Seminal Vesiculography Research Articles

(182) Transurethral Laser Incision of Ejaculatory Duct for Complete Ejaculatory Duct Obstruction

Abstract Introduction It is estimated that approximately 5% of men presenting with infertility suffer from ejaculatory duct obstruction (EDO). Patients suspected to have EDO typically have a palpable vas deferens and normal testicular exam. On semen analysis, low volume and acidic pH should increase suspicion, and transrectal ultrasound is most commonly the first diagnostic modality utilized to confirm the diagnosis when suspecting EDO. Objective The objective of this surgical video is to describe the use of holmium laser for the management of ejaculatory duct obstruction (EDO) in the setting of obstructive azoospermia. Methods This was a 35 year old male with no significant past medical history who presented with obstructive azoospermia. His partner was a 32 year old female with no significant past medical history, with regular menstrual cycles, and a normal female reproductive evaluation. Semen analysis was significant for low volume (0.5 mL) azoospermia with an acidic pH (6.8). Abdominal and pelvic computerized tomography (CT) scan from 2017 when the patient presented for appendicitis noted an incidental finding of a 9.9 cm prostatic cyst. Thus, a transrectal ultrasound (TRUS) guided aspiration was performed in the ambulatory clinic which demonstrated a large prostatic cyst, with non-motile sperm in the aspirate. The patient was consented for Cystoscopy with transurethral laser incision of ejaculatory ducts. A 22 French (F) cystoscope was used, first for pan-cystourethroscopy, and then to cannulate the right ejaculatory duct with 5F pollack catheter and guide wire. Guide wire and catheter positioning within the cyst was confirmed with fluoroscopy. A 24F resectoscope with a laser bridge working element and 550 micron holmium laser fiber at settings of 1 Joule of energy and 10 hertz frequency to incise the right ejaculatory duct, circumferentially around the wire. The ejaculatory duct was incised and cyst was drained until the ejaculatory duct and thus prostatic cyst could be cannulated and examined with the cystoscope. On examination of the cyst, no vasal openings were identified. Left seminal vesiculography was attempted but unsuccessful due to significant contrast extravasation into the urethra. Results The case went well and was uncomplicated. There were no immediate or delayed complications or adverse effects reported by the patient. Post-operative instructions included rest for 1 week, followed by ejaculation every other day for 3 months. Semen analysis and transrectal ultrasound will be performed at 3 months post-operative. Conclusions Transurethral laser incision of ejaculatory duct is a safe surgical intervention for management of complete ejaculatory duct obstruction, and is demonstrated successfully in this step-by-step surgical video. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Boston Scientific.

Red Sky in Morning: A Case of Concurrent Hematospermia and Anorgasmia

ABSTRACT Introduction Hematospermia, or blood in the ejaculate, usually follows a benign course. However, it can be a source of considerable anxiety in patients. Similarly anorgasmia, or the inability to achieve orgasm despite adequate sexual stimulation may cause significant psychological distress. These rare conditions pose unique challenges for diagnosis and treatment and have distinct considerations when they occur together. Objective We present a case of concurrent hematospermia and anorgasmia with the diagnostic and treatment procedures for both. We report that simultaneous cystoscopy, electroejaculation (EEJ), transurethral resection of ejaculatory ducts (TURED), and seminal vesiculography is safe and effective as a diagnostic and treatment modality. Methods Medical history, physical exam, laboratory analyses of blood, urine, and semen were performed. A cystoscopic video of the prostatic urethra was recorded while performing EEJ, in order to observe hematospermia under direct vision. A TURED was then performed to evaluate the ejaculatory ducts and to facilitate seminal vesiculography. Results A healthy 36 year old man reported avoidance of all sexual activity after a few episodes of hematospermia due to extreme fear. He continued to note bloody discharge on occasion in the morning, attributing this to bloody nocturnal emissions. Despite normal erectile function, he adamantly avoided all sexual activity including masturbation. Prior STI workup, cystoscopy, urinalysis, urine and semen cultures were all negative. Prior treatments with finasteride, NSAIDs, and antibiotics failed to reduce the frequency of hematospermia, and he had minimal improvement in libido with cabergoline and buproprion. Concurrent urethroscopy and EEJ revealed initial hematospermia from bilateral ejaculatory ducts with normal, white emission after several seconds. A TURED and direct seminal vesiculography revealed hypoplastic seminal vesicles bilaterally. The patient tolerated the procedure well and had resolution of hematospermia post-operatively. He reports improvement in libido and willingness to attempt sexual activity. Conclusions Despite a usually benign clinical course, hematospermia can provoke great anxiety in patients to the point of avoidance of sexual activity. We propose a causal relationship between hematospermia and our patient's sexual dysfunction and anorgasmia, as the patient reports renewed interest in sex after his hematospermia resolved post-operatively. A thorough evaluation to rule out more serious pathology and to address the patient's anxiety included simultaneous cystoscopy, EEJ, TURED, and seminal vesiculography. This was both safe and effective in diagnosis and treatment of concurrent hematospermia and anorgasmia, and is the first video demonstration of simultaneous cystoscopy and EEJ reported in the literature to our knowledge. Disclosure No

An update on the diagnosis and management of ejaculatory duct obstruction.

Ejaculatory duct obstruction (EDO) remains a rare but surgically correctable cause of male sexual dysfunction and male infertility due to obstructive azoospermia, diagnosed in up to 5% of infertile men. EDO should, therefore, be considered within the list of differential diagnoses for men undergoing infertility investigations, with work up including clinical examination, transurethral ultrasonography, semen analysis, chromotubation, seminal vesiculography and seminal vesicle aspiration. Obstruction can be limited to the distal ends of the ducts or it can extend proximally to include the terminal portions of the vasa deferentia, with the site and length of the obstruction having implications for surgical intervention. Early endoscopic treatment can reverse symptoms and prevent the progression of partial obstruction to bilateral, complete obstruction, and transurethral resection of the ejaculatory duct remains the main treatment option for EDO. Alternative treatment options include endoscopic laser-assisted resection of the ducts, antegrade seminal-vesicle lavage to relieve EDO secondary to inspissated material or calculi, or dilatation of the ejaculatory ducts using 9F seminal vesicoscopy or balloon.

Hybrid Method of Transurethral Resection of Ejaculatory Ducts Using Holmium:Yttriumaluminium Garnet Laser on Complete Ejaculatory Duct Obstruction

A 32-year old single man presented with azoospermia and low semen volume which was noted one and half a year ago. Transrectal ultrasonography and seminal vesiculography were performed to evaluate ejaculatory duct obstruction, and transurethral resection of the ejaculatory duct was performed using a hybrid technique of holmium:yttriumaluminium garnet laser with monopolar transurethral resection to overcome the narrow prostatic urethra. To our knowledge, this is the first report on the successful outcome of a hybrid technique applied for transurethral resection of the ejaculatory duct.

Ectopic insertion of the ureter into the seminal vesicle

We present a case of left ectopic ureter insertion into the left seminal vesicle which is a rare anomaly. The incidence of ectopic insertion of the ureter is more common in females and is usually associated with incontinence, leading to the diagnosis, while in males it is present with infection. Ectopic ureter is defined as abnormal insertion of the ureter, occurring in the posterior urethra in approximately 50% of cases in males. Other sites include the seminal vesicle (approximately one-third), vas deferens, bladder neck, prostate and epididymis, while the urethra and vagina are commonly affected in females. Management is usually addressed to the upper tract only; if there is incontinence it requires removal of the ureteric stump. Our case was initially diagnosed by magnetic resonance imaging and the diagnosis confirmed by computed tomography (CT) guided seminal vesiculography as transrectal guidance for seminal vesiculography was refused by the patient. CT guided seminal vesiculography is less painful and more tolerable than the transrectal route.

Radiological Evaluation of Lower Genitourinary Tract Cysts in Males

Aim of the Work: The present wok aims to assess how to reach the optimum diagnosis of the nature and the complications of lower genitourinary tract cyst in male patient using different radiological imaging modalities. Patients and Methods: 1000 male patients were evaluated with pelvic ultrasound and if lower genitourinary tract cysts were present, the patients were further subjected to either trans-rectal ultrasound (TRUS), TRUS guided aspiration for presence of spermatozoa, TRUS guided seminal vesiculography or CT urography in order to reach the origin of the cyst and the complications of its presence. Results: 14 cases were detected with lower genitourinary tract cysts among our patients with an overall incidence 1.4%; among them 3 patients with mid line prostatic cysts showed normal seminal analysis; 1 patient with prostatic cyst was infertile; 3 patients were detected with infravesical cysts after transurethral resection prostatectomy; 2 cases with small retention cysts were associated with benign prostatic hyperplasia; 1 case was detected with prostatic abscess; 1 patient was detected with unilateral ureterocele; 1 patient was detected with large pelvi abdominal unilateral seminal vesicle cyst; 1 patient was with unilateral ejaculatory duct cyst; 1 patient with small cystic dilation of prostatic urethra was associated with urethral stone.

Trus-guided seminal vesicle aspiration in diagnosis of partial ejeculatory duct obstruction

There has been recent interest in techniques for diagnosing ejaculatory duct obstruction (EDO), especially when the partial form of the disease is suspected clinically. Currently, there is no gold standard technique for diagnosing EDO. Transrectal ultrasonography (TRUS), which is the technique used most widely, can overdiagnose EDO. As adjunctive diagnostic techniques, duct chromotubation and seminal vesiculography cannot distinguish patients with partial obstruction from those without EDO. TRUS-guided seminal vesicle aspiration can be used in conjunction with TRUS to confirm the diagnosis pre-operatively, especially in patients with seminal vesicle dilation and a prostatic midline/ejaculatory duct cyst on TRUS. In patients with findings of chronic inflammation, such as ejaculatory duct calcifications and seminal vesicle atrophy/ hypoplasia on TRUS, proximal vasal obstruction or functional EDO should be excluded.

Simultaneous computed tomography and seminal vesiculography in a patient with ejaculatory duct obstruction.

A 32-year-old man presented with primary infertility. He had azoospermia with low volume ejaculate. Physical examination was normal. Transrectal ultrasonography (TRUS) revealed grossly dilated seminal vesicles. No other genitourinary tract abnormality was noted. He underwent TRUS-guided aspiration of the seminal vesicles with simultaneous instillation of contrast media and methylene blue dye into the seminal vesicles. The aspirate showed scanty sperms. Conventional radiograph (Figure 1) and simultaneous computed tomography (CT) and seminal vesiculogram images (Figure 2) were taken, which revealed the spectacular appearance of huge seminal vesicles and retrograde flow of contrast media into the proximally dilated system upto the epididymis. The dilated ejaculatory duct anatomy could be seen with exceptional clarity. The patient underwent transurethral resection of the ejaculatory ducts on the same day until free flow of methylene blue was noted from a wide open orifice (Figure 3). Postoperatively, he developed seminal vesiculitis which was treated with oral ciprofloxacin. He showed a delayed return of sperms into the ejaculate at 9 months.

Imaging in male-factor obstructive infertility

The main purpose of imaging evaluation in male infertility is to identify and treat correctable causes of infertility, such as obstruction of the seminal tract. Various imaging modalities are available to evaluate men with obstructive infertility including scrotal ultrasonography, transrectal ultrasound (TRUS), vasography, magnetic resonance imaging, seminal vesicle aspiration, seminal tract washout, and seminal vesiculography. To date the most reliable and accurate diagnostic technique for obstructive infertility is unclear. In this review article, we report the role of these modalities in diagnosis of obstructive infertility. Scrotal sonography is the initial modality, and if patient results indicate non obstructive azoospermia as varicocele or testicular pathology they will be treated according to standard protocols for management of these pathologies. If the patient findings indicate proximal obstructive azoospermia, they can be managed by vasoepididymostomy. If the scrotal ultrasound is normal, TRUS is the second imaging modality. Accordingly, they are classified into patients with criteria of obstructive infertility without urogenital cysts where TRUS-guided aspiration and seminal vesiculography can be performed and transurethral resection of the ejaculatory ducts (TURED) will be the management of choice. In patients with urogenital cyst, TRUS-guided cyst aspiration and opacification are performed. If the cyst is communicating with the seminal tract, management will be transurethral incision of the cyst. If the cyst is not in communication, the obstruction may be relieved after cyst aspiration. If the obstruction is not relieved, TURED will be the management of choice. Sperm harvested during aspiration may be stored and used in assisted reproduction techniques. If the results of TRUS are inconclusive or doubtful, endorectal magnetic resonance imaging should be performed to serve as a "detailed map" for guiding corrective operative interventions.

Transrectal Ultrasound- and Fluoroscopic-Assisted Transurethral Incision of Ejaculatory Ducts: A Problem-Solving Approach to Nonmalignant Hematospermia Due to Ejaculatory Duct Obstruction

Ejaculatory duct obstruction (EJDO) has traditionally been managed with transurethral resection of ejaculatory ducts (TURED). However, wide resection has potential complications and risk of postoperative morbidity. We demonstrate a technique using transrectal ultrasonography (TRUS) and fluoroscopy to assist with transurethral incision of the ejaculatory duct (TUIED) to treat hematospermia due to obstruction by either a stone or a prostatic cyst. Twenty-five patients with ejaculatory disorders including hematospermia underwent TUIED between 1997 and 2005. Diagnosis, the cause of hematospermia, and the level of EJDO was confirmed by semen analysis, semen culture, and TRUS. All patients were subjected to TRUS-guided seminal vesicle aspiration followed by seminal vesiculography using methylene blue mixed with contrast under biplanar TRUS guidance and fluoroscopic monitoring. After confirming the cause and level of obstruction, the ejaculatory duct was opened using endoscissors until the obstruction was relieved as confirmed by free flow of methylene blue. Stones were removed if any were present. A Foley catheter was kept in place for 24 hours. Improvement of symptoms was noted in 96% of patients with ejaculatory disorders. All patients with painful ejaculation and hematospermia had complete remission of symptoms at 3 months postoperatively; three patients had transient epididymo-orchitis, and none had retrograde ejaculation or incontinence. TUIED is a viable and minimally-invasive option for treating EJDO causing ejaculatory disorders including hematospermia with minimal morbidity and early recovery.

Ejaculatory Duct Manometry in Normal Men and in Patients With Ejaculatory Duct Obstruction

Ejaculatory duct obstruction is a treatable cause of male infertility but the diagnosis can be difficult to make. Transrectal ultrasound is valuable but not specific for ejaculatory duct obstruction. Adjunctive procedures, such as chromotubation and seminal vesicle aspiration, are more sensitive but not definitive, especially for partial obstruction. We describe what is to our knowledge a new hydraulic test and report its ability to identify physical and functional ejaculatory duct obstruction. Two groups of men were studied, including patients with infertility or ejaculatory pain in whom ejaculatory duct obstruction was suspected and fertile men undergoing vasectomy reversal (controls). In each cohort ejaculatory duct injection and manometry were performed. Patients with ejaculatory duct obstruction underwent transurethral ejaculatory duct resection based on routine criteria. Pressure was reassessed after resection. Manometry pressures were compared between controls and patients with ejaculatory duct obstruction, and correlated with the response to transurethral ejaculatory duct resection. In the 7 controls (14 sides) mean ejaculatory duct opening pressure was 33.2 cm H(2)O. In the 9 patients (17 sides) with suspected ejaculatory duct obstruction mean ejaculatory duct opening pressure before transurethral ejaculatory duct resection was 116 cm H(2)O. In the 6 patients who underwent resection, which was unilateral and bilateral in 3 each, mean ejaculatory duct opening pressure decreased from 118 to 53 cm H(2)O. Of the 5 patients who underwent semen analyses before and after resection 80% showed an increase in ejaculate volume and/or at least 100% improvement in TMC (volume x concentration x motile fraction). Ejaculatory duct manometry with baseline values defined in fertile men demonstrates that men with clinically suspected ejaculatory duct obstruction have higher ejaculatory duct opening pressure than fertile men and ejaculatory duct pressure decreases after transurethral ejaculatory duct resection.

Report on evaluation of the azoospermic male

Report on evaluation of the azoospermic male

Transrectal US–guided Seminal Vesiculography and Ejaculatory Duct Recanalization and Balloon Dilation for Treatment of Chronic Pelvic Pain

Ejaculatory duct obstruction (EDO) is an uncommon but correctable cause of infertility and male chronic pelvic pain. The condition is thought to be underdiagnosed, but the increased application of noninvasive imaging tools, specifically transrectal ultrasonography (US), has lead to greater recognition of EDO. Moreover, the development of minimally invasive therapies now offers comprehensive evaluation and treatment options with low morbidity for select patient groups. This report describes the technique of transrectal US-guided seminal vesiculography, percutaneous recanalization, and ejaculatory duct balloon dilation for EDO as a treatment for male chronic pelvic pain.

A Prospective Comparison of 3 Diagnostic Methods to Evaluate Ejaculatory Duct Obstruction

Various diagnostic tests are available to evaluate patients with ejaculatory duct obstruction (EDO). However, the most accurate diagnostic technique, defined as the one that best predicts a successful outcome after ejaculatory duct resection, is unclear. We prospectively performed transrectal ultrasound (TRUS) and 3 other tests in men with EDO and determined their relative value in this diagnosis. Patients with suspected EDO on clinical evaluation that included TRUS proceeded to further intraoperative evaluation with duct chromotubation, seminal vesicle aspiration and seminal vesiculography. A comparative analysis of findings from each technique was performed and the success of subsequent transurethral resection procedures was assessed. All 25 patients had evidence of EDO on diagnostic TRUS, a finding that merited further evaluation with other modalities. However, TRUS findings correlated poorly with those of the other diagnostic tests. Obstruction on TRUS was confirmed in only 52%, 48% and 36% of vesiculography, seminal vesicle aspiration and duct chromotubation studies, respectively. A better correlation was observed between the dynamic tests of duct chromotubation and seminal vesiculography. Based on all diagnostic tests only 12 patients (48%) proceeded to duct resection, of whom 10 (83%) showed significant improvement in semen analysis parameters or clinical symptoms after the procedure. A comparative analysis of 4 diagnostic techniques suggests that TRUS alone has poor specificity for EDO evaluation. Incorporating dynamic tests into the algorithm of EDO diagnosis may decrease unnecessary duct resection procedures and improve the success of the resection procedures that are indicated.

Can ejaculatory duct obstruction be due to unilateral blockage?

Objectives: Ejaculatory duct obstruction due to bilateral blockage of the ducts is a well recognized and treatable cause of male infertility. In these cases, duct obstruction can be either complete (azoospermia) or partial (sperm in ejaculate) in nature. Through the use of functional diagnostic tests in addition to transrectal ultrasound, we have identified the fact that ejaculatory duct obstruction can result from unilateral instead of bilateral blockage within the ductal system and report our treatment findings in affected patients.Design: Prospective study of a consecutive series of male infertility patients in a single institution.Methods: Twelve male infertility patients with suspected EDO by clinical evaluation that included TRUS proceeded to further intraoperative evaluation with duct chromotubation, seminal vesicle aspiration, and seminal vesiculography. Eight patients proceeded to transurethral resection procedures after confirmation of the diagnosis with further testing. An analysis of diagnostic findings and postoperative outcomes was undertaken in this surgical cohort.Results: Diagnostic TRUS suggested bilateral EDO in all 8 patients. However, chromotubation and seminal vesiculography each suggested unilateral obstruction in 5/8 (62%) of patients. Among patients with EDO due to unilateral blockage, the obstruction was complete in 1/5 and partial in 4/5. TURED successfully increased semen quality (>50% increase in total motile sperm count) in 5/5 men with unilateral obstruction.Conclusions: Unilateral blockage as a cause of EDO is an understudied but treatable condition. It is more likely to present as partial rather than complete obstruction and the addition of “functional” diagnostic tests may be needed to accurately make the diagnosis. Objectives: Ejaculatory duct obstruction due to bilateral blockage of the ducts is a well recognized and treatable cause of male infertility. In these cases, duct obstruction can be either complete (azoospermia) or partial (sperm in ejaculate) in nature. Through the use of functional diagnostic tests in addition to transrectal ultrasound, we have identified the fact that ejaculatory duct obstruction can result from unilateral instead of bilateral blockage within the ductal system and report our treatment findings in affected patients. Design: Prospective study of a consecutive series of male infertility patients in a single institution. Methods: Twelve male infertility patients with suspected EDO by clinical evaluation that included TRUS proceeded to further intraoperative evaluation with duct chromotubation, seminal vesicle aspiration, and seminal vesiculography. Eight patients proceeded to transurethral resection procedures after confirmation of the diagnosis with further testing. An analysis of diagnostic findings and postoperative outcomes was undertaken in this surgical cohort. Results: Diagnostic TRUS suggested bilateral EDO in all 8 patients. However, chromotubation and seminal vesiculography each suggested unilateral obstruction in 5/8 (62%) of patients. Among patients with EDO due to unilateral blockage, the obstruction was complete in 1/5 and partial in 4/5. TURED successfully increased semen quality (>50% increase in total motile sperm count) in 5/5 men with unilateral obstruction. Conclusions: Unilateral blockage as a cause of EDO is an understudied but treatable condition. It is more likely to present as partial rather than complete obstruction and the addition of “functional” diagnostic tests may be needed to accurately make the diagnosis.

Best practice policies for male infertility

University of California, San Francisco, San Francisco, California; Johns Hopkins University School of Medicine, Baltimore, Maryland; University of Louisville School of Medicine, Louisville, Kentucky; Baylor College of Medicine, Houston, Texas; Brown University, Providence, Rhode Island; Cleveland Clinic Foundation, Cleveland, Ohio; New York Presbyterian Hospital-Cornell, New York, New York; University of Virginia School of Medicine, Charlottesville, Virginia; Mayo Medical School, Rochester, Minnesota; University of Pennsylvania School of Medicine, York, Pennsylvania; University of California, Davis, Davis, California; and SUNY Health Science Center at Brooklyn, Brooklyn, New York

Imaging of the Male Reproductive Tract

Radiologic imaging may often play a critical role in the evaluation and management of patients with male factor infertility. Historically, the role of radiologic imaging was confined to vasography in the diagnosis of obstructive azoospermia. Today, radiologic imaging modalities have three indications in subfertile men. The first is the evaluation and management of obstruction of the excurrent ductal system in patients with azoospermia. Vasography, transrectal ultrasonography (TRUS), or seminal vesiculography is performed in this situation. The second indication is the evaluation and management of varicoceles, for which either venography or scrotal ultrasonography is routinely performed. Finally, radiologic imaging studies of the upper urinary tract are indicated for patients with congenital anomalies of the Wolffian duct system. Ultrasonography is the modality of choice for screening the upper tracts of men with vasal agenesis. Patients with bilateral vasal agenesis have a much lower frequency (< 20%) of upper tract abnormalities than patients with unilateral vasal agenesis (up to 70%). This chapter specifically discusses imaging modalities used in the management of obstruction and varicoceles.

Transrectal US-guided seminal vesiculography.

Transrectal ultrasound (US)-guided seminal vesiculography is a technique that couples US with radiography to evaluate male-factor infertility. Seminal vesiculography was performed in 12 patients after needle puncture of the seminal vesicle to inject contrast material for radiography. Seminal vesiculography helped imaging of the distal male reproductive tract (vas deferens, seminal vesicles, ejaculatory ducts). This method is an improvement over standard vasography for evaluation of infertility in men with suspected ejaculatory-duct obstruction.

Role of ultrasound in the assessment of male infertility.

The use of ultrasonography has become an important component in the evaluation and treatment of male reproductive tract disorders. From the use of color flow Doppler ultrasonography for the assessment of varicoceles to transrectal ultrasonography combined with seminal vesiculography for the evaluation of ejaculatory duct obstruction, ultrasonography has practical clinical applications. In this article, the authors review the indications and use of ultrasonography in the assessment and treatment of the infertile male. The recent advances in diagnostic transrectal ultrasonography for ejaculatory duct obstruction, in particular, are emphasized.

Diagnosis of vasal obstruction with seminal vesiculography: an alternative to vasography in select patients

To determine whether the pelvic and inguinal portion of the vas deferens can be visualized during seminal vesiculography. Retrospective review of the seminal vesiculograms performed in six patients to determine the frequency of visualization of the vas deferens. A prospective evaluation to determine the amount of contrast necessary to visualize the vas deferens was performed in three patients. The vas deferens was visualized down to the level of the scrotum in four of the six initial studies examined retrospectively. The vas deferens was visualized adequately after the infusion of > or = 10 mL of contrast in all three studies performed prospectively. Seminal vesiculography is a minimally invasive diagnostic alternative to vasography that can be used to document the patency of the pelvic and inguinal portions of the vas deferens in select patients.