Hematospermia: imaging findings

Extraprostatic incidental findings on prostate mpMRI: A pictorial review from the ESUR junior network

The role of multiparametric MRI (mpMRI) in prostate cancer setting is increasingly consolidated and, as a result, its usage in clinical practice is in exponential growth. However, beyond the prostate gland, several key structures are included in the field of view of mpMRI scans. Consequently, various extra-prostatic incidental findings (IFs) belonging to different anatomical systems can be accidentally recognized. Therefore, it is mandatory for a radiologist to be familiar with the wide range of pathologies potentially encountered, to guide management and avoid patient anxiety and costs due to additional work-up prompted by clinically insignificant extra-prostatic findings. With this pictorial review, we aim to illustrate a wide range of IFs that can be detected when performing mpMRI of the prostate, focusing on their imaging characteristics, differential diagnosis, and clinical relevance. Additionally, we propose the CheckDEEP, the Checklist for DEtection of ExtraProstatic findings, to be used for a thorough evaluation of target areas within each anatomical system.

Imaging in Male Infertility

Infertility is defined as inability to conceive despite regular unprotected sexual intercourse for greater than 1 year. Conditions involving the male partner accounts for the infertility in approximately 50% of cases. The goals of imaging in male infertility are to detect treatable/ reversible causes, imaging for sperm retrieval from testis or epididymis for assisted reproductive techniques like in vitro fertilization or intracytoplasmic sperm injection and to provide appropriate genetic counselling for prevention of occurrence of disease in future offspring. The purpose of this article is to describe imaging features in various causes of male infertility to acquaint radiologists with various imaging appearances of causes of male infertility to avoid missing these pathologies.

Hematospermia is rarely associated with urologic malignancy: Analysis of United States claims data

BACKGROUND

Hematospermia is an alarming symptom and can cause significant patient distress, but work-up is often negative.

OBJECTIVE

To characterize the clinical evaluation of hematospermia and its association with the diagnosis of urologic malignancy.

MATERIALS AND METHODS

Using MarketScan insurance claims database, we identified adult males 18-64 years old diagnosed with hematospermia from 2010 to 2018. Benign hematospermia was defined as the absence of hematuria and elevated prostate-specific antigen. Patients with urologic cancer prior to diagnosis of hematospermia were excluded. We identified those who were diagnosed with a urologic malignancy.

RESULTS

The annual average incidence rate of hematospermia was 56.6 per 100,000 (95% confidence interval 55.4-57.8 per 100,000) in 2010 and increased to 73.6 per 100,000 (95% confidence interval 71.7-75.4 per 100,000) in 2018. A total of 56,157 patients presented with benign hematospermia. Most (57.5%) underwent at least one test, with the most common being urinalysis (51.7%), followed by prostate-specific antigen testing (11.9%). All other tests were performed in less than 3% of patients. Forty-seven patients were diagnosed with a urologic cancer, including 28 with prostate cancer (0.05%), nine with testicular cancer (0.016%), six with prostate carcinoma in situ (0.01%), and four with bladder cancer (0.007%). Stratified by age, there was only one cancer diagnosis (testicular) in 15,106 patients under 40 years (0.01%) and 46 cancer diagnoses in 40,611 patients 40 years old or above (0.11%). The median age of patients diagnosed with cancer was 56 years (interquartile range 52-61).

DISCUSSION AND CONCLUSION

A small minority of patients with benign hematospermia were later diagnosed with urologic cancer in a large nationally representative sample. After excluding hematuria with urinalysis, physicians should conservatively manage and reassure patients with hematospermia, especially those under 40 years of age.

Hematospermia Etiology, Diagnosis, Treatment, and Sexual Ramifications: A Narrative Review

INTRODUCTION

Hematospermia (HS) is the presence of blood in ejaculatory fluid. It is a rare condition that is historically idiopathic or associated with sexual behavior. Technological advances have identified many of the etiologies behind HS, improving treatment. Though often benign, HS remains a source of considerable sexual anxiety for patients. Few papers have outlined a diagnostic and therapeutic approach to HS, and none have explicitly addressed its sexual consequences.

OBJECTIVES

To provide a comprehensive overview of HS, emphasizing its sexual ramifications.

METHODS

A PubMed literature search was performed through May 2021 to identify all relevant publications related to etiology, diagnosis, treatment, and sexual effects of HS. Original research and reviews were analyzed, and pertinent studies were included in this review.

RESULTS

Iatrogenic interventions (eg, transrectal ultrasound-guided prostate biopsies) are the most common cause of HS. Infection and/or nonspecific inflammation is the most common non-iatrogenic etiology. Malignancies, including prostate, testicular, and other genitourinary cancers, are rarely the cause of HS. Diagnostic approaches to HS can be organized according to patient age (less than or greater than 40 years old), persistence of bleeding, and the presence/absence of concerning symptoms. Though HS often spontaneously resolves, treatment may require various medications (eg, antibiotics, anti-inflammatories) or surgical interventions. HS has several sexual ramifications, including libido-affecting anxiety, social repercussions from sexual partners and non-sexual affiliates, increased risk of erectile dysfunction or transmission of sexual infections, and compromised fertility, especially when cryopreservation is utilized.

CONCLUSION

HS may significantly affect sexual health through several mechanisms, though there is a paucity of formal data on this subject. Further research is needed to fully understand the severity and extent of HS's effect on sexual well-being, especially in those with refractory bleeding. Drury RH, King B, Herzog B, et al. Hematospermia Etiology, Diagnosis, Treatment, and Sexual Ramifications: A Narrative Review. Sex Med Rev. 2021;XX:XXX-XXX.

ACR Appropriateness Criteria® Hematospermia

Most men with hematospermia or hemospermia (HS) are young (<40 years of age), presenting with transient or episodic HS without other signs or symptoms of disease. The condition is self-limiting in most cases and idiopathic in nature. When a cause can be identified, infections of the urogenital tract are the most common. Imaging does not play a role in this patient population. In older men (>40 years of age), clinical screening for prostate cancer is advised. Furthermore, when HS is persistent or has symptoms, causes include obstruction or stricture at the level of the verumontanum, calcifications or calculi in the prostate, ejaculatory ducts or seminal vesicles, and cysts arising within these structures. Noninvasive imaging, predominantly transrectal ultrasound (TRUS) and MRI, can be used in men of any age with persistent or refractory HS, or other associated symptoms or signs. TRUS is considered as the first-line imaging with MRI used when TRUS is inconclusive or negative. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Magnetic Resonance Imaging in Hematospermia: Does It Increase Unnecessary Prostate Biopsy?

INTRODUCTION

Hematospermia is an uncommon presentation of prostate cancer. Following the introduction of MRI for patients with hematospermia we evaluated its use and effect on prostate biopsy and cancer detection rates.

MATERIALS AND METHODS

Analysis of patients attending our outpatient department over 2 years was undertaken. Diagnostic workup included digital rectal examination and PSA. Those with abnormal findings or persisting symptoms were offered prostate biopsy. In the second year MRI became available for patients with hematospermia. Abnormal MRI or persisting symptoms were offered biopsy. We compared the frequency of prostate biopsy and cancer detection in patients undergoing MRI and those not having imaging.

RESULTS

Forty-seven patients were referred with hematospermia. Nineteen patients did not undergo MRI; four received prostate biopsy with one adenocarcinoma found. Twenty-four patients had an MRI with 17 biopsies undertaken. Three biopsies revealed adenocarcinoma. In the MRI group 71% of patients underwent prostate biopsy but only 21% from the non-MRI group (p < 0.05). Prostate cancer detection rate in the MRI group was 18% whilst in the non-MRI group was 25% (p = 0.7).

CONCLUSIONS

Our findings indicate that caution should be used with MRI as it can lead to an increase in prostate biopsy with no change in cancer detection rate.

Natural history of hematospermia in 189 Japanese men

OBJECTIVES

To prospectively investigate the natural history of hematospermia.

METHODS

This study included 189 patients with hematospermia. All the patients underwent watchful waiting without any empirical treatment.

RESULTS

The median observation period was 52 months. Hematospermia resolved spontaneously in 168 (88.9%) of the 189 patients, and the median disease duration was 1.5 months. Kaplan-Meier analysis showed that the persistence rates of hematospermia were 57.7% at 1 month, 34.2% at 3 months, 23.3% at 6 months, 12.5% at 1 year and 7.6% at 2 years. Hematospermia reoccurred in 20 (13.5%) of the 148 patients who had adequate follow up. The recurrence-free rates were 96.6% at 3 months, 89.0% at 1 year, 84.8% at 5 years and 78.2% at 10 years. Multivariate analysis showed that seminal vesicle hemorrhage and a midline cyst of the prostate were significant factors to predict the duration of hematospermia until spontaneous resolution. The nine patients with persisting hematospermia for more than 1 year were treated with transurethral endoscopic surgery (unroofing of the midline cyst in six, and transurethral resection of the ejaculatory duct in three), and hematospermia resolved postoperatively in all these patients.

CONCLUSIONS

In patients with hematospermia without inflammation, infection or malignancy, it is important to provide information on the possibility that symptoms will resolve spontaneously and to implement measures to relieve their anxiety. Detection of seminal vesicle hemorrhage and a midline cyst of the prostate is important for prediction of the duration of hematospermia.

Hematospermia Evaluation at MR Imaging

Hematospermia is a challenging and anxiety-provoking condition that can manifest as a single episode or recur over the course of weeks to months. It is usually a benign self-limiting condition in younger sexually active males without a history of risk factors such as cancer, urogenital malformations, bleeding disorders, and their associated symptoms. However, patients with recurrent, refractory and painful hematospermia with associated symptoms, such as fever, pain, or weight loss, require evaluation through clinical assessment and noninvasive investigations to rule out underlying pathologic conditions such as ejaculatory obstruction, infectious and inflammatory causes, malignancy, vascular malformations, and systemic disorders that increase the risk of bleeding, especially when presenting in older men. If these investigations are negative, the patient should be reassured and treated accordingly. In the recent past, magnetic resonance (MR) imaging has assumed a major role in the investigation of hematospermia due to its excellent soft-tissue contrast and multiplanar capabilities. In this review, we will discuss the potential causes of hematospermia and its diagnostic workup, including pathophysiology, anatomic considerations, the imaging appearance of associated pathologic conditions, and management. (©)RSNA, 2016.

MR Imaging of the Prostate Gland

This article discusses MR imaging of the normal prostate and of disease conditions of the prostate including prostatitis, cystic lesions, amyloidosis, calculi, hematospermia, benign prostatic hyperplasia, and malignancy.

Hemospermia: long-term outcome in 165 patients

Long-term course of hemospermia has not been addressed in the sexual medicine literature. We report our 15 years' experience. From 1997 to 2012, 165 patients presented with hemospermia. Mean age was 38 years. Mean follow-up was 83 months. Laboratory evaluation and testis and transabdominal ultrasonography was done in all. Since 2008, all sonographies were done by the first author. One patient had urinary tuberculosis, one had bladder tumor and three had benign lesions at verumontanum. One patient had bilateral partial ejaculatory duct obstruction by stones. All six patients had persistent, frequently recurring or high-volume hemospermia. All pathologies were found in young patients. In the remaining 159 patients (96%), empiric treatment was given with a fluoroquinolone (Ciprofloxacin) plus an nonsteroidal anti-inflammatory drug (Celecoxib). In our 15 years of follow-up, no patient later developed life-threatening disease. Diagnostic evaluation of hemospermia is not worthwhile in the absolute majority of cases. Advanced age makes no difference. Only high-risk patients need to be evaluated. The vast majority of cases may be safely and effectively treated with empiric therapy. Almost all patients do well in long term.

Transurethral seminal vesiculoscopy in the diagnosis and treatment of intractable seminal vesiculitis

OBJECTIVE

To investigate the efficacy and safety of transurethral seminal vesiculoscopy in the diagnosis and treatment of intractable seminal vesiculitis.

METHODS

This prospective observational study enrolled patients with intractable seminal vesiculitis. The transurethral seminal vesiculoscope was inserted into the bilateral ejaculatory ducts and seminal vesicles, via the urethra. The ejaculatory ducts and seminal vesicles were visualized to confirm the diagnosis of seminal vesiculitis and to determine the cause of the disease. The seminal vesicles were washed repeatedly using 0.90% (w/v) sodium chloride before a 0.50% (w/v) levofloxacin solution was injected into the seminal vesicles.

RESULTS

A total of 114 patients participated in the study and 106 patients underwent bilateral seminal vesiculoscopy. Six patients with postoperative painful ejaculation were treated successfully with oral antibiotics and α-blockers. Two patients with postoperative epididymitis were treated successfully with a 1-week course of antibiotics. Haematospermia was alleviated in 94 of 106 patients (89%), and their pain and discomfort had either disappeared or had been obviously relieved, following treatment.

CONCLUSION

Transurethral seminal vesiculoscopy is effective for diagnosing and treating intractable seminal vesiculitis.

Abnormal signal intensities of the seminal vesicles in a screening population

PURPOSE

To investigate the incidence of abnormal signal hyperintensity on T1-weighted magnetic resonance imaging (MRI) of the seminal vesicles in a screening population in order to compare clinical indicators between subjects with and without signal abnormality.

MATERIALS AND METHODS

Signal intensity of the seminal vesicles on T1-weighted images and clinical examinations were investigated in 3570 examinations of 1865 male subjects (mean age 54.8 years, range 23-86 years at the first examination).

RESULTS

Abnormal signal hyperintensity was observed at least once in 32 subjects (1.7%). Subjects with the abnormality were significantly older (average age with and without the abnormality, 64.1 vs. 54.6, respectively, P < 0.001), and the incidence of abnormality increased with increasing age (0% for the age group <40, 0.3% for 40-49, 1.3% for 50-59, 2.9% for 60-69, 5.9% for 70-79, and 10.1% for >80). No significant difference was found in clinical indicators except for serum creatinine (1.10 vs. 0.84 mg/dL, P < 0.001). Of 12 subjects with abnormal signal intensity and follow-up data, the finding persisted on the same side for at least 11 months in seven subjects (58%).

CONCLUSION

Abnormal signal intensity of the seminal vesicles was observed in 1.7% of screening population, and the imaging finding in isolation is unlikely to have clinical significance.

Clinical analysis of the characterization of magnetic resonance imaging in 102 cases of refractory haematospermia

To analyze the pathogenesis of persistent and refractory haematospermia and to evaluate the aetiological diagnostic value of magnetic resonance imaging (MRI) for this type of haematospermia. Clinical data from 102 patients with persistent and refractory haematospermia was retrospectively analysed. Data collected included history, symptoms, as well as ultrasound and MRI of the morphological features of the bilateral seminal vesicles (SV) and ejaculatory duct (ED) areas. Criteria for inclusion were haematospermia symptoms that occurred more than six times, that lasted more than 6 months, and that did not improve after >1 month of conservative treatment. Patients underwent seminal vesiculoscopy with a post-surgery follow-up of 3-48 months [average (18.1 ± 10.3) months]. Of the 102 patients that underwent MRI examination, data from 88 patients (86.3%) showed typical and characteristic changes in the ED area, including the signal intensity changes in 60 (58.8%), SV volume changes in 32(31.4%), the formation of cysts such as prostatic utricular cysts in 27 (26.5%), Müllerian cysts in 4 (3.9%), ED cysts in 5 (4.9%) and a SV cyst in 1(1.0%). The MRI findings were confirmed by seminal vesiculoscopy and all patients received appropriate treatment. In 14 patients (13.7%), no obvious abnormal changes were observed with MRIs, however, these patients were diagnosed and successfully managed using seminal vesiculoscopy. Some degrees of ED obstruction was usually found during surgery. The symptoms of haematospermia disappeared 1-2 months after surgery in all patients. Two patients had a recurrence of haematospermia, underwent the same treatment, and recovered during the follow-up period. The aetiology of the most cases of the refractory haematospermia can be distinguished using the three-dimensional MRI. Typical abnormalities observed on MR images are signal intensity, SV volume changes and cyst formation. MRI has significant etiological diagnostic value and provides reliable information for the subsequent treatment of patients with persistent and refractory haematospermia.

Hematospermia--the added value of transrectal ultrasound to clinical evaluation: is transrectal ultrasound necessary for evaluation of hematospermia?

Hematospermia is usually caused by nonspecific inflammation of the prostate and seminal vesicles. Transrectal ultrasound (TRUS) is a safe and inexpensive modality for evaluating patients with hematospermia. The aim of this study is to describe the findings of TRUS and its contribution to patients' management. A total of 115 consecutive patients presented with hematospermia and evaluated with TRUS between 2006 and 2012. All patients exhibited an abnormality in the TRUS examination. A 12-core TRUS-guided biopsy of the prostate was taken from 10 patients, but none of these samples were positive for tumor. In the vast majority of cases, a benign cause can be identified using TRUS. These causes usually do not require treatment.

Hemosepermia after transrectal ultrasound-guided prostatic biopsy: A prospective study

Objectives:

Trans-rectal ultrasound (TRUS) is a safe, cost-effective, radiation-free imaging modality for evaluation of prostate. But unfortunately, hemospermia is known to be associated with TRUS–guided prostate biopsy. The aim of this study is to measure the incidence and risk factors of hemospermia in patients undergoing TRUS.

Patients and Methods:

A prospective observational study involving patients undergoing TRUS for suspected prostate cancer has been conducted at Al-Hussein and Sayed Galal Hospitals. Forty patients were included in the study.

Results:

Most men (90% = 36 patient) undergoing TRUS-guided prostatic biopsy, who were able to ejaculate, experienced hemospermia, which was associated with some degree of anxiety. The mean duration of hemospermia was 4 (±1.4) weeks. The number of ejaculations before the complete resolution of hemospermia was 6 (±5.6). None of the clinical and pathological factors was a significant predictor of the duration of hemospermia.

Conclusion:

Patients should be adequately counseled before TRUS-guided prostatic biopsy to avoid anxiety and alterations in sexual activity.

Hematospermia: etiology, diagnosis, and treatment

Hematospermia is a relatively frequent, distressing, and frightening symptom for the majority of men. Although the differential diagnosis list is extensive, it is usually a benign, self-limiting disorder, including inflammatory and infective pathologies, resolving in several weeks. However, in some cases, hematospermia is the harbinger of more serious pathological lesions that should not be missed. In younger patients below 40 years of age, infection of the urogenital tract is the most common etiology. Simple routine laboratory studies should identify the pathological factors. In patients 40 years or older, or those with persistent or recurrent conditions or associated symptoms, it is necessary to exclude urogenital malignant disorders. Patients should also undergo medical history taking, physical examination including temperature and blood pressure assessment, digital rectal palpation, and laboratory blood, urine, and semen tests. If the diagnosis is still unclear, further investigations involve transrectal ultrasonography, magnetic resonance imaging, urethrocystoscopy, and histological confirmation by biopsy. Treatment for hematospermia depends on the underlying pathological lesions, but often involves only minimal examinations and simple reassurance in most cases. Hematospermia caused by genitourinary infections is effectively treated with appropriate antiviral, antibiotic, or antiparasitic agents. Hematospermia due to malignant disorders including prostate, testis, and seminal vesicle cancers resolves with definitive treatment of the primary lesions.

Transrectal ultrasound in patients with hematospermia

INTRODUCTION

To illustrate the lesions detected with transrectal ultrasound (TRUS) in patients with hematospermia.

MATERIAL AND METHODS

This study included 74 male patients (25-73 years old) affected by hematospermia. Clinical history was obtained and all patients underwent rectal examination as well as TRUS examination in both axial and coronal planes to evaluate the prostate, ejaculatory ducts and seminal vesicles. Biopsy was performed in 10 patients.

RESULTS

Abnormalities were detected in 59 patients. Calculi (n = 20) were seen within the prostate, seminal vesicles and along the course of the ejaculatory ducts. Chronic prostatitis (n = 14) appeared as hyperechoic and hypoechoic areas within the prostate with capsule thickening suggesting seminal vesiculitis (n = 8). Granulomatous prostatitis (n = 3) appeared as hyperechoic and calcified areas scattered within the prostate and the seminal vesicles. Hypoechoic focal lesions and heterogeneous texture were seen in prostate cancer (n = 5). Utricular cysts (n = 3) appeared as small midline lesions, and Mullerian duct cysts (n = 8) appeared as larger midline cysts protruding above the prostate. Ejaculatory duct cysts (n = 4) appeared as thick walled cystic lesions along the course of the ejaculatory duct. Seminal vesicle cysts were detected in 2 patients.

CONCLUSION

Our conclusion is that TRUS is a safe, non-invasive technique which can be used to detect lesions of the prostate, seminal vesicles and the ejaculatory ducts in patients with hematospermia.

Endorectal magnetic resonance imaging in persistent hemospermia

OBJECTIVE

To present the spectrum of abnormalities found at endorectal magnetic resonance imaging (E-MRI), in patients with persistent hemospermia.

MATERIALS AND METHODS

A review of E-MRI findings observed in 86 patients with persistent hemospermia was performed and results compared with those reported in the literature. Follow-up was possible in 37 of 86 (43%) patients with hemospermia.

RESULTS

E-MRI showed abnormal findings in 52 of 86 (60%) patients with hemospermia. These findings were: a) hemorrhagic seminal vesicle and ejaculatory duct, isolated (n = 11 or 21%) or associated with complicated midline prostatic cyst (n = 10 or 19.0%); b) hemorrhagic chronic seminal vesiculitis, isolated (n = 14 or 27%) or associated with calculi within dilated ejaculatory ducts (n = 2 or 4 %); c) hemorrhagic seminal vesicle associated with calculi within dilated ejaculatory duct (n = 4 or 7.7%) or within seminal vesicle (n = 4 or 7.7%); d) non-complicated midline prostatic cyst (n = 6 or 11.5%); and e) prostate cancer (n = 1 or 2%). Successful treatment was more frequent in patients with chronic inflammatory and/or obstructive abnormalities.

CONCLUSION

E-MRI should be considered the modality of choice, for the evaluation of patients with persistent hemospermia.

Hematospermia: etiological and management considerations

BACKGROUND

Hematospermia, or blood in the ejaculate, usually follows a benign self-limiting course. However, it can be a source of considerable anxiety in patients. The purpose of this article is to provide the primary care physician an algorithm for the evaluation and management of hematospermia based on frequency of occurrence and patient age.

METHODS

We performed an English language MEDLINE (1966 to present) search for the terms hematospermia, hemospermia, management, prostate biopsy and combinations thereof. We then constructed a management algorithm based on available evidence.

RESULTS

Typically, patients present to their primary care physician after a single episode of hematospermia out of concern for malignancy or venereal disease. In men 40 years old or younger, it is most often due to inflammatory or infectious processes. In men over 40 years of age, however, an association exists between hematospermia and more serious underlying pathology. A significant number of cases remain idiopathic even after extensive investigation.

CONCLUSIONS

Hematospermia is an anxiety-provoking sign that is usually due to inflammatory or infectious causes. Recurrent or symptomatic hematospermia may herald more serious underlying pathology, especially in those patients over 40 years old. A thorough evaluation is warranted to both rule out more serious pathology and to adequately address patient anxiety. With modern imaging techniques, the number of "idiopathic" cases should be much lower than historically reported.

Age-Related Structural and Metabolic Changes in the Pelvic Reproductive End Organs

In this work, we provide preliminary data and a review of the literature regarding normal structural and functional changes that occur in the aging uterus, ovary, testicle, and prostate gland. It is expected that such knowledge will help physicians to distinguish physiologic changes from pathologic changes at an early stage. We retrospectively reviewed pelvic magnetic resonance imaging (MRI) scans of 131 female and 79 male subjects ages 13 to 86 years to determine changes in volume of the uterus, ovary, and prostate gland with age. Scrotal ultrasound examinations of 150 male subjects ages 0 to 96 years also were analyzed retrospectively to determine changes in testicular volume with age. In addition, (18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG-PET) scans of 145 male subjects ages 11 to 90 years were analyzed retrospectively to assess for changes in maximum standardized uptake value (SUV(max)) of the testicles with age. The uterus had a mean volume of 38.55 +/- 3.68 cm(3) at 17 to 19 years of age, increased to a peak volume of 71.76 +/- 19.81 cm(3) between 35 to 40 years, and then declined to 24.02 +/- 8.11 cm(3) by the eighth decade of life. The maximal ovarian volume per subject maintained a relatively stable size in early life, measuring 9.46 +/- 3.25 cm(3) during the second decade of life, 8.46 +/- 3.32 cm(3) in the mid-fourth decade of life, and 7.46 +/- 3.33 cm(3) at 45 years of age, after which it declined to 4.44 +/- 2.02 cm(3) by the late fifth decade of life. The ovaries were not identifiable on MRI in subjects beyond the sixth decade of life. The volume of the prostate increased from 23.45 +/- 6.20 cm(3) during the second decade of life to 47.5 +/- 41.59 cm(3) by the late eighth decade of life; the central gland of the prostate increased from 9.96 +/- 3.99 cm(3) to 29.49 +/- 28.88 cm(3) during the same age range. Mean testicular volume was 11.2 +/- 5.9 cm(3). Testicular volume increased with age from birth to 25 years. After age 25, there was a significant decline in the testicular volume. The mean SUV(max) for the testicles was 1.9 +/- 0.5. Testicular metabolic activity demonstrated an increasing trend until the age of 35 years. A plateau in SUV(max) was observed after the age of 35 years until the age of 65 years. A slight decrease in SUV(max) was observed after the age of 65 years. The pelvic structures of men and women change both structurally and functionally over the lifespan, and such changes can be quantified using ultrasound, MRI, and (18)F-FDG-PET.