What is the initial workup for a patient presenting with seminal vasculitis?

Initial Workup for Seminal Vesiculitis

The initial workup for seminal vesiculitis should include a comprehensive clinical evaluation, semen analysis, laboratory tests for infection, and transrectal ultrasonography to assess the seminal vesicles and surrounding structures. 1

Clinical Evaluation

• Obtain a detailed history focusing on symptoms such as hemospermia, pain during ejaculation, perineal discomfort, and infertility 2, 3
• Perform a digital rectal examination to assess for tenderness, enlargement, or induration of the seminal vesicles and prostate 2
• Evaluate for systemic symptoms that might suggest vasculitis (fever, weight loss, fatigue) as a rare but serious complication 4, 5

Laboratory Testing

• Complete semen analysis including:

  • Physical properties (coagulation, liquefaction, volume, viscosity, pH) 3
  • Microscopic examination for white blood cells and red blood cells 2
  • Biochemical markers of seminal vesicle function (fructose, inorganic phosphorus) 3
  • Semen culture to identify potential infectious agents 2

• Blood tests:

  • Complete blood count to assess for leukocytosis 2
  • C-reactive protein and erythrocyte sedimentation rate to evaluate inflammation 6
  • In cases with suspected vasculitis component, ANCA testing (including indirect immunofluorescence and ELISA) should be performed 1

Imaging Studies

• Transrectal ultrasonography (TRUS) is the first-line imaging modality to:

  • Evaluate seminal vesicle size and wall thickness 2
  • Assess for calcifications, cysts, or masses 1
  • Identify potential ejaculatory duct obstruction 1

• MRI with an endorectal coil may be considered if TRUS findings are inconclusive or if more detailed anatomical information is needed 1

Additional Diagnostic Procedures

• Post-ejaculatory urinalysis should be performed if ejaculate volume is low (<1 mL) to rule out retrograde ejaculation 1

• In cases of persistent symptoms despite initial treatment, or when malignancy is suspected:

  • Transrectal biopsy may be necessary to rule out seminal vesicle adenocarcinoma, which is rare but has been reported 4
  • In suspected vasculitis cases, biopsy provides histopathological evidence which remains the gold standard for diagnosis 1, 5

Special Considerations

• For patients with recurrent or chronic seminal vesiculitis not responding to conventional treatment, transurethral seminal vesiculoscopy may be both diagnostic and therapeutic 2

• In cases where vasculitis is suspected as an underlying cause (particularly in patients with systemic symptoms), referral to a rheumatologist is recommended for specialized evaluation 6

• Be aware that isolated vasculitis of the seminal vesicle has been reported and may not present with systemic symptoms 5

Common Pitfalls to Avoid

• Failing to differentiate between seminal vesiculitis and other causes of similar symptoms such as prostatitis, epididymitis, or urethritis 1

• Overlooking the possibility of malignancy, especially in older patients or those with persistent symptoms despite appropriate treatment 4

• Not considering the rare association between seminal vesiculitis and systemic vasculitis, which requires different management approaches 4, 5