Benign disease

Benign diseases of the seminal vesicles include infection, stones, and cysts. Seminal vesicle amyloidosis has also been reported [5]. Infection of the seminal vesicles is more common in developing countries, as a result of tuberculosis and schistosomiasis [6, 7]. However, bacterial infection of the seminal vesicles may also occur as a result of instrumentation (e.g. during prostate biopsy), sexually transmitted diseases, or from a urinary source in an immunocompromised patient (Figure 112.1). Once the infection progresses to an abscess, surgical or percutaneous intervention is often required [8]. In the rare case of echinococcal disease involving the seminal vesicle, forming a hydatid cyst, treatment requires systematic antiparasitic medication, aspiration and injection of cysts with hydrogen peroxide and 10% formalin, followed by cyst excision [9].

Seminal vesicle calcifications (Figure 112.2) and stones may be a later sequela of infection and are associated with obstruction [10]. Intervention may be required for seminal vesicle stones associated with symptoms, such as chronic pelvic pain, hematospermia, ejaculatory pain, or infertility [11, 12].

Cysts of the seminal vesicle are rare, with estimated incidence of 1 out of 20 000 males [13]. Although typically asymptomatic, seminal vesicle cysts may cause pelvic pain, hematospermia, or urinary symptoms [14]. Congenital cysts occur as a result of Wolffian duct anomalies, and consequently are associated with ipsilateral renal abnormalities, such as agenesis or dysplasia, polycystic kidney disease, ureteral ectopia, or ureterocele [13–16]. In the case of associated ejaculatory duct obstruction, the finding of unilateral renal agenesis and ipsilateral seminal vesicle cyst is termed Zinner syndrome [17]. Due to the close association with ipsilateral renal anomalies, the finding of a seminal vesicle cyst necessitates upper urinary tract imaging. Cysts of the seminal vesicle may also be acquired as a result of chronic ejaculatory duct or lower urinary tract obstruction [18, 19]. Surgical intervention is required in the case of superimposed infection and abscess (Figure 112.3), compression of urinary structures resulting in obstruction, or concern for malignant transformation [20–24].

Benign tumors

Primary tumors of the seminal vesicle are rare, and include papillary adenoma and cystadenoma [25]. Schwannoma of the seminal vesicle has also been described [26]. Unlike malignant involvement of the seminal vesicle, benign tumors of the seminal vesicle demonstrate absence of adjacent organ involvement on imaging and do not cause elevations in serum tumor markers (e.g. prostate‐specific antigen [PSA], carcinoembryonic antigen [CEA]) [27]. These tumors are often diagnosed due to symptoms, and pathologic diagnosis is made at the time of surgical excision [28]. Alternatively, if incidentally diagnosed and confirmed to be benign on biopsy, these tumors may be followed with serial transrectal ultrasound or cross‐sectional imaging.

Malignant tumors

Malignant involvement of the seminal vesicles from locally advanced pelvic tumors greatly outnumbers the frequency of primary malignancies of the seminal vesicles [29]. In the case of diagnostic uncertainty based on examination and imaging alone, serum tumor markers, cystoscopy, and/or sigmoidoscopy may be helpful in distinguishing prostate, bladder, or rectal carcinoma from a primary seminal vesicle malignancy. In the case of primary seminal vesicle malignancy, one would expect negative cystoscopic and sigmoidoscopic evaluations, normal PSA, normal CEA, and elevated cancer antigen 125 (CA‐125) [30, 31].

Adenocarcinoma comprises the majority of malignant tumors of the seminal vesicle, with presenting symptoms including hematuria, hematospermia, dysuria, urinary retention, and rarely ureteral obstruction [29, 32]. In the case of advanced disease, pathologic diagnosis may be made by transrectal ultrasound‐guided needle biopsy or transurethral resection. However, in the case of organ‐confined disease on cross‐sectional imaging, the pathologic diagnosis is often made at the time of surgical excision. Immunohistochemical profile includes positive CA‐125, positive cytokeratin‐7, and negative cytokeratin‐20 staining [29–31]. In the case of CA‐125‐producing seminal vesicle carcinoma, the response to therapy may be monitored by serum CA‐125 levels [31]. Other malignant tumors of the seminal vesicle include cystosarcoma phyllodes [33], sarcomas (rhabdomyosarcoma, leiomyosarcoma, and fibrosarcoma) [34, 35], extragastrointestinal stromal tumors [36], and primary germ cell tumors [37, 38]. Some have proposed that cystadenomas, cystosarcoma phyllodes, and sarcomas represent an increasingly aggressive spectrum of mixed epithelial stromal tumors [39].

History and examination

The signs and symptoms of seminal vesicle pathology are vague and nonspecific; furthermore, seminal vesicle cysts and tumors may be completely asymptomatic. Reported symptoms, as described above, may include perineal or pelvic pain, pain with ejaculation, hematospermia, lower urinary tract symptoms, hematuria, infertility, and symptoms consistent with urinary tract obstruction. Physical examination of the seminal vesicles is limited. Digital rectal examination may be revealing in the case of infection or abscess due to exquisite tenderness, and a large seminal vesicle mass may be palpated. Urinalysis may reveal microscopic hematuria in some cases, prompting further evaluation with imaging and cystoscopy. Cystoscopic evaluation may reveal distortion of the ipsilateral trigone (i.e. asymmetric elevation of the trigonal ridge) or of the ipsilateral prostatic urethra [40].

Imaging

Given the limitations of history and physical examination for seminal vesicle pathology, radiographic imaging is often necessary for accurate diagnosis. Transrectal ultrasound is the most commonly employed imaging modality for seminal vesicle pathology, and is the recommended initial study of choice for its cost, relative availability, and avoidance of ionizing radiation. The seminal vesicles are well visualized on transrectal ultrasound, and are normally symmetric, paired cystic structures located immediately superior to the prostate [41, 42]. Although cystic and solid components can be distinguished on ultrasound imaging, no specific imaging characteristics differentiate benign from malignant seminal vesicle tumors. This distinction can only be made with histopathology on either transrectal ultrasound‐guided biopsy or surgical excision of the specimen. Secondary involvement of the seminal vesicle may be appreciated as lesions contiguous with the adjacent organ of primary disease, often affecting both seminal vesicles.

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