European Journal of Radiology, 12 (1991) 60-62 Elsevier
60
EURRAD
00128
MRI of bilateral seminal vesicle abscesses E. Doringer ‘, I. Chandra2,
K. Sarica2, J. Frick2 and Hj. Schmoller
*
‘Department of Radiology and 2Department of Urology, Salzburg General Hospital, Salzburg, Austria (Received
Key words: Magnetic resonance
12 September
imaging, seminal vesicle; Intervention
Introduction Seminal vesicle abscess is a very rare pathological entity [l-7]. Because of its non-specific clinical symptoms, clinical diagnosis is often ambiguous, and several imaging modalities, including ultrasound, computed tomography (CT) and MRI may be necessary
[2,‘4Vl. Case report A 32-year-old white male presented with perineal and inguinal pain, associated with fever and chills. Past medical history was significant for insulin-dependent diabetes mellitus, and a prior left inguinal herniorrhaphy at the age of 25. Pertinent abnormal laboratory values included an elevated erythrocyte sedimentation rate, a WBC of 30000 with a left-sided shift, and a urineanalysis demonstrating leucocyturia (> 100 WBC/ HPC). A general surgery consultation was obtained, and the presumptive diagnosis of an incarcerated, recurrent left inguinal hernia was made. During inguinal exploration the intraoperative findings were normal. The patient’s symptoms persisted postoperatively. A transabdominal sonogram revealed an extrinsic mass elevating the bladder base (Fig. 1). Digital rectal examination revealed painless enlargement of the left side of the prostate. The seminal vesicles could not be palpated. The subsequent intravenous urogram was normal. An MR examination of the pelvis was carried out
Address for reprints: E. Doringer, M.D., Department of Radiology, Landeskrankenanstalten Salzburg, Miillner Hauptstrasse 48, A-5020 Salzburg, Austria. 0720-048X/91/$03.50
1990; accepted 2 October
0 1991 Elsevier Science Publishers
1990)
radiology, transperineal
punction;
Seminal vesicle, abscess
(Philips Gyroscan S 15, Eindhoven, Netherlands). Tl (TR/TE = 600/20 ms)and T2 (TR/TE = 2327/ 100 ms)-weighted, as well as Gadolinium-DTPA enhanced Tl (TR/TE = 500/20 ms)-weighted images were performed in SE-technique. Tl-weighed images (Fig. 2a) of the seminal vesicles produced lower signal intensity than normal. T2-weighted images (Fig. 2b) showed a higher signal intensity than fat. Gadolinium enhanced Tl-weighted images (Fig. 2c) demonstrated a multiseptic structure with a significant ring enhancement. With the diagnosis of seminal vesicle abscess highly suspected by MRI, a percutaneous transperineal aspiration was performed under general anesthesia [ 1,5]. About 50 cc of purulent material was aspirated through
Fig. 1. Axial transabdominal ultrasound image. Large tumorous lesion behind the urinary bladder (arrows).
B.V. (Biomedical
Division)
61
a 14 G Tru-Cut needle. A guidewire was introduced through the Tru-Cut. The puncture channel was dilated using a Teflon dilator up to 10 F to accommodate subsequent placement of the silicon drain 8 F. Postoperatively, the patient was given a broadspectrum intravenous antibiotic. Fluid-culture grew Staphylococcus aweus. Over the next 3 days the patient showed improvement and his drains were then removed. Parenteral antibiotics were continued for 1 week and followed by a 7-week-course of oral antibiotics. A second MRI at 8 weeks demonstrated reduction in the size of the seminal vesicle. A repeated percutaneous needle aspiration revealed no more purulent material. Also a percutaneous needle biopsy was carried out. Histopathological analysis of the biopsy demonstrated chronic inflammation of the seminal vesicle. The patient remained clinically asymptomatic 4 months after termination of oral antibiotics. Discussion
Fig. 2. Bilateral seminal vesicle abscess. (a) Tl-weighted image (TR/TE = 600/20 ms) axial plane, large tumorous lesion with decreased signal intensity (arrows). (b) T2-weighted image (TR/TE = 2327/100 ms) axial plane, the tumor (arrows) shows an immediate to high signal intensity. (c) Tl-weighted DTPA enhanced image (TR/TE = 500/20 ms) coronal plane. Multiseptic structure with significant ring enhancement of the tumor.
There have been only few reports on seminal vesicle Within the last abscesses in the literature [l-7]. 30 years there were no accumulated series of patients with seminal vesicle abscesses and - as far we know only seven case reports. In general, seminal vesicle pathological conditions are considered to be rare [6,10-131. The etiology of a seminal vesicle abscess is unclear; however, predisposing factors include urinary tract infection, diabetes mellitus, chronic indwelling urethral catheterisation, and any urological endoscopic procedure [ 11. Because of the seminal vesicle’s close proximity to the surrounding pelvic organs, the resulting symptoms may be related to other structures, i.e., urinary bladder, prostate, distal urether, ejaculatory duct, rectum or peritoneum [ 111. Symptoms include voiding dysfunction, perineal, testicular, inguinal or abdominal pain, malaise, fever, chills, and occasionally erectile dysfunction [ 1,3,6,12,14]. Thus an accurate imaging modality is even more essential. A seminal vesicle abscess can be verified by MRI [ 10,141. Normal seminal vesicles measure 4 to 5 cm in length and 1 to 2 cm in width [ 131. Due to their fluidrichness they are hypointense on Tl-weighted and hypet-intense on T2-weighted images. Inflammatory changes of the seminal vesicles include enlargements and an alteration of signal intensity. On Tl-weighted images the inflamed seminal vesicles show a decreased signal intensity as compared to normal, whereas on T2-weighted images the signal intensity increases significantly and is distinctly higher than fat, and if a unilateral inflammatory process is present, it is higher than that for the contralateral noninvolved vesicle [lo].
62
Nevertheless the evaluation of signal intensities on T2-weighted images is practically impossible in the case of bilateral involvement. Gadolinium-DTPA leads to a significant increase in signal intensity, and the multiseptic abscess structure can best be displayed on the Gadolinium-DTPA contrast-enhanced image. Until now the following imaging modalities were used for the diagnosis of seminal vesicle inflammation : CT, transrectal ultrasound. IVP, vesiculography; Although all the listed procedures contribute diagnostically to the question of a seminal vesicle abscess, they still are unspecific and have their respective disadvantages [ 141: IVP shows indirect signs - if any. Vesiculography is invasive, and at the puncture site a stenosis of the vas deferens is a possible complication [ 141. CT-imaging is limited to the axial plane. Beam-hardening artefacts originating from the urinary bladder or the rectum, respectively, both filled with contrast medium, can impede the evaluation of the seminal vesicle. Furthermore, the intravenous administration of an iodinated contrast medium is required. Also ionizing radiation upon the reproductive tract should be kept at a possible minimum. Transrectal ultrasound (6) also offers the opportunity of imaging in numerous longitudinal and transversal planes, but is often diicult to orientate within the limited field of view of a high frequency transducer. Moreover, some patients may possibly consider this application as uncomfortable. MRI shows specific signal characteristics of the normal seminal vesicles [ 131 and can well demonstrate the pathologically changed organ in multiplanar sections [ $13,141. The anatomical relationship of pelvic structures can be shown much better by MRI than by CT. As compared
to ultrasound information.
MRI produces
a distinctly larger detail
References 1 Fox CW, Vaccaro
5 6
1
8 9
10 11 12
13
14
3A, Kiesling VJ Jr, Belville WD. Seminal vesicle abscess: The use of computerized co-axial tomography for diagnosis and therapy. J Urol 1988; 139: 384. Frye K, Loughlin K. Successful transurethral drainage of bilateral seminal vesicle abscesses. J Urol 1988: 139: 1323. Jensen KH, Lundvall L. Peritonitis caused by abscess in the seminal vesicle. Acta Chir Scan 1988; 154: 245. Kang YS, Fishman EK, Kuhlman JE, Goldman SM. Seminal vesicle abscesses: spectrum of computed tomographic findings. Urol Radio1 1989; 11: 182-185. Kennelly MJ, Oesterling JE. Conservative management of a seminal vesicle abscess. J Urol 1989; 141: 1432. Lee SB, Lee F, Salomon MH, Kumasaka GH, Straub WH, MC Leary RD. Seminal vesicle abscess: diagnosis by transrectal ultrasound. J Clin Ultrasound 1986; 14: 546. Zagoria RJ, Papanicolaou N, P&ten RC, Stafford SA, Young HH. Seminal vesicle abscess after vasectomy: evaluation by transrectal sonography and CT. AJR 1987; 149: 137. Pate1 PS, Wilbur AC. Cystic seminal vesiculitis: CT demonstration. J Comput Assist Tomogr 1987; 11: 1103. Rajfer J, Eggleston JC, Sanders RC, Walsh PC. Fever and prostatic mass in a young man. J Urol 1978; 119: 555. Higgins CB, Hricak H (eds). Magnetic resonance imaging of the body. New York: Raven Press, 1987: 455. Schnitzer B. Ectopic ureteral opening into seminal vesicle: a report of four cases. J Urol 1965; 93: 567. Wallenberg HV, Burger R, Riedmiller H, Jacobi GH, Hohenfllner R. Differentialdiagnostische Aspekte der vergrosserten Samenblase. Akta Urol 1988; 19: 225. King BF, Hattery RR, Lieber MM, Williamson B Jr, Hartman GW, Berquist TH. Seminal vesicle imaging. RadioGraphics 1989; 9: 653. Sue DE, Chicola C, Brant-Zawadzki MN, Scidmore GF, Hart JB, Hanna JE. MR imaging in seminal vesiculitis. J Comput Assist Tomogr 1989; 13: 662-664.
60
EURRAD
00128
MRI of bilateral seminal vesicle abscesses E. Doringer ‘, I. Chandra2,
K. Sarica2, J. Frick2 and Hj. Schmoller
*
‘Department of Radiology and 2Department of Urology, Salzburg General Hospital, Salzburg, Austria (Received
Key words: Magnetic resonance
12 September
imaging, seminal vesicle; Intervention
Introduction Seminal vesicle abscess is a very rare pathological entity [l-7]. Because of its non-specific clinical symptoms, clinical diagnosis is often ambiguous, and several imaging modalities, including ultrasound, computed tomography (CT) and MRI may be necessary
[2,‘4Vl. Case report A 32-year-old white male presented with perineal and inguinal pain, associated with fever and chills. Past medical history was significant for insulin-dependent diabetes mellitus, and a prior left inguinal herniorrhaphy at the age of 25. Pertinent abnormal laboratory values included an elevated erythrocyte sedimentation rate, a WBC of 30000 with a left-sided shift, and a urineanalysis demonstrating leucocyturia (> 100 WBC/ HPC). A general surgery consultation was obtained, and the presumptive diagnosis of an incarcerated, recurrent left inguinal hernia was made. During inguinal exploration the intraoperative findings were normal. The patient’s symptoms persisted postoperatively. A transabdominal sonogram revealed an extrinsic mass elevating the bladder base (Fig. 1). Digital rectal examination revealed painless enlargement of the left side of the prostate. The seminal vesicles could not be palpated. The subsequent intravenous urogram was normal. An MR examination of the pelvis was carried out
Address for reprints: E. Doringer, M.D., Department of Radiology, Landeskrankenanstalten Salzburg, Miillner Hauptstrasse 48, A-5020 Salzburg, Austria. 0720-048X/91/$03.50
1990; accepted 2 October
0 1991 Elsevier Science Publishers
1990)
radiology, transperineal
punction;
Seminal vesicle, abscess
(Philips Gyroscan S 15, Eindhoven, Netherlands). Tl (TR/TE = 600/20 ms)and T2 (TR/TE = 2327/ 100 ms)-weighted, as well as Gadolinium-DTPA enhanced Tl (TR/TE = 500/20 ms)-weighted images were performed in SE-technique. Tl-weighed images (Fig. 2a) of the seminal vesicles produced lower signal intensity than normal. T2-weighted images (Fig. 2b) showed a higher signal intensity than fat. Gadolinium enhanced Tl-weighted images (Fig. 2c) demonstrated a multiseptic structure with a significant ring enhancement. With the diagnosis of seminal vesicle abscess highly suspected by MRI, a percutaneous transperineal aspiration was performed under general anesthesia [ 1,5]. About 50 cc of purulent material was aspirated through
Fig. 1. Axial transabdominal ultrasound image. Large tumorous lesion behind the urinary bladder (arrows).
B.V. (Biomedical
Division)
61
a 14 G Tru-Cut needle. A guidewire was introduced through the Tru-Cut. The puncture channel was dilated using a Teflon dilator up to 10 F to accommodate subsequent placement of the silicon drain 8 F. Postoperatively, the patient was given a broadspectrum intravenous antibiotic. Fluid-culture grew Staphylococcus aweus. Over the next 3 days the patient showed improvement and his drains were then removed. Parenteral antibiotics were continued for 1 week and followed by a 7-week-course of oral antibiotics. A second MRI at 8 weeks demonstrated reduction in the size of the seminal vesicle. A repeated percutaneous needle aspiration revealed no more purulent material. Also a percutaneous needle biopsy was carried out. Histopathological analysis of the biopsy demonstrated chronic inflammation of the seminal vesicle. The patient remained clinically asymptomatic 4 months after termination of oral antibiotics. Discussion
Fig. 2. Bilateral seminal vesicle abscess. (a) Tl-weighted image (TR/TE = 600/20 ms) axial plane, large tumorous lesion with decreased signal intensity (arrows). (b) T2-weighted image (TR/TE = 2327/100 ms) axial plane, the tumor (arrows) shows an immediate to high signal intensity. (c) Tl-weighted DTPA enhanced image (TR/TE = 500/20 ms) coronal plane. Multiseptic structure with significant ring enhancement of the tumor.
There have been only few reports on seminal vesicle Within the last abscesses in the literature [l-7]. 30 years there were no accumulated series of patients with seminal vesicle abscesses and - as far we know only seven case reports. In general, seminal vesicle pathological conditions are considered to be rare [6,10-131. The etiology of a seminal vesicle abscess is unclear; however, predisposing factors include urinary tract infection, diabetes mellitus, chronic indwelling urethral catheterisation, and any urological endoscopic procedure [ 11. Because of the seminal vesicle’s close proximity to the surrounding pelvic organs, the resulting symptoms may be related to other structures, i.e., urinary bladder, prostate, distal urether, ejaculatory duct, rectum or peritoneum [ 111. Symptoms include voiding dysfunction, perineal, testicular, inguinal or abdominal pain, malaise, fever, chills, and occasionally erectile dysfunction [ 1,3,6,12,14]. Thus an accurate imaging modality is even more essential. A seminal vesicle abscess can be verified by MRI [ 10,141. Normal seminal vesicles measure 4 to 5 cm in length and 1 to 2 cm in width [ 131. Due to their fluidrichness they are hypointense on Tl-weighted and hypet-intense on T2-weighted images. Inflammatory changes of the seminal vesicles include enlargements and an alteration of signal intensity. On Tl-weighted images the inflamed seminal vesicles show a decreased signal intensity as compared to normal, whereas on T2-weighted images the signal intensity increases significantly and is distinctly higher than fat, and if a unilateral inflammatory process is present, it is higher than that for the contralateral noninvolved vesicle [lo].
62
Nevertheless the evaluation of signal intensities on T2-weighted images is practically impossible in the case of bilateral involvement. Gadolinium-DTPA leads to a significant increase in signal intensity, and the multiseptic abscess structure can best be displayed on the Gadolinium-DTPA contrast-enhanced image. Until now the following imaging modalities were used for the diagnosis of seminal vesicle inflammation : CT, transrectal ultrasound. IVP, vesiculography; Although all the listed procedures contribute diagnostically to the question of a seminal vesicle abscess, they still are unspecific and have their respective disadvantages [ 141: IVP shows indirect signs - if any. Vesiculography is invasive, and at the puncture site a stenosis of the vas deferens is a possible complication [ 141. CT-imaging is limited to the axial plane. Beam-hardening artefacts originating from the urinary bladder or the rectum, respectively, both filled with contrast medium, can impede the evaluation of the seminal vesicle. Furthermore, the intravenous administration of an iodinated contrast medium is required. Also ionizing radiation upon the reproductive tract should be kept at a possible minimum. Transrectal ultrasound (6) also offers the opportunity of imaging in numerous longitudinal and transversal planes, but is often diicult to orientate within the limited field of view of a high frequency transducer. Moreover, some patients may possibly consider this application as uncomfortable. MRI shows specific signal characteristics of the normal seminal vesicles [ 131 and can well demonstrate the pathologically changed organ in multiplanar sections [ $13,141. The anatomical relationship of pelvic structures can be shown much better by MRI than by CT. As compared
to ultrasound information.
MRI produces
a distinctly larger detail
References 1 Fox CW, Vaccaro
5 6
1
8 9
10 11 12
13
14
3A, Kiesling VJ Jr, Belville WD. Seminal vesicle abscess: The use of computerized co-axial tomography for diagnosis and therapy. J Urol 1988; 139: 384. Frye K, Loughlin K. Successful transurethral drainage of bilateral seminal vesicle abscesses. J Urol 1988: 139: 1323. Jensen KH, Lundvall L. Peritonitis caused by abscess in the seminal vesicle. Acta Chir Scan 1988; 154: 245. Kang YS, Fishman EK, Kuhlman JE, Goldman SM. Seminal vesicle abscesses: spectrum of computed tomographic findings. Urol Radio1 1989; 11: 182-185. Kennelly MJ, Oesterling JE. Conservative management of a seminal vesicle abscess. J Urol 1989; 141: 1432. Lee SB, Lee F, Salomon MH, Kumasaka GH, Straub WH, MC Leary RD. Seminal vesicle abscess: diagnosis by transrectal ultrasound. J Clin Ultrasound 1986; 14: 546. Zagoria RJ, Papanicolaou N, P&ten RC, Stafford SA, Young HH. Seminal vesicle abscess after vasectomy: evaluation by transrectal sonography and CT. AJR 1987; 149: 137. Pate1 PS, Wilbur AC. Cystic seminal vesiculitis: CT demonstration. J Comput Assist Tomogr 1987; 11: 1103. Rajfer J, Eggleston JC, Sanders RC, Walsh PC. Fever and prostatic mass in a young man. J Urol 1978; 119: 555. Higgins CB, Hricak H (eds). Magnetic resonance imaging of the body. New York: Raven Press, 1987: 455. Schnitzer B. Ectopic ureteral opening into seminal vesicle: a report of four cases. J Urol 1965; 93: 567. Wallenberg HV, Burger R, Riedmiller H, Jacobi GH, Hohenfllner R. Differentialdiagnostische Aspekte der vergrosserten Samenblase. Akta Urol 1988; 19: 225. King BF, Hattery RR, Lieber MM, Williamson B Jr, Hartman GW, Berquist TH. Seminal vesicle imaging. RadioGraphics 1989; 9: 653. Sue DE, Chicola C, Brant-Zawadzki MN, Scidmore GF, Hart JB, Hanna JE. MR imaging in seminal vesiculitis. J Comput Assist Tomogr 1989; 13: 662-664.
