What is the treatment for seminal vasculitis?

Treatment for Seminal Vasculitis

For seminal vasculitis, treatment should follow the established protocols for small and medium vessel vasculitis, with cyclophosphamide and glucocorticoids as the first-line therapy for severe disease, or less toxic alternatives like methotrexate for non-severe cases. 1

Disease Classification and Initial Approach

• Seminal vasculitis should be categorized according to severity (non-severe vs. severe) to guide appropriate treatment decisions 1
• Management should ideally involve collaboration with centers of expertise in vasculitis 1
• Diagnostic evaluation should include ANCA testing and potentially biopsy to confirm the diagnosis 1

Treatment Recommendations Based on Disease Severity

For Severe Seminal Vasculitis:

• First-line therapy: Combination of cyclophosphamide (intravenous or oral) and glucocorticoids 1
  • Cyclophosphamide dosing: 2 mg/kg/day orally (maximum 200 mg/day) or pulsed intravenous administration 1
  • Glucocorticoids: Prednisolone 1 mg/kg/day (maximum 60 mg/day) with gradual tapering 1
• Consider Mesna as a uroprotective agent when using cyclophosphamide to reduce bladder toxicity 1
• For refractory cases, rituximab is an effective alternative 1, 2

For Non-Severe Seminal Vasculitis:

• First-line therapy: Methotrexate (oral or parenteral) combined with glucocorticoids 1
• Alternative options include azathioprine or mycophenolate mofetil with glucocorticoids 1, 2
• For mild disease, consider colchicine or dapsone 2

Remission Maintenance Therapy

• Once remission is achieved, transition to maintenance therapy with 1:
  • Low-dose glucocorticoids plus one of the following:
    • Azathioprine (preferred option)
    • Methotrexate
    • Leflunomide

Special Considerations

• If there is concurrent epididymitis (common with seminal vesiculitis), antimicrobial therapy may be necessary 3:
  • For suspected gonococcal or chlamydial infection: Ceftriaxone 250 mg IM single dose plus doxycycline 100 mg orally twice daily for 10 days 1
  • For enteric organisms: Ofloxacin 300 mg orally twice daily for 10 days or levofloxacin 500 mg orally once daily for 10 days 1

Monitoring and Follow-up

• Regular structured clinical assessments, urinalysis, and laboratory tests should be performed at each clinical visit 1
• Failure to improve within 3 days of antimicrobial therapy (if infectious etiology) requires reevaluation of diagnosis and treatment 1
• Monitor for cyclophosphamide toxicity, including regular urinalysis to detect hematuria which may indicate bladder cancer risk 1

Treatment for Refractory Disease

• For patients who fail to achieve remission on standard therapy, consider 1, 2:
  • Rituximab
  • Intravenous immunoglobulin
  • Mycophenolate mofetil
  • Plasmapheresis in severe cases

Adjunctive Measures

• Bed rest, analgesics, and anti-inflammatory medications for symptomatic relief 1, 2
• For isolated seminal vesiculitis without systemic vasculitis, local treatment approaches may be considered, including transperineal seminal vesicle puncture under ultrasound guidance with antibiotic instillation 4