Vesiculitis

 

The Clinical Course of Acute and Chronic Vesiculitis

Vesiculitis can be classified into acute and chronic forms based on its clinical course and duration of symptoms.

 

Acute Vesiculitis

Acute vesiculitis typically presents with a sudden onset of symptoms, which can be quite severe:

• Pain: A feeling of heaviness or significant pain in the perineal, suprapubic, or rectal region. The pain may radiate to the groin, sacrum, or lower back and is often aggravated by urination or defecation, sometimes leading to tenesmus (painful, ineffective straining).
• Ejaculatory Symptoms:
  • Painful ejaculation (odynorgasmia).
  • Hemospermia (blood in the semen), which can be alarming to the patient.
  • Increased frequency of nocturnal emissions (wet dreams), sometimes with purulent or bloody content.
• Urinary Symptoms: Dysuria (painful urination), urinary frequency, and urgency may occur due to associated prostatitis or bladder neck irritation.
• Systemic Symptoms: General weakness, malaise, and fever, which can rise to 39-40°C (102.2-104°F) or higher, often accompanied by chills.

The diagnosis of acute vesiculitis in these cases, with such pronounced symptoms, is usually not particularly difficult. Acute vesiculitis typically has a relatively intense course for 5-7 days. It can resolve with appropriate treatment, transition into a chronic form, or, in severe cases, progress to the formation of an **empyema** (abscess) of the seminal vesicle.

If an empyema forms, the abscess can potentially rupture. The most favorable outcome is rupture into the urethra, allowing drainage. Less commonly, it may rupture into surrounding tissues, the ampulla of the rectum, the bladder, or, rarely, into the abdominal cavity, leading to serious complications like peritonitis.

 

Chronic Vesiculitis

Vesiculitis can also present as a sluggish, chronic condition from its very beginning, or it can develop after an inadequately treated acute episode. In chronic vesiculitis, symptoms are often milder and more insidious:

• Chronic Pelvic Pain or Discomfort: A persistent dull ache or discomfort in the perineum, suprapubic area, or rectum.
• Neuro-sexual Symptoms: These often come to the fore in the chronic stage:
  • Frequent nocturnal emissions.
  • Painful erections.
  • Increased or decreased sex drive (libido).
  • Weak or "erased" orgasm.
  • Sluggish or rapid (premature) ejaculation of semen, which may sometimes be mixed with blood (hemospermia).
• Recurrent UTIs or Prostatitis Symptoms.
• Lower Back Pain.
• Fertility Issues: Chronic inflammation can affect semen quality.

In cases where only an insignificant area of the seminal vesicle mucous membrane is involved, or after acute symptoms have subsided, the process can enter a latent state and persist in this manner for many years, with intermittent flare-ups.

 

Diagnosis of Vesiculitis

The diagnosis of vesiculitis is based on a combination of clinical history, physical examination, laboratory tests, and imaging studies.

1. Medical History: Detailed history of symptoms (pelvic pain, ejaculatory pain, hemospermia, urinary symptoms, fever), sexual history, previous UTIs, prostatitis, or urological procedures.
2. Physical Examination:
   • Digital Rectal Examination (DRE): This is a key component. Examination of the seminal vesicles is carried out through the rectum. The patient may be in a standing position, leaning forward and asked to "sit" on the examiner's lubricated index finger, or in the lateral decubitus (Sims') position with the lower limbs drawn up to the stomach.
     • In acute vesiculitis, the seminal vesicle(s) may be palpably enlarged, tense, and exquisitely tender.
     • In chronic vesiculitis, the vesicles may feel indurated (hardened), irregularly thickened, or less distinctly palpable.
3. Laboratory Tests:
   • Urinalysis and Urine Culture: To check for associated UTI or pyuria.
   • Expressed Prostatic Secretions (EPS) and Seminal Fluid Analysis: The secret_ obtained by massage of the seminal vesicles (often done in conjunction with prostatic massage) is examined microscopically. Characteristic findings in vesiculitis include:
     • A large number of leukocytes (white blood cells).
     • Amorphous debris or decay products.
     • Exfoliated epithelial cells.
     • Red blood cells or hematoidin crystals (indicating old bleeding).
     • Presence of deformed, immotile spermatozoa.
     Semen culture may identify causative organisms.
   • Tests for STIs: Urethral swabs or urine for *N. gonorrhoeae* and *C. trachomatis* (e.g., NAATs).
   • Complete Blood Count (CBC): May show leukocytosis in acute vesiculitis.
   • Inflammatory Markers (ESR, CRP): May be elevated.
4. Imaging Studies:
   • Transrectal Ultrasound (TRUS): This is the most useful imaging modality for evaluating the seminal vesicles. It can show enlargement, wall thickening, fluid collections (abscess/empyema), calcifications, or cysts within the seminal vesicles.
   • MRI of the Pelvis: May be used in complex cases or if TRUS is inconclusive, providing excellent soft tissue detail.
   • CT Scan: Less commonly used for primary diagnosis of vesiculitis but may be helpful if complications or involvement of adjacent structures is suspected.

Anamnesis (patient history), along with DRE findings of enlargement, tight tension of the seminal vesicle, and pain on pressure, are the most characteristic objective signs of an acute inflammatory process.

 

Treatment of Vesiculitis

The treatment approach for vesiculitis depends on whether the condition is acute or chronic and the identified causative factors.

 

Medical Management

• Antibiotics: For bacterial vesiculitis, appropriate antibiotic therapy is crucial. The choice of antibiotic should target likely pathogens (e.g., enteric gram-negative bacilli, STI pathogens) and ideally be guided by culture and sensitivity results from urine, EPS, or semen. Longer courses (e.g., 2-6 weeks) are often required, similar to chronic bacterial prostatitis, due to poor antibiotic penetration into the seminal vesicles.
• Anti-inflammatory Drugs: NSAIDs (e.g., ibuprofen, diclofenac) to reduce pain and inflammation.
• Analgesics: For pain relief.
• Alpha-Blockers: Medications like tamsulosin may be used if there are significant voiding symptoms, as they can relax smooth muscle in the bladder neck and prostate, potentially improving drainage from the ejaculatory ducts.
• Supportive Care for Acute Stage: Treatment of acute vesiculitis should also focus on enhancing the body's defenses. This may include:
  • Bed rest.
  • Adequate hydration.
  • Stool softeners to avoid straining during defecation.
  • Immunotherapy (e.g., use of immune-modulating agents) has been mentioned historically but is not standard modern practice for uncomplicated vesiculitis. Focus is on appropriate antibiotics and supportive care.

 

Local and Physical Therapies (Mainly for Chronic Vesiculitis)

In the treatment of chronic forms of vesiculitis, in addition to general systemic treatment (like prolonged antibiotics), direct effects on the seminal vesicles are also considered necessary by some practitioners. These may include:

• Seminal Vesicle Massage: Performed via the rectum to promote drainage of infected secretions. Its efficacy is debated, and it should be done cautiously.
• Local Heat Therapy:
  • Warming them up by diathermy (deep heat therapy).
  • Hot microclysters (medicated enemas with warm solutions).
  These methods are thought to improve blood circulation and reduce inflammation, and historically were reported to give good results.
• Physiotherapy: Other forms of pelvic physiotherapy may be beneficial for chronic pelvic pain symptoms.

 

Surgical Interventions

Surgical treatment is indicated in a minority of cases, typically if medical management is unsatisfactory, or for complications like empyema or persistent obstruction.

• For Catarrhal Forms (if refractory and causing significant symptoms - historical/rare indication): Vasotomy (incision into the vas deferens, potentially for irrigation or drainage access) or vasopuncture. These are rarely performed today for simple catarrhal vesiculitis.
• For Fibrous Vesiculitis and Empyema (Abscess):
  • Vesiculotomy: Surgical incision and drainage of an infected or obstructed seminal vesicle (empyema). This can be done via transrectal ultrasound-guided aspiration, or through open or laparoscopic/robotic surgical approaches.
  • Vesiculectomy: Surgical removal of the seminal vesicle(s). This is a more radical procedure reserved for severe, intractable chronic vesiculitis, persistent empyema, or sometimes for tumors, when other treatments have failed and symptoms are debilitating.

 

Potential Complications of Vesiculitis

If vesiculitis is not adequately treated, it can lead to several complications:

• Chronic Vesiculitis: Acute episodes can transition into a persistent, chronic inflammatory state.
• Empyema/Abscess of the Seminal Vesicle: Collection of pus requiring drainage.
• Spread of Infection: To adjacent structures like the epididymis (epididymitis), testis (orchitis), or bladder.
• Ejaculatory Duct Obstruction: Scarring from chronic inflammation can block the ejaculatory ducts, leading to low semen volume (hypospermia) and infertility.
• Male Infertility: Inflammation can affect sperm quality (motility, morphology) and seminal fluid composition.
• Chronic Pelvic Pain Syndrome.
• Hemospermia (Persistent Blood in Semen).
• Sexual Dysfunction: Persistent painful ejaculation or erectile dysfunction.
• Sepsis (Rare): If a severe infection like an abscess spreads systemically.

 

Differential Diagnosis of Pelvic Pain and Ejaculatory Symptoms in Males

Symptoms suggestive of vesiculitis can overlap with other conditions affecting the male pelvis and genitourinary tract:

Condition	Key Differentiating Features
Vesiculitis (Seminal Vesiculitis)	Pain in perineum/rectum/suprapubic area, painful ejaculation, hemospermia, LUTS. Tender/enlarged seminal vesicles on DRE. TRUS shows SV abnormalities. Leukocytes/bacteria in EPS/semen.
Acute or Chronic Prostatitis	Pelvic/perineal pain, LUTS, ejaculatory pain. Tender/boggy (acute) or normal/firm (chronic) prostate on DRE. Leukocytes/bacteria in EPS/post-massage urine. Often coexists with vesiculitis.
Epididymitis / Epididymo-orchitis	Scrotal pain, swelling, tenderness localized to epididymis +/- testis. Often with fever, urethral discharge, LUTS. Doppler US confirms epididymal/testicular inflammation.
Urethritis	Urethral discharge, dysuria. No deep pelvic pain typically. Positive tests for STI pathogens.
Benign Prostatic Hyperplasia (BPH)	Primarily obstructive and irritative LUTS in older men. Prostate often enlarged. Usually not acutely painful unless complicated by infection/retention.
Urinary Tract Infection (Cystitis)	Dysuria, frequency, urgency, suprapubic pain. Urinalysis shows pyuria/bacteriuria. Usually no specific ejaculatory symptoms.
Ejaculatory Duct Obstruction (EDO)	Low semen volume, infertility, sometimes perineal pain. Diagnosed by TRUS showing dilated seminal vesicles/ejaculatory ducts, or vasography.
Prostate or Seminal Vesicle Cancer/Cyst	May cause pain, hemospermia, obstructive symptoms. TRUS, MRI, PSA, biopsy for diagnosis.
Interstitial Cystitis/Bladder Pain Syndrome (in males)	Suprapubic pain related to bladder filling, frequency, urgency. Often a diagnosis of exclusion.

 

Prevention and When to Consult a Urologist

Preventive measures aim to reduce risk factors:

• Prompt and complete treatment of UTIs, prostatitis, and STIs.
• Practicing safe sex to avoid STIs.
• Maintaining good personal hygiene.
• Avoiding prolonged pelvic congestion (though evidence for specific activities is weak).

Consultation with a urologist is essential if symptoms suggestive of vesiculitis occur, such as:

• Pain in the perineum, rectum, or lower abdomen, especially if related to ejaculation.
• Blood in the semen (hemospermia).
• Painful ejaculation.
• Persistent urinary symptoms.
• Fever and chills associated with pelvic pain.
• Concerns about male infertility.

A urologist can perform the necessary diagnostic evaluations, including DRE, TRUS, and seminal fluid analysis, to confirm the diagnosis and recommend an appropriate treatment plan to prevent chronic issues and complications.