What is the management of calcification of seminal vesicles?

Management of Calcification of Seminal Vesicles

For patients with calcification of seminal vesicles, the management should be guided by the presence of symptoms, with transrectal ultrasound (TRUS) as the first-line imaging modality for evaluation and MRI reserved for cases where TRUS is inconclusive or negative. 1

Diagnostic Approach

Initial Evaluation

• Determine if the patient has symptoms (hematospermia, pain, infertility concerns)
• Screen for associated conditions:
  • Diabetes mellitus (most common association) 2
  • Genitourinary tuberculosis
  • Hyperparathyroidism 3

Imaging Studies

1. Transrectal Ultrasound (TRUS) - First-line imaging

   • Highly sensitive for detecting calcifications in seminal vesicles 1
   • Can identify other abnormalities including cysts, ejaculatory duct obstruction
   • Reported to demonstrate abnormalities in 82-95% of men with hematospermia 1

2. MRI of the Pelvis

   • Indicated when TRUS results are negative or inconclusive 1
   • Superior for demonstrating anatomic abnormalities and determining the organ of origin
   • Better for assessing ejaculatory duct obstruction 1

Management Algorithm

Asymptomatic Patients

• No specific treatment required
• Consider screening for diabetes if not previously diagnosed 2
• Monitor for development of symptoms

Symptomatic Patients (Hematospermia)

1. Age <40 years with transient hematospermia

   • Watchful waiting and reassurance (no imaging typically required) 1
   • Laboratory testing: semen analysis, urinalysis, urine culture, coagulation studies 1

2. Age ≥40 years OR persistent hematospermia OR other symptoms

   • TRUS as first-line imaging 1
   • PSA testing to screen for prostate cancer 1
   • If TRUS inconclusive → MRI pelvis 1

For Seminal Vesicle Cysts with Calcifications

• Consider transperineal aspiration under ultrasound guidance if symptomatic 4
• TRUS-guided aspiration may be considered for diagnostic and therapeutic purposes 1

For Ejaculatory Duct Obstruction with Calcifications

• Consider transurethral resection of ejaculatory ducts (TURED) if fertility is desired 1
• Surgical sperm extraction may be considered as an alternative 1

Important Clinical Considerations

Potential Pitfalls

1. Cancer Overstaging - Calcifications can be misinterpreted as tumor invasion of seminal vesicles on imaging, leading to prostate cancer overstaging 5

2. Misdiagnosis - Idiopathic calcifications are extremely rare; always rule out underlying conditions (especially diabetes) 6

3. Fertility Impact - Calcifications may contribute to male factor infertility through obstruction 3

Follow-up

• For symptomatic patients who undergo intervention, follow-up should include:
  • Semen analysis if fertility is a concern
  • Symptom assessment
  • Repeat imaging if symptoms persist or recur

Prognosis

• Most cases are benign and incidental findings
• Treatment outcomes depend on underlying cause
• It remains unknown whether treating the underlying condition improves the appearance or function of the affected structures 3

Special Situations

Infertility Concerns

• For men with infertility and seminal vesicle calcifications:
  • Complete fertility workup including hormone levels
  • Consider assisted reproductive technologies if obstruction is confirmed 1
  • Surgical sperm extraction may be necessary if ejaculatory ducts are obstructed 1

Diabetes-Associated Calcifications

• These are considered almost pathognomonic of diabetes mellitus in some cases 2
• Management should include optimal glycemic control
• Most diabetic patients with these calcifications do not present with urological symptoms 2