Case No. :	52
Month :	April
Year :	2003
Contributor :	Dr.Abhijit Sunnapwar.

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A 30- year-old man presented with complaints of dysuria, increased frequency of micturation and pain on ejaculation since four months. There was no history of fever, hematuria or lithuria. On per-rectal examination, a firm mass was felt anteriorly which was thought to be of prostatic origin.

An ultrasonography (USG) of the abdomen and pelvis of was performed. On trans-abdominal scanning, the lesion was found to be of cystic nature, seen within the
bladder at the region of its base. A tubular, anechoic channel was seen communicating with the cyst on the right side (Fig 1).

Fig.1

The right kidney could not be identified in the renal fossa or in the pelvis. On Doppler study, the lesion showed no flow, suggesting its non-vascular origin.(Fig 2 ) .

Fig.2

Transrectal USG revealed the cystic lesion to be extravesical, near the base of the projecting inside the bladder. There was a communicating, blind ending channel
outside the bladder on the right side. The seminal vesicle adjacent to this cyst (on the right side) was prominent. The left seminal vesicle was normal. There was no
other lesion in the pelvis (Figs.3,4).

Fig. 3	Fig.4

Plain and contrast enhanced CT scan of the abdomen and pelvis was performed to locate the right kidney and also for better characterization of the cyst. The CT
scan confirmed the other imaging findings.(Fig.5).

Fig.5

Films of an excretory urogram showed no-opacification of the right pelvi-calyceal system (PCS). The PCS on the left side was normal. The full bladder film showed
a well-defined filling defect at the bladder base approximately 6 x 3 cm in size.(Fig. 6).

Fig.6

DIFFERENTIAL DIAGNOSIS:

1) Seminal vesical cyst
2) Prostatic cysts
3) Tumors arising from prostatic urethra , bladder or retroperitoneal structures.
4) Ureterocele
5) Hydronephrotic pelvic kidney

Considering the clinical and imaging profile of the patient, a diagnosis of seminal vesicular cyst was thought to be of more relevance .For confirmation of the diagnosis,
a TRUSS guided aspiration of cyst was done following which the cyst collapsed completely. It yielded brown colored viscous fluid which showed non-motile spermatozoa
and pus cells and thus the diagnosis of a seminal vesical cyst was reached.

TREATMENT:

Treatment of seminal vesicle cysts is reserved for symptomatic cases. Operative treatment involves en bloc excision of the seminal vesicle, cyst and ipsilateral ureter and dysplastic renal tissue, if present. TRUSS guided decompression of the cyst is a less invasive and equally effective treatment - as in our case - where at three months follow up, there was no recurrence of cyst or symptoms.

DISCUSSION:

Aberrations of the distal Wolffian ducts often lead to atresia or stenosis of the ejaculatory ducts, resulting in obstruction and congenital seminal vesicle cyst formation. Congenital seminal vesicle cysts may be associated with ipsilateral renal abnormalities such as agenesis, dysplasia or hypoplasia. Approximately 2/3rds of seminal vesicle cysts are associated with ipsilateral renal agenesis. In the absence of associated renal anomalies, differentiation between congenital and acquired vesical cysts is not possible. The content of the cyst is a viscous, brownish fluid, containing sperm and blood decay products. The cyst wall is thickened and sometimes calcified. Seminal vesicle cysts become symptomatic in the third or fourth decade of life. The possible symptoms include pain (abdominal, pelvic, perineal), dysuria, painful ejaculation, chronic recurrent epididymitis or prostatitis and occasionally infertility. Infection of the cyst is a frequent complication. Two cases of malignant transformation in the seminal vesicle cyst have been reported. Thus, while scanning any male patient with absent kidney and cystic structure in the pelvis, the possibility of seminal vesical cyst should be kept in mind.

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