Tuberculosis of seminal vesicles: a rare case report

Abstract

Tuberculosis of seminal vesicles is an uncommon form of genitourinary tuberculosis, frequently presenting with nonspecific symptoms and posing diagnostic challenges. Herein is reported a case of a 33-year-old male with a history of pulmonary tuberculosis in childhood who presented with nonspecific urinary symptoms. Imaging and histopathological findings confirmed tuberculosis of the seminal vesicle. This case underscores the importance of considering tuberculosis in the differential diagnosis of genitourinary symptoms, especially in patients with a prior history of tuberculosis. Early diagnosis and timely treatment are important to prevent complications and improve outcomes.

Introduction

Tuberculosis (TB) remains a global health challenge, with 10.6 million new cases reported in 2022.[1] While pulmonary TB is the most common form, extrapulmonary tuberculosis (EPTB) represents 30–50 % of cases in endemic regions, including our country.[2]

Among EPTB manifestations, urogenital tuberculosis (UGTB) is the third most frequent, following lymph node and pleural involvement [3]. UGTB can affect various organs such as the kidneys, ureters, prostate, vas deferens, seminal vesicles, testes, and epididymis.

Tuberculosis of the seminal vesicles is particularly rare and often underdiagnosed due to its nonspecific clinical presentation. Awareness of this condition is especially limited among practitioners in non-endemic regions, such as Europe, where tropical diseases are uncommon. A recent international survey highlighted the poor awareness of European practitioners toward rare tropical diseases, including GUTB, underscoring the need for educational efforts in this area [4].

We report a case of a 33-year-old male with a history of childhood pulmonary tuberculosis who was diagnosed with tuberculosis of the seminal vesicles. This case highlights the complexities of diagnosis and the importance of a multidisciplinary approach. It also serves as an important educational case for urologists in non-endemic regions, emphasizing the need for heightened awareness of this rare condition.

Case presentation

A 33-year-old male, treated for pulmonary tuberculosis at the age of ten, presented with a 3 month history of nonspecific urinary symptoms including dysuria, urinary frequency, hesitancy, and perineal discomfort. Physical examination revealed tenderness in the right epididymal region, mild scrotal swelling, and perineal tenderness. Routine laboratory tests were unremarkable.

Ultrasound showed thickening and hyperechogenicity of the right epididymis, thickening of the right spermatic cord, and no focal testicular lesions (Fig. 1). MRI confirmed inflammation of the right epididymis and spermatic cord, along with wall thickening and cystic dilatation of the right seminal vesicle, consistent with active vesiculitis (Fig. 2). These findings suggested right-sided epididymitis with vesiculitis, likely secondary to an ascending genitourinary infection.

Fig. 1.

Ultrasound images: A – showing thickening and hyperechogenicity of the right epididymis consistent with epididymitis. B: Thickening of the right spermatic cord, confirming an inflammatory process.

Fig. 2.

Pelvic MRI Images: A – Axial T1 Fat-SAT with gadolinium image showing right epididymis with heterogeneous enhancement (red arrow). B: Axial T1 Far-SAT with gadolinium image showing thickening of the right spermatic cord (blue arrow). C: Axial T2 image showing wall thickening and cystic dilatation of the right seminal vesicle with abnormal T2 hypointensity (yellow arrow).

Ultrasound-guided drainage of the seminal vesicle was performed, and secretions were sent for bacteriological examination. Biopsy of the prostate and seminal vesicle revealed granulomatous inflammation with caseous necrosis, confirming the diagnosis of tuberculosis (Fig. 3). The histological findings, combined with imaging results, indicated extensive genital involvement, including the prostate, right seminal vesicle, vas deferens, and epididymis.

Fig. 3.

Epithelioid and giant-cell granulomas with caseous necroisis. (HE staining, Magnification x20).

The patient was treated with a standard antituberculosis regimen consisting of a 2-month intensive phase (rifampicin, isoniazid, pyrazinamide, and ethambutol) and a 4-month continuation phase (rifampicin and isoniazid).

The patient’s follow-up included regular clinical evaluations and imaging studies to monitor treatment response. Post-treatment ultrasound imaging was performed at 3 months, showing the resolution of inflammation with no evidence of residual disease or complications (Fig. 4). These findings correlated with the patient’s significant clinical improvement.

Fig. 4.

Ultrasound images showing resolution of thickening and hyperechogenicity of the right epididymis.

Discussion

Tuberculosis of the seminal vesicles is a rare manifestation of UGTB, typically resulting from hematogenous or retrograde spread from the prostate via the vas deferens, peri-vas lymphatics, or capillaries.[3] In this case, the most likely route was retrograde spread from the epididymis.

Tuberculous infection of the seminal vesicles can lead to abscess formation, fibrosis, and calcifications, potentially causing infertility, hemospermia, or decreased ejaculatory volume.[4] The latency period between primary infection and reactivation can span decades, as observed in this case.[5]

Early and accurate diagnosis of UGTB is critical for effective treatment. It requires a combination of clinical history, imaging, and microbiological, molecular, and histopathological tests.[3]

The nonspecific clinical presentation of seminal vesicle tuberculosis often delays diagnosis. Common symptoms include lower urinary tract symptoms (dysuria, frequency, hesitancy), perineal pain, hemospermia, erectile dysfunction, and infertility. Physical examination may reveal an enlarged seminal vesicle.[4], [6]

Imaging plays a critical role in evaluating suspected seminal vesicle tuberculosis and guiding procedures such as biopsies or abscess aspirations. Although vesiculography was once the primary diagnostic tool for tuberculous infections, it has been largely replaced by more advanced imaging modalities. Radiographs may detect calcifications in the seminal vesicles, though these findings are nonspecific and can also be seen in conditions like diabetes mellitus.[7] Transrectal ultrasound may reveal dilated seminal vesicles, indicating possible ejaculatory duct obstruction, along with thickened walls or calcifications.[8] On CT and MRI, diffuse wall and septal thickening with enhancement are common findings. Cystic dilatation of seminal vesicles may be observed during the acute to subacute phase. As fibrosis progresses, the seminal vesicles often atrophy and appear hypointense on both T1- and T2-weighted MR images. CT scans may show internal hypoattenuation with surrounding hypervascularity or complications such as abscess formation, cavitation, and caseous necrosis. In advanced or "burned-out" stages, calcifications are frequently present. [9], [10]

Uretroscopy can be employed to access the prostatic utricle or ejaculatory ducts, enabling direct visualization of the seminal vesicles and facilitating the collection of biopsy samples from abnormal lesions. [3], [11]

Biopsy plays a crucial role in confirming the diagnosis of seminal vesicle tuberculosis. Histological examination of biopsy specimens or fine-needle aspirates can identify granulomas and acid-fast Mycobacterium tuberculosis (Mtb) bacilli using stains such as Ziehl-Neelsen or Kinyoun acid-fast stains. [8] In this case, biopsy was crucial not only for confirming the diagnosis but also for excluding other potential conditions, such as malignancies, abscesses of non-tuberculous origin, or other granulomatous diseases.

Our case is consistent with prior descriptions of male genital tuberculosis, characterized by its diagnostic challenges, frequent presentation with chronic epididymitis and prostatitis, and reliance on histological confirmation for definitive diagnosis.[12]

The primary goal of UGTB management is to eradicate Mtb with anti-TB therapy. Empirical treatment is often initiated based on clinical suspicion when microbiological tests are inconclusive. The standard regimen for drug-sensitive TB includes a 2-month intensive phase (rifampicin, isoniazid, pyrazinamide, and ethambutol) followed by a 4-month continuation phase (rifampicin and isoniazid). The continuation phase is extended to 7 months for immunosuppressed patients to minimize relapse risk.[13]

In cases with abscess formation, conservative management is insufficient. Ultrasound-guided transrectal or transurethral drainage is often required.[14]

Meanwhile, the growing prevalence of multidrug-resistant tuberculosis (MDR-TB), which accounts for 1.9 % of new cases and 10 % of previously treated cases in Morocco [15], underscores the necessity of developing individualized therapeutic regimens to address this challenge effectively.

Conclusion

Seminal vesicle tuberculosis, though rare, should be considered in the differential diagnosis of patients presenting with urogenital symptoms, particularly those with a history of tuberculosis. This case emphasizes the importance of combining clinical history, advanced imaging, and histopathological examination for accurate diagnosis. Early detection, appropriate anti-tuberculosis therapy, and surgical intervention when indicated are crucial for optimal outcomes.

Ethical approval

In our institution case reports don’t need ethical committee approval for conduction.

Funding

N/A

CRediT authorship contribution statement

Boughaleb Abdelmounim: Methodology, Data curation, Writing – review & editing. Hicham El Boté: Writing – original draft, Visualization, Validation, Supervision, Conceptualization.

Declaration of Competing Interest

The authors declare that they have no conflict of interest.