顽固性血精病因和治疗初探

Etiology and Management of Persistent Hematospermia: a Pilot Study

目的 :探讨顽固性血精的病因特点和影响治疗的因素 ,评价经直肠超声 (TRUS)引导下经会阴穿刺抽吸精囊液和灌注抗生素诊治顽固性血精的有效性。 方法 :入选 12例病人 ,平均年龄 (36 .4± 10 .8)岁 ,平均病程 (13.9± 6 .4 )个月。病人先行前列腺按摩 ,取得前列腺液 (EPS)并进行细菌培养。在TRUS引导下经会阴穿刺抽吸影像异常侧精囊液 (SVF)进行细菌培养和细胞学检查。根据EPS细菌培养和药敏试验结果选择抗生素 ,如细菌培养阴性则选择广谱抗生素 ,在TRUS引导下穿刺精囊进行灌注和冲洗。 1个月后复查时如血精未消失 ,则再次穿刺灌药。以后每 3个月随访 1次。 结果 :B超发现精囊异常影像位于左侧 4例 ,右侧 3例 ,双侧 2例 ,未见异常 3例。异常影像包括 :精囊或 和射精管扩张 7例 ;精囊壁增厚 3例 ;精囊壁钙化或精囊结石 3例 ;副中肾管 (M櫣ｌｌｅｒｉａｎｄｕｃｔ)囊肿1例。 7例SVF培养阳性 :耐甲氧西林金黄色葡萄球菌 (MRSA) 4例 ,耐甲氧西林凝固酶阴性葡萄球菌 (MRCNS)、大肠埃希菌、奇异变形杆菌各 1例。此 7例病人中 5例SVF和EPS细菌培养结果相同。在TRUS引导下经会阴穿刺精囊灌注抗生素并冲洗 ,7例灌注 1次 ,5例灌注 2次。随访 10例 ,平均 (16 .7± 5 .9)个月 ,6例未复发 ,4例仍反复发作。 结论

Objectives: To study the etiology of persistent hematospermia and to evaluate the efficacy of transrectal ultrasonography (TRUS) guided transperineal needle aspiration and irrigation for diagnosis and treatment of persistent hematospermia. Methods: Twelve patients were included in the study, with a mean age of ( 36.4 ± 10.8 ) years old, and a mean duration of the disease of ( 13.9 ± 6.4 ) months. After the expressed prostatic secretion (EPS) by prostatic massage was cultured, patients with recurrent hematospermia received TRUS guided transperineal needle aspiration for seminal vesicle fluid (SVF), which was sent for bacteriological and cytological examination. If the EPS culture were positive, certain antibiotics according to the drug sensitivity assay were injected into the abnormal seminal vesicle(s) via TRUS guided transperineal needle puncture. The treatment would be repeated one month later if the patients still had hematospermia. The patients were followed up every three months. Results: Abnormal images were found in left seminal vesicle (SV) in 4 cases, right in 3 cases, bilateral in 2 cases, and no abnormal findings in 3 cases. The abnormal findings included: 7 cases of SV and/or ejaculatory duct dilation, 3 cases of thickening SV wall, 3 cases of calcification or calculi of SV, and 1 case of Müllerian duct cyst. SVF cultures were positive in 7 cases: methicillin resistant Staphylococcus aureus (MRSA) 4 cases, methicillin resistant coagulase negative Staphylococcus (MRCNS), E. Coli , Proteus mirabilis 1 case, respectively. In five of these 7 cases, bacteriological cultures of SVF and EPS showed the same results. All patients were treated by TRUS guided transperineal injection of certain antibiotics into SV. Seven cases were injected once, 5 cases twice. The mean follow up period of 10 patients was ( 16.7 ± 5.9 ) months. Hematospermia disappeared in 6 cases. Conclusions: SV infection of bacteria, especially infection of the drug resistant strains was one of the main causes of persistent hematospermia. The difficulties in treatment of persistent hematospermia were due to infection of drug resistant bacteria, calcification or calculi of SV, obstruction of ejaculatory duct. TRUS guided transperineal aspiration of SVF was helpful to the etiologic diagnosis of persistent hematospermia.