1021

Cysts of the Prostate and Seminal Vesicles: MR Imaging Findings in II

Cases

:.

P. A. Gevenois1 M. L. Van Sinoy1 S. A. Sintzoff, Jr.1 B. Stallenberg1 I. Salmon2 G. Van Regemorter J_ Struyven1

Cysts of the prostate and seminal vesicles are confusing abnormalities because they are uncommon and their origin is uncertain. Several approaches to diagnosis have been used, most recently CT and transrectal sonography. In this study, we investigated the value of MR imaging in the diagnosis of six cases of prostatic cyst and five cases of cysts of the seminal vesicles. All patients were symptomatic. TI- and T2-weighted spinecho images were obtained in all cases; pathologic confirmation was available in four

patients. MR images were analyzed prospectively without knowledge of clinical data or the results of other imaging procedures. In all cases, low- and high-signal masses were

observed

on Ti- and T2-weighted

images,

respectively.

The cysts were unilocular

with

a sharply defined margin, ranging from 0.5 to 3.0 cm in diameter. The thin wall was of low signal intensity on T2-weighted images. Our experience suggests that MR imaging is useful in demonstrating the liquid content of prostatic and seminal-vesicle cysts and in establishing their size and location.

AJR 155:1021-1024,

November

1990

Cysts of the seminal vesicles are an uncommon congenital or acquired abnormality. In some cases, they are accompanied by ipsilateral renal agenesis [1 ]. The

MR features
utricular cysts,

of this disorder
mUllerian duct

have been described

cysts, prostatic

[2, 3]. Prostatic

cysts, and

cysts
cysts

include
of the

retention

ejaculatory duct. The CT and sonographic findings of midline prostatic cysts have been reported. More recently, MR imaging has proved to be reliable in identifying
mUllerian diagnose duct cysts cysts [1-9]. We report our experience in using of the prostate and seminal vesicles in 1 1 patients. MR imaging to

Subjects

and

Methods in six patients The patients

were suspected

MR imaging was performed cysts of the seminal vesicles.

patients Received March 23, 1990; sionJune 15, 1990. 1 Department of Radiology, accepted Cliniques after reviwere symptomatic and

with were

prostatic

cysts

and in five patients

with

24-84

years old (mean,

of having disorders

60 years).
of the prostate

All

clinically

and seminal vesicles. The examinations were performed without knowledge sonographic findings. Prostatism was present in six cases, acute prostatitis
and hemospermia in one case each. in one case. Chronic prostatic abscess Digital examination revealed a smooth and urothelial cystic swelling

of clinical or in two cases,

Universide Lenreprint Universi-

taires do Bruxelles, H#{243}pital Erasme, Route nik 808, 1070 Brussels, Belgium. Address

cancer were present of the prostate or of

requests to P. A. Gevenois.
2

a seminal vesicle in two cases. Pathologic confirmation was obtained

in four patients by either transurethral

with benign hyperplasia).

resection
hyperplasia One patient

(one
and has

Department de Bruxelles,

of Pathology,

Cliniques

taires

H#{244}pital Erasme, of Urology. Cliniques

1 070 Brussels, Universitaires

prostatic cyst) or surgery (two seminal vesicle cysts associated chronic abscess and one prostatic cyst associated with benign

Belgium. 3 Department

been treated by transrectal

No chemical MR images
555-1 021

needle aspiration

without

histologic
patients

examination
were treated

of any material.
conservatively. Eindhoven,

analyses

of the cystic

fluid were done. Other

de Bruxelles,
gium. 0361 -803X/90/1

H#{244}pital Erasme, 1070 Brussels, Bel-

In these cases, the diagnoses

were obtained

were not confirmed

with a 1 .5-T Gyroscan
the patients were

by histologic

examination.
unit (Philips,
supine.

515 MR imaging
examined while

American Roentgen Ray Society

the Netherlands) that was operated cases, a body coil was used, and

at 0.5 T for one patient and at 1 .5 T for the others.

A 256-

In all

by 256-

1022

GEVENOIS

El

AL.

AJR:155,

November

1990

pixel

matrix with

was

used.

In all 1 1 patients,

sagittal 0.5-mm

Ti -weighted, gaps. acid Sagittal

350/ T2was

be excluded.

Congenital

enlargement

of the utricle

may occur

20 (TRITE), and transaxial

obtained 5-mm-thick

T2-weighted,
sections and

2020/20-100,

images were
gadolin-

and may be associated

with hypospadias,

cryptorchidism,

or

weighted
ium 1 4,7,1

images

were obtained

in two patients.
tetraacetic

In one case,
(Gd-DOTA)

0-tetraazacyclododecane

used, and enhanced Ti-weighted transverse images were obtained. MR images were analyzed prospectively by an experienced radiologist without tests. knowledge The of the appearance clinical of the findings cysts or the was results of other for size, imaging analyzed

renal agenesis. Such association did not occur in any of our cases. Enlargement also can result from obstruction caused by inflammation. MUllerian duct Cysts also are midline, but

extend superiorly from the level of the verumontanum [9], even outside the prostate. The last feature was observed in one case (Fig. 4). On the basis of this feature, the mass was
supposed to be m#{252}llerian origin. Anatomically, in midline prostatic cysts derive from the caudal fused ends of mUllerian ducts at the level of the verumontanum. Recently, several reports have emphasized the differences in the embryologic origin of the urogenital sinus and the mUllerian ducts from the entoderm and mesoderm, respectively [1 0]. Histopathologically, the distinction is confusing. Transitional epithelium, stratified squamous epithelium, cuboidal epithelium, and even no epithelial lining have been reported [1 1]. The contents of mUllerian duct cysts vary (mucoid, purulent, serous, or hemorrhagic). When blood is present (not observed in our series), both Ti - and 12-weighted images show a high signal within the cyst [9]. In a previous study [1 2] of 22 normal volunteers with no known urinary tract disorders who were less than 30 years old, we observed a high-intensity signal on 12-weighted im-

margins, patients
cystic

location,

and signal

intensity.

One patient had transabdominal

had transrectal
nature of the

sonography
This
in all but one

and CT. The other

suggested
In this

sonography.

method
case.

the

abnormality

patient,

the cystic

nature

was revealed

by transurethral

resection.

Results

All cases high-signal

had a similar appearance masses were observed

on MR images: low- and on Ti - and 12-weighted

images,

respectively.

This feature

suggests

that the lesion

was filled with fluid. The cysts were all unilocular with sharply defined margins. The thin wall was of low signal intensity on 12-weighted images. The cysts were similar in size, from 0.5

to 3.0 cm in diameter. They were hypointense to the prostate on unenhanced 11 -weighted

with respect images. After

injection of Gd-DOIA (one case), no significant enhancement was noted. In the seminal vesicles (Figs. 1 and 2), cysts were

ages in the midline,

between

the peripheral

and the central

localized on the left in three cases and on the right in two cases. In the prostate, they were in the midline in four cases
(Figs. 3 and 4) and lateral in two cases (Figs. 5 and 6). When in the midline, they arose at the level of the verumontanum and, in one case, extended upward from the prostate between the seminal vesicle (Fig. 4).
Discussion

parts of the prostate. They were less than 3 mm in diameter in our three cases. The significance of such a finding is unclear. The demonstration of a midline cystic structure relating to the prostate and the verumontanum is helpful in differentiating a mUllerian duct cyst from other anomalies, including a cyst of the seminal vesicles or of the prostate, as well as from a posterior bladder diverticulum [8] or a mucinous cystadenoma of the appendix [9]. Lateral Prostatic Cysts

Midline

Prostatic

Cysts The cause of lateral prostatic cysts is unclear, and the embryologic origin is not established. Acquired cysts include

Although the origin of midline prostatic cysts could not be determined noninvasively, it is likely that they were prostatic utricular or mUllerian duct cysts. A true prostatic cyst cannot

Fig. 1.-Seminal

vesicle

cyst (surgical

confir-

mation). Sagittal MR image, 350/20, shows cyst (C) with low-intensity signal between prostate (P), rectum (R), and bladder (B). 5 = symphysis pubis.

Fig. 2.-Seminal mation). Transverse

vesicle cyst (surgical MR image, 2000/50, (L5V). RSv R = rectum.

=

confirshows

high-intensity

signal in seminal

cyst (C) arising

right seminal

in left seminal vesicle vesicle, B = bladder,

Fig. 3.-Midline prostatic cyst (confirmed by transurethral resection). Transverse MR image, 2000/50, shows a high-intensity signal between two parts of peripheral prostate (p), in midline (arrow). c = central prostate, R = rectum.

AJR:155,

November

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MR

OF

PROSTATE

AND

SEMINAL

VESICLE

CYSIS

1023

Fig. 4.-Midline prostatic cyst. MUllenan duct cyst (confirmed by transrectal needle signal between two parts of peripheral prostate (pp). A, Cyst (C) arises at level of verumontanum (arrows), in posterior part of prostate, prostate, R = rectum. B, Cyst extends superiorly between two parts of peripheral prostate, outside gland. C, Cyst extends outside gland, in prostatoseminal angle. P = prostate, B = bladder.

puncture). between

Transverse two crescents

MR images, of peripheral

2000/50, prostate

show (pp).

high-intensity cp
=

central

Fig. 5.-Lateral prostatic cyst. Transverse MR image, 2000/50. Cyst (arrows) in anterior part of left peripheral prostate (p) is associated with urothelial carcinoma in defect (d) after a surgical removal of adenoma. Because of no surgical

confirmation,

pseudodiverticulum
cannot

resulting
be excluded

from
defin-

irregular tumor growth itively. R = rectum.

Fig. 6.-Lateral prostatic cyst (surgical confirmation). Transverse MR image, 2000/50, shows cyst (C) in anterior part of right peripheral prostate (P). Upper transverse images showed benign prostatic hyperplasia. 5 = symphysis pubis, R = rectum.

,,

5
parasitic cysts, cysts associated with carcinoma, and retention cysts. One of our cases was associated with benign prostatic hyperplasia, and one was associated with urothelial carcinoma in the defect after surgical removal of an adenoma. In this case, a pseudodiverticulum resulting from irregular tumor growth could not be firmly excluded. Differentiation of a prostatic cyst from a dilated prostatic acinus is established arbitrarily by size: cysts are more than 7.5 mm in diameter [1 0]. In our series, there were two cases of lateral prostatic cyst, one less than and one more than 7.5 mm in diameter. Prostatic abscesses also cause fluid-filled masses in the prostate. These occur in symptomatic patients in association with complicated acute prostatitis. real frequency. Diagnosis of these lesions has been uncommon in the past because of the difficulty in imaging these structures. Of cysts of the seminal vesicle, 32% are not associated with ipsilateral renal agenesis. In our series, no association with renal agenesis was found. Postinfection fibrosis has been suggested as the cause [1 3]. Infection of the prostate has been found in two cases, benign prostatic hyperplasia in three others. Acquired cysts are usually associated with obstruction of the ejaculatory ducts due to urinary tract infection, usually ascending from the lumen of the prostatic urethra into the seminal vesicles. Compression of the ejaculatory ducts by prostatic adenomatous nodules explains the association with benign prostatic hyperplasia. To our knowledge, no previous reports have mentioned this association. Seminal-vesicle cysts must be differentiated from cysts arising from the prostate, utricle, or mUllerian duct and from abscesses or tumors [2]. Investigation of the seminal tract

Seminal

Vesicle

Cysts

than

Cysts of the seminal vesicles are uncommon, with fewer 1 00 cases reported. This number does not reflect the

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has involved injection of the cyst with contrast material or vasovesiculography. Both Cl and transrectal sonography can delineate a prostatic or a seminal-vesicle tumor. These techniques also allow a distinction between solid and cystic structures. In one report, it was mentioned that the cyst appeared as a solid mass [1 ]. Hemorrhagic seminal vesicle cysts have been reported [2]. In this study [2], no Hounsfield numbers were mentioned, but these cysts could appear with a high attenuation rate. Transabdominal and transrectal sonography and Cl should be used as the initial diagnostic studies; MR should be reserved for more complex situations. The nature of many, if not most, pelvic cysts can be determined invasively by injecting them with contrast material or by vasovesiculography. Noninvasive methods such as sonography, Cl, or MR imaging should be performed before invasive techniques. Because of the capability of direct acquisition of multiplanar images,

management is planned. Before surgical imaging provides full anatomic definition.

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6. Elder JS, Mostwin JL. Cyst of the ejaculatory duct/urogenital sinus. J Urol 1984;132:768-771 7. Schwarts JM, Bosniak MA, Hulnick OH, Megibow AJ, Raghavendra BN. Computed tomography of midline prostatic cysts of the prostate. J Comput Assist Tomogr 1988;12:215-218 8. Neustein P, Hem PS, Goergen TG. Chronic hemospermia due to m#{252}llerian duct cyst: diagnosis by magnetic resonance imaging. J Urol 1989;142:828 9. Thumher S, Hricak H, Tanagho EA. MUllerian duct cyst: diagnosis with MR imaging. Radiology 1988;168:25-28 10. Emmett JL, Braasch WF. Cysts of the prostate gland. J Urol 1936;36:

MR imaging

is superior

to Cl and sonography

in delineating

the anatomic relationships. King et al. [1 4] reported a case in which the cystic architecture of a hemorrhagic seminal vesicle cyst was clearly depicted only on the MR image. In the same article, they stated that cysts of the male genital tract frequently are of high signal intensity on both Ti- and 12weighted images. On the basis of these features, the cysts are likely hemorrhagic and probably associated with hemospermia. It is important to show that vesicle cysts are unilocular, because malignant cystosarcoma phyllodes are described. In these malignant conditions, the tumor is multiloculated [15]. The clinical usefulness of MR imaging in evaluating seminalvesicle and prostatic cysts is in the demonstration of a cystic tumor and the location of the mass by observation of contiguous thin slices. As the definitive diagnosis requires a histologic specimen obtained by an invasive procedure, diagnosis by noninvasive methods would be appropriate if conservative

236-249
1 1 . Shuhrke TO, Kaplan GW. Prostatic utricle cyst (mUllerian duct cysts). J Urol 1978;1 19:765-767 1 2. Gevenois PA, Salmon I, Stallenberg B, Van Sinoy ML, Van Regemorter G, Struyven J. MR imaging of the normal prostate at 1 .5 telsa. Br J Radio! 1990;63: 101-107 1 3. Haeney JA, Pfister RC, Maeres EM Jr. Giant cysts of the seminal vesicles with renal agenesis. AJR 1987;1 49:139-140 14. King BF, Williamson B Jr, Hattery RR, Hartman GW, Lieber MM, Berquist TH. Seminal vesicle imaigng. RadioGraphics 1989;9:653-674 1 5. Mazur MT. Myers JL, Maddox WA. Cystic epithelial-stromal tumor of the seminal vesicle. Am J Surg Pathol 1987;1 1 :210-217