1157Vol. 10 | No. 4 | Autumn 2013 |U R O LO G Y J O U R N A L Acute Infection of a Documented Seminal Vesicle Cyst via Hematogenous Seeding William C. Palmer,1 Neal C. Patel,2 Johnathan R. Renew,3 Mellena D. Bridges,4 Fernando F. Stancampiano5 Keywords: seminal vesicles; cysts; genital diseases; complications; microbiology; abscess. INTRODUCTION Genital abnormalities have been reported in up to 12 percent of men with unilat-eral renal agenesis.(1) There have also been reports of neurofibromatosis patients manifesting ipsilateral renal agenesis.(2) Abnormal development of the mesone- phric duct between the fourth and thirteenth week of embryonic life seems to be the origin of such cysts, which can have a variable clinical presentation.(3) The presence of seminal vesicle cysts in patients with renal agenesis is well documented.(4,5) Approximately 68 percent of all seminal vesicle cysts are associated with renal agenesis.(1) Here we report a 26-year old patient with neurofibromatosis type 1, unilateral renal agenesis, and a known seminal vesicle cyst who presented to the Emergency Department with bacteremia caused by an infected dual lumen hemodialysis catheter. CASE REPORT A 26-year old Caucasian male with a history of neurofibromatosis type 1 and left renal agene- sis was admitted to the hospital because of perineal pain and fever. Twelve days earlier, he had been found to have methicillin-sensitive staphylococcus aureus (MSSA) bacteremia, which was treated with intravenous antibiotics (vancomycin, piperacillin-tazobactam, and nafcillin) and dual-lumen hemodialysis catheter removal. Simultaneous blood cultures obtained from the new dialysis catheter and periphery at the time of admission were negative and a com- puted tomography (CT) without contrast of the abdomen and pelvis revealed the acute expan- Corresponding Author: William Palmer, MD 4500 San Pablo Road South, Jackson- ville, FL USA Tel: +1 904 953 2000 Fax: +1 904 953 0655 Email: palmer.william@mayo.edu Received October 2011 Accepted October 2011 1 Division of Gastroenterology, Mayo Clinic, Jacksonville, FL USA 2 Division of Gastroenterology, Mayo Clinic, Arizona, USA 3 Division of Anesthesiology, Mayo Clinic, Jacksonville, FL USA 4 Division of Radiology, Mayo Clinic, Jacksonville, FL USA 5 Division of Internal Medicine, Mayo Clinic, Jacksonville, FL USA CASE REPORT 1158 | sion of a left seminal vesicle cyst with a displaced bladder (Figure 1). The first documented visualization of the 6 × 5 × 9 cm cyst by CT scan had been 17 months earlier. Failed Foley catheter placement by the Urology team and the need for more definite evaluation of anatomy prompted further imaging. A magnetic resonance image (MRI) without con- trast demonstrated an 11.5 × 9 × 3.4 cm cystic mass com- pressing the bladder anteriorly, which was consistent with a large infected left seminal vesicle cyst (Figure 2). Percutaneous drainage of the cyst yielded 720 mL of dark fluid at the time of placement, and another 400 mL over the next several days via an indwelling drain. Culture of the flu- id showed methicillin-sensitive staphylococcus aureus with the same sensitivity pattern as the positive blood culture that was performed during the previous hospitalization. The drain was removed and the patient was discharged on van- comycin. Blood cultures drawn two weeks later remained negative but the patient required transurethral unroofing of the cyst due to recurrence of the abscess. DISCUSSION Patients with seminal vesicle cysts can present with dysuria, epididymitis, prostatitis, or simply vague pain complaints of the lower abdomen, perineum, scrotum or lower back.(6) However, patients with small cysts found incidentally often require no intervention.(7) There has been at least one case report of a chronic seminal vesicle cyst infections in which pain was not present, with the only symptoms being urinary frequency and nocturia.(6) Imaging techniques depend on presentation and clinical in- tuition. However, all have limitations. Vesiculography calls for general anesthesia and radiation exposure, along with needle insertion through the scrotal sac and vas deferens.(8) Transrectal ultrasound is invasive and limited by low reso- lution and soft-tissue contrast.(7) MRI can provide more in- formation regarding tissue density and characteristics than any of the other imaging modality. This is key in determin- ing whether the fluid inside the cyst is thin, proteinaceous, or hemorrhagic. However, MRI has its own drawbacks. It is more expensive than CT, and the administration of gado- linium may be contraindicated in renal patients due to the risk of nephrogenic systemic fibrosis.(9) This case suggests that, the threshold to use MRI to assess the cyst for infection should be low. In low risk patients with a recent abdominal image that can be used for com- parison, a contrast-assisted CT scan is reasonable to assess cyst anatomy. However, in light of the need for very ac- curate soft tissue differentiation in diagnosing an infected Figure 1. Non-contrasted CT on the day of admission showed a large fluid filled structure, thought to be bladder. Figure 2. MRI without contrast showing infection of a giant semi- nal vesicle cyst. Case Report 1159Vol. 10 | No. 4 | Autumn 2013 |U R O LO G Y J O U R N A L Seminal Vesicle Cyst Infection | Palmer et al seminal vesicular cyst, high clinical suspicion for infection should steer clinical management toward a non-contrasted MRI in order to make both the diagnosis and the appropri- ate therapeutic decisions. CONFLICT OF INTEREST None declared. REFERENCES 1. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. N Engl J Med. 1980;302:1246- 51. 2. Demierre MF, Gerstein W. Segmental neurofibromatosis with ipsilateral renal agenesis. Int J Dermatol. 1996;35:445-7. 3. Gallmetzer J, Gozzi C, Dolif R, Salsa A. Seminal vesicle cyst (and ejaculatory duct cyst) with ipsilateral renal agenesis. Report of five cases and review of literature. Minerva Urol Nefrol. 1999;51:27-31. 4. Denes FT, Montellato NI, Lopes RN, Barbosa Filho CM, Cabral AD. Seminal vesicle cyst and ipsilateral renal agenesis. Urol- ogy. 1986;28:313-315 5. Rappe BJ, Meuleman EJ, Debruyne FM. Seminal Vesicle Cyst with Ipsilateral Renal Agenesis. Urol Int. 1993;50:54-6. 6. Chen TW, Yang ZG, Li Y, Zhou P, Qian LL, Zhang SF. Chronic infection of seminal vesicle cyst as depicted on MR Imaging. Korean J Radiol. 2008;9 Suppl:S73-6. 7. Carter SS, Shinohara K, Lipshultz LI. Transrectal ultrasonog- raphy in disorder of the seminal vesicles and ejaculatory ducts. Urol Clin North Am. 1989;16:773-90. 8. Dunnick NR, Ford K, Osborne D, Carson CC 3rd, Paulson DF. Seminal vesiculography: limited value in vesiculitis. Urology. 1982;20:454-457 9. Centers for Disease Control and Prevention (CDC). Nephro- genic fibrosing dermopathy associated with exposure to gadolinium-containing contrast agents--St. Louis, Missouri, 2002-2006. MMWR Morb Mortal Wkly Rep. 2007;56:137-41.