patients (30.1%) had no identifiable cause of hemospermia. Among those, 22 patients (15.4%) had a common finding of hyperuricemia and the other 21 patients were categorized as idiopathic hemospermia. For confirmation of our postulation; clinical, laboratory, imaging data of both groups as well as their therapeutic outcome were compared. A therapeutic trial was planned to the hyperuricemic patients. This was in the form of reassurance, dietary restriction of purine rich food, abundant water intake, and allopurinol 300-mg tablets given twice daily for 8 weeks followed by a maintenance dose of 1 tablet daily thereafter. For idiopathic hemospermia, reassurance was done together with the use of an antifibrinolytic drug (finasteride 5 mg once daily for 3 months and then on demand during any recurrence of hemospermic episode). Statistical analysis was performed using intercooled Stata, version 9.2. A univariate analysis was done to compare the 2 treatment groups. Analysis included the chi square test or Fisher exact test for comparison of the categorical data and the MannWhitney U test (values expressed as median, interquartile range) to compare the noncategorical data.
RESULTS The possible causes of hemospermia as reported on individual basis are shown in Table 2. 610
%
Inflammatory and infections Bilharziasis Chronic prostatitis Tuberculosis Chronic epididymitis Systemic factors Hypertension Anticoagulants/bleeding tendency Ductal obstruction/tumors/vascular abnormalities Ejaculatory duct cysts Prostate cancer Ejaculatory duct stones Posterior urethral vessels Excessive masturbation Hyperuricemia Idiopathic
21.6 8.4 8.4 5.6 4.9 4.9 3.5 3.5 2.8 2.8 3.5 15.4 14.7
The characteristics at presentation of hyperuricemic and idiopathic hemospermia were summarized in Table 3. Hyperuricemia patients were significantly of younger age, complaining of more painful ejaculation and had higher serum uric acid compared with those of idiopathic hemospermia. Urate crystals were seen in semen or expressed prostatic secretion (EPS) in the hyperuricemia group only (7 of 22 patients [31.8%]). Urine, EPS, and semen cultures (both specific and nonspecific) showed absence of infection in all patients. Plain x-ray of the urinary tract and abdominal ultrasonography were normal in all patients. In either group, prostate-specific antigen level measurement was done for patients aged >40 years, including 8 of 22 (36.4%) of the hyperuricemia group and 15 of 21 (71.4%) of the idiopathic group, with normal values (
