Category: Other, Miscellaneous
Introduction & Objective :
A 29 year old male presented to the ED on a Friday night with severe left testicular pain and swelling. Ultrasound revealed left epididymoorchitis, normal left testicle. Patient was discharged with levofloxacin. Urine culture and gonorrhea/chlamydia testing returned negative.
Three days later, the patient presented again to the ED, now with severe right testicular pain and swelling. The left testicular pain and swelling had resolved. Testicular ultrasound was repeated, showing right epididymoorchitis with resolution of previously seen left epididymoorchitis. Additionally he was hypotensive, tachycardic and febrile to 38.6 C. The patient was admitted to the hospital. A CT was obtained was reported as normal, after Urologist review there was evidence of a prostatic calcification.
Objectives included treatment of this septic obstructing stone in the ejaculatory duct
The patient was taken to the OR where TRUS revealed a midline hyperechoic lesion consistent with stone. After this, a 21-French cystoscope was advanced through the urethra into the bladder, which was normal. The prostate was then evaluated And the verumontanum could easily be seen. We then advanced a 0.035 guidewire within a 5-french open-ended catheter into the opening of the ejaculatory ducts . The open-ended catheter was advanced 2 cm into the ejaculatory system.
Next a 2 cm tipped passport balloon was passed through the utricle and this was dilated up to 10 ATM, equal to 4mm of dilation. After 3 minutes the balloon was deflated leaving a patulous orifice.
A 7 French rigid ureteroscope was then used to investigate the ejaculatory duct. The fluid was initially murky but was aspirated and flushed. A yellow calcification was visualized and was grasped using a zero tip nitinol basket. The calcification fragmented within the basket. All fragments were removed. The ureteroscope easily negotiated the dilated orifice. The internal anatomy of the seminal vesicles was appreciated. Additionally the opening of the vas deferens was visualized. All stone fragments had been removed in their entirety.
Transrectal ultrasound was repeated and confirmed complete clearance of the calcification, the previously dilated area was now compressible.
Results : POD 1 pain resolved, WBC normalized, he remaine afebrile and tachycardia resolved
Patient was stable for discharge on POD 2
Seminal vesiculoscopy with balloon dilation is a safe and effective management strategy for stones within the ejaculatory system
This is a very unique case of an obstructing ejaculatory system stone leading to alternating epididymoorchitis and sepsis
This is an excellent surgical intervention for an uncommon problem
Texas A&M University/Scott & White Memorial hospital