Ultrasound
Ultrasonic Diagnosis of Seminal'Vesicle Cyst Case Report 1 William J. Walls, M.D., and Fritz Lin, M.D. Seminal vesicle cysts are uncommon, particularly when associated with ipsilateral agenesis of the kidney, ureter, and/or trigone. This entity should be considered when a cystic pelviC mass is seen in a young male. B-scan ultrasound can be of considerable aid in making the diagnosis. INDEX TERMS:
Seminal Vesicles, cysts - Ultrasound· Urinary Tract. abnor-
malities Radiology 114: 693-694, March 1975
vesicle cysts are extremely uncommon, particularly in association with ipsilateral agenesis of the upper urinary tract. Reddy and Winter (6) recently reviewed 2 cases of ipsilateral agenesis of the kidney, ureter, and trigone (2, 3) and added one case of their own. Three other cases involving ipsilateral agenesis of the kidney only (4, 6, 7) have been reported. As far as we know, this entity has not been reported in the radiological literature. We wish to report an additional case of seminal vesicle cyst with apparent agenesis of the ipsilateral kidney and ureter examined by B-scan 'ultrasound, a modality not employed previously. Although sonography did not enable a specific diagnosis, it did demonstrate the cystic nature of the lesion, its size and location, and its origin from the pelvis.
S
EMIN AL
CASE REPORT D.S., a well-nourished 34-year-old black man, was found to have a palpable abdominal mass on a physical examination given prior to employment. The patient denied any symptoms and had no known history of genitourinary disease. The present physical examination was normal except for a soft, nontender abdominal mass approxlrnately 5 cm in diameter to the right of the umbilicus. Chest films and laboratory data, including a complete urinalysis, were normal. B-scan ultrasound of the abdomen and pelvis revealed a large cystic mass in the right abdomen extending into the pelvis posterior to and to the right of the urinary bladder (Fig. 1). The right kidney could not be seen. A subsequent upper gastrointestinal series and barium enema examination showed displacement of the small bowel and right colon by a large right abdominal mass extrinsic to the gastrointestinal tract. The pelvic component of the mass was not evident. The possibility of a mesenteric cyst or pancreatic pseudocyst was entertained, and the patient was admitted to the hospital for definitive surgery. Excretory urography and cystoscopy were not performed prior to surgery. At surgery, the right kidney was not visible, though the left kidney appeared to be normal. A large cystic mass was pres1
ent in the right abdomen under the mesentery of the small bowel. A portion of the mass extended retroperitoneally to the urinary bladder on the right and was thought to represent a dilated ureter. The entire mass was excised to the level of the bladder (Fig. 2). The resected specimen consisted primarily of a cystic structure containing approximately 900 ml of yellowish brown, cloudy fluid. The interior of the cyst was smooth and pinkish tan to light yellow in color. Microscopically, the specimen consisted predominantly of well-formed tubules. These were lined with columnar cells having cilia, clear cytoplasm, and basally located nuclei and also contained spermatozoa. Associated connective tissue, smooth muscle, and areas of focal chronic inflammation also made up part of the specimen. No renal or ureteric tissue was identified. The pathological diagnosis was a seminal vesicle cyst. During subsequent postoperative evaluation, excretory urography demonstrated a nonfunctlonlng right kidney and a normal left upper urinary tract. Cystoscopy revealed an intravesical component of the resected seminal vesicle cyst, which was aspirated. The aspirate contained numerous spermatozoa and red blood cells, with no cells of urothelial origin. There was no right ureteral orifice. On follow-up examination and cystoscopy 3 months after discharge, the patient was asymptomatic and the intravesical portion of the cyst had decreased in size. No fluid could be aspirated from the cyst. The patient remains asymptomatic. DISCUSSION A cyst of the seminal vesicle is generally the result of discontinuity between the seminal vesicle and ejaculatory duct
and can be either congenital or acquired. The embryologic origin .of this anomaly has been described elsewhere (6). These cysts occur in young males, usually in the second or third decade. Symptoms are usually lacking; when present, they depend on the size of the cyst. Pain is the most common symptom, sometimes accompanied by frequency, dysuria, or difficulty in voiding. Hemospermia and recurrent epididymitis and prostatitis can occur. The diagnosis may not be made preoperatively; when it Is, it is sometimes necessary to catheterize the utricle or ejaculatory ducts and obtain a vesiculogram to make the diagnosis (1). Some have confirmed the diagnosis by perineal aspiration of the cyst (4). Although the diagnosis was not made preoperatively in this case, it would have been if this entity had been considered. Because of the intra-abdominal location of the mass, other diagnoses were entertained; however, ultrasound indicated the size and unilateral position of the mass and revealed that it was cystic and had a considerable pelvic component. If a seminal vesicle cyst had been considered, excretory urography and a more extensive urologic work-up prior to surgery would have confirmed the diagnosis and demonstrated aqenesls of the right upper urinary tract. The differential diagnosis includes primarily mullertan-duct cysts, which are more common. A\though they can be quite large, they are usually in the midline; moreover, they do not contain spermatozoa as a seminal vesicle cyst does: Epididymal cysts of the simple serous type are usually small and
From the Departments of Diagnostic Radiology (W. J W.) and Pathology (F. L.), University of Kansas Medical Center, Kansas City, Kansas.
Accepted for publication in October 1974.
sjh
693
694
WILLIAM
J.
WALLS AND FRITZ LIN
March 1975
Fig. 1. A. Longitudinal B-scan to the right of the midline demonstrates an irregular cystic mass extending from the pelvis (black arrow) retroperitoneally into the abdomen (white arrow). B urinary bladder. (Compare with Fig. 2) B. Transverse scan outlines the mass posterior to the urinary bladder (8) . C. Transverse scan through the abdominal component of the mass (white arrow) . S spine; ps psoas muscle.
=
=
=
multiple and should not pose a diagnostic problem. Rarer conditions include echlnococcal cyst, dermoid cyst, hemangioma , and lymphangioma. ACKNOWLEDGMENT: We wish to thank Dr. Arch W. Templeton for reviewing this manuscript. Department of Diagnostic Radiology University of Kansas Medical Center Kansas City, Kan. 66103
REFERENCES 1. Campbell MF, Harrison JH, ed: Urology. Philadelphia, Saunders, 3d Ed, 1970, Vol 2, pp 1230-1233 2. Hart JB: A case of cyst of the seminal vesicle. JUral 96: 247-249, Aug 1966 3. Hart JB: A case of cyst or hydrops of the seminal vesicle. J UroI86:137-141 , Jul 1961 4. Heetderks DR Jr, Delambre LC: Cyst of the seminal vesicle. J UroI93:725-728, Jun 1965 5. Kimchi D, Wiesenfeld A: Cyst of seminal vesicle associated with ipsilateral renal agenesis: case report . J Ural 89:906~907, Jun 1963
Fig. 2. Intact surgical specimen illustrates the pelvic (short arrow) and abdominal components of the mass (long arrow). (Compare with Fig. 1, A) 6. Reddy YN, Winter CC: Cyst of the seminal vesicle. A case report and review of the literature. J Ural 108:134-135, Ju11972 7. Zinner A: Ein Fall von intravesikaler Samenblasencyste. Wien Med Wochenschr 64:605-609. 1914
(See also pages 571 and 575)
Ultrasonic Diagnosis of Seminal'Vesicle Cyst Case Report 1 William J. Walls, M.D., and Fritz Lin, M.D. Seminal vesicle cysts are uncommon, particularly when associated with ipsilateral agenesis of the kidney, ureter, and/or trigone. This entity should be considered when a cystic pelviC mass is seen in a young male. B-scan ultrasound can be of considerable aid in making the diagnosis. INDEX TERMS:
Seminal Vesicles, cysts - Ultrasound· Urinary Tract. abnor-
malities Radiology 114: 693-694, March 1975
vesicle cysts are extremely uncommon, particularly in association with ipsilateral agenesis of the upper urinary tract. Reddy and Winter (6) recently reviewed 2 cases of ipsilateral agenesis of the kidney, ureter, and trigone (2, 3) and added one case of their own. Three other cases involving ipsilateral agenesis of the kidney only (4, 6, 7) have been reported. As far as we know, this entity has not been reported in the radiological literature. We wish to report an additional case of seminal vesicle cyst with apparent agenesis of the ipsilateral kidney and ureter examined by B-scan 'ultrasound, a modality not employed previously. Although sonography did not enable a specific diagnosis, it did demonstrate the cystic nature of the lesion, its size and location, and its origin from the pelvis.
S
EMIN AL
CASE REPORT D.S., a well-nourished 34-year-old black man, was found to have a palpable abdominal mass on a physical examination given prior to employment. The patient denied any symptoms and had no known history of genitourinary disease. The present physical examination was normal except for a soft, nontender abdominal mass approxlrnately 5 cm in diameter to the right of the umbilicus. Chest films and laboratory data, including a complete urinalysis, were normal. B-scan ultrasound of the abdomen and pelvis revealed a large cystic mass in the right abdomen extending into the pelvis posterior to and to the right of the urinary bladder (Fig. 1). The right kidney could not be seen. A subsequent upper gastrointestinal series and barium enema examination showed displacement of the small bowel and right colon by a large right abdominal mass extrinsic to the gastrointestinal tract. The pelvic component of the mass was not evident. The possibility of a mesenteric cyst or pancreatic pseudocyst was entertained, and the patient was admitted to the hospital for definitive surgery. Excretory urography and cystoscopy were not performed prior to surgery. At surgery, the right kidney was not visible, though the left kidney appeared to be normal. A large cystic mass was pres1
ent in the right abdomen under the mesentery of the small bowel. A portion of the mass extended retroperitoneally to the urinary bladder on the right and was thought to represent a dilated ureter. The entire mass was excised to the level of the bladder (Fig. 2). The resected specimen consisted primarily of a cystic structure containing approximately 900 ml of yellowish brown, cloudy fluid. The interior of the cyst was smooth and pinkish tan to light yellow in color. Microscopically, the specimen consisted predominantly of well-formed tubules. These were lined with columnar cells having cilia, clear cytoplasm, and basally located nuclei and also contained spermatozoa. Associated connective tissue, smooth muscle, and areas of focal chronic inflammation also made up part of the specimen. No renal or ureteric tissue was identified. The pathological diagnosis was a seminal vesicle cyst. During subsequent postoperative evaluation, excretory urography demonstrated a nonfunctlonlng right kidney and a normal left upper urinary tract. Cystoscopy revealed an intravesical component of the resected seminal vesicle cyst, which was aspirated. The aspirate contained numerous spermatozoa and red blood cells, with no cells of urothelial origin. There was no right ureteral orifice. On follow-up examination and cystoscopy 3 months after discharge, the patient was asymptomatic and the intravesical portion of the cyst had decreased in size. No fluid could be aspirated from the cyst. The patient remains asymptomatic. DISCUSSION A cyst of the seminal vesicle is generally the result of discontinuity between the seminal vesicle and ejaculatory duct
and can be either congenital or acquired. The embryologic origin .of this anomaly has been described elsewhere (6). These cysts occur in young males, usually in the second or third decade. Symptoms are usually lacking; when present, they depend on the size of the cyst. Pain is the most common symptom, sometimes accompanied by frequency, dysuria, or difficulty in voiding. Hemospermia and recurrent epididymitis and prostatitis can occur. The diagnosis may not be made preoperatively; when it Is, it is sometimes necessary to catheterize the utricle or ejaculatory ducts and obtain a vesiculogram to make the diagnosis (1). Some have confirmed the diagnosis by perineal aspiration of the cyst (4). Although the diagnosis was not made preoperatively in this case, it would have been if this entity had been considered. Because of the intra-abdominal location of the mass, other diagnoses were entertained; however, ultrasound indicated the size and unilateral position of the mass and revealed that it was cystic and had a considerable pelvic component. If a seminal vesicle cyst had been considered, excretory urography and a more extensive urologic work-up prior to surgery would have confirmed the diagnosis and demonstrated aqenesls of the right upper urinary tract. The differential diagnosis includes primarily mullertan-duct cysts, which are more common. A\though they can be quite large, they are usually in the midline; moreover, they do not contain spermatozoa as a seminal vesicle cyst does: Epididymal cysts of the simple serous type are usually small and
From the Departments of Diagnostic Radiology (W. J W.) and Pathology (F. L.), University of Kansas Medical Center, Kansas City, Kansas.
Accepted for publication in October 1974.
sjh
693
694
WILLIAM
J.
WALLS AND FRITZ LIN
March 1975
Fig. 1. A. Longitudinal B-scan to the right of the midline demonstrates an irregular cystic mass extending from the pelvis (black arrow) retroperitoneally into the abdomen (white arrow). B urinary bladder. (Compare with Fig. 2) B. Transverse scan outlines the mass posterior to the urinary bladder (8) . C. Transverse scan through the abdominal component of the mass (white arrow) . S spine; ps psoas muscle.
=
=
=
multiple and should not pose a diagnostic problem. Rarer conditions include echlnococcal cyst, dermoid cyst, hemangioma , and lymphangioma. ACKNOWLEDGMENT: We wish to thank Dr. Arch W. Templeton for reviewing this manuscript. Department of Diagnostic Radiology University of Kansas Medical Center Kansas City, Kan. 66103
REFERENCES 1. Campbell MF, Harrison JH, ed: Urology. Philadelphia, Saunders, 3d Ed, 1970, Vol 2, pp 1230-1233 2. Hart JB: A case of cyst of the seminal vesicle. JUral 96: 247-249, Aug 1966 3. Hart JB: A case of cyst or hydrops of the seminal vesicle. J UroI86:137-141 , Jul 1961 4. Heetderks DR Jr, Delambre LC: Cyst of the seminal vesicle. J UroI93:725-728, Jun 1965 5. Kimchi D, Wiesenfeld A: Cyst of seminal vesicle associated with ipsilateral renal agenesis: case report . J Ural 89:906~907, Jun 1963
Fig. 2. Intact surgical specimen illustrates the pelvic (short arrow) and abdominal components of the mass (long arrow). (Compare with Fig. 1, A) 6. Reddy YN, Winter CC: Cyst of the seminal vesicle. A case report and review of the literature. J Ural 108:134-135, Ju11972 7. Zinner A: Ein Fall von intravesikaler Samenblasencyste. Wien Med Wochenschr 64:605-609. 1914
(See also pages 571 and 575)
