Cystic enlargement of prostatic utricle, a vestigial remnant of mullerian duct, is a rare condition in males. The prostatic utricle distends with urine during voiding and then passively drains. Poor emptying leads to urine retention and stasis. Stone formation may result from obstruction. Patients present clinically with chronic urinary tract infection, hematuria, urethral discharge, epididymitis, and voiding dysfunction. We present a case of multiple stones in the enlarged prostatic utricle associated with hemospermia.
The prostatic utricle is an enlarged diverticulum in the posterior urethra of males, result from incomplete regression of the mullerian duct or decreased androgenic stimulation of the urogenital sinus . In normal men, enlarged prostatic utricle is rare and there is no direct report about its incidence. An infected enlarged prostatic utricle may cause urinary tract infection, stone formation, urinary obstruction, hematuria, and recurrent epididymitis and may also lead to infertility, calcification, and neoplastic degeneration [1,2]. We report this case to describe prostatic utricle stones in a patient with hemospermia diagnosed by transrectal ultrasonography.
A 32-year-old male presented with hemospermia and scrotal pain for 1 year. He had a history of appendicitis and surgery for it. He reported that the ejaculate was partially or completely bloody at every ejaculation. On physical examination, there is no abnormality of the external genital organs. The complete blood count was unremarkable and total prostate specific antigen was 0.201 ng/mL. The microbiological examination of the ejaculate revealed no infection. Microscopic examination of the ejaculate showed abundant erythrocytes. Semen analysis revealed a spermiogram with a volume of 1.5 mL, a number of 6×106/mL, motility of 80%, and teratospermia of 8%. Transrectal ultrasonography demonstrated enlarged utricle cyst with calcified wall and multiple stones in it (Fig. 1). Based on the examinations, the patient was diagnosed the prostatic utricle cyst with multiple stones. We performed cystoscopy under general anesthesia and observed normal sized verumontanum and two ejaculatory duct openings. We approached to the cyst using ureteroscope through the opening of ejaculatory duct. Multiple utricle stones were clearly observed (Fig. 2) and removed after fragmentation using Holmium laser. We also performed biopsy on the cyst wall. After 2 weeks of surgery, the patient reported that there was no scrotal pain and no blood in the ejaculate. The result of biopsy showed negative for malignant cells.
The prostatic utricle is a small, epithelium-lined diverticulum of the prostatic urethra. It is located in the verumontanum between the two openings of the ejaculatory ducts and extends backward and slightly upward for a very short distance within the medial lobe of the prostate. An enlarged prostatic utricle may be seen due to a lack of receptor or a delayed release of male hormones during sexual differentiation . It can be congenital and often associated with hypospadias, cryptorchidism, or renal agenesis . Urethral secretion, hematuria, frequency, perineal discomfort, or dysuria may be seen due to an enlargement of the prostatic utricle . The prostatic utricle distends with urine during voiding and then passively drains. Poor emptying leads to urine retention and stasis. Stone formation may result from obstruction. Not only an enlarged prostatic utricle, but also the presence of a utricle stone is infrequent . Enlarged prostatic utricle stones may lead to hematuria and infection. In this case, scrotal pain and hemospermia were present. The patient had persistent hemospermia which had lasted for 1 year and had not improved despite various medical therapies. Enlarged prostatic utricle stones were diagnosed by transrectal ultrasonography and removed by transurethral surgery. The patient had no hemospermia and scrotal pain after 2 weeks of surgery. Hemospermia is usually intermittent, benign, and self-limited, and it usually requires no intensive clinical investigation. Although the etiology of hemospermia is reported as idiopathic in approximately 30%–70% and hemospermia often occurs without recognizable physical dysfunction, there is a variety of pathological processes that can be categorized by the pathophysiologic mechanisms as follows: inflammation and infections, ductal obstruction and cysts of accessory sexual glands, tumors, vascular abnormalities, and systemic and iatrogenic factors . There is numerous etiological factors leading to hemospermia and it is often hard to find the cause. We report this case to suggest considering prostatic utricle stones for the cause of hemospermia.
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