Seminal vesicle aspiration in the management of patients with ejaculatory duct obstruction

Azoospermia Due to Functional and Partial Ejaculatory Duct Obstruction: A Rare Case Report and Literature Review

Ejaculatory duct obstruction (EDO) is a rare but treatable cause of male infertility. This case report describes a 28-year-old male with obstructive azoospermia. The patient came to our hospital after a fertility check-up revealed azoospermia. A subsequent semen analysis confirmed azoospermia. Transrectal ultrasonography (TRUS) and magnetic resonance imaging (MRI) revealed bilaterally enlarged seminal vesicles and thickened, calcified ejaculatory duct walls. The patient underwent transurethral seminal vesiculoscopy and transurethral resection of the ejaculatory ducts (TURED) for presumed partial EDO. Despite two transurethral seminal vesiculoscopy and TURED procedures, postoperative semen analysis still showed azoospermia. TRUS indicated non-contractile seminal vesicles and an unobstructed ejaculatory duct. The patient ultimately underwent percutaneous epididymal sperm aspiration for assisted reproductive technology and his spouse got pregnant. We identified a case of azoospermia caused by a rare combination of partial and functional ejaculatory duct obstruction. There are currently no reports of similar cases. This case report aims to provide valuable insights for diagnosing and treating EDO.

[Surgery to improve male fertility]

BACKGROUND

At a time when increasing attention is being paid to the limitations and risks of in vitro fertilisation techniques, surgeries to improve male fertility are attracting growing interest.

METHODS

Systematic review based on a Pubmed search of surgeries to improve male fertility.

RESULTS

Vasovasostomy (VV) gives patency rates of 70-97% and pregnancy rates of 30-76%. Vasoepididymostomy (VE) gives patency rates of 80-84%, with pregnancy rates of 40-44%. The duration of obstruction and the age of the partner are 2 predictive parameters for the occurrence of a natural pregnancy. In cases of obstructive azoospermia due to pelvic obstruction (prostatic cyst, obstruction of the ejaculatory ducts), several surgical procedures may be proposed. Transurethral resection of the ejaculatory ducts leads to an improvement in sperm parameters in 63-83% of patients, with spontaneous pregnancy occurring in 12-31% of cases. Microsurgical cure of varicocele by the subinguinal route is a benchmark technique with recurrence rates of less than 4%. It improves live birth and pregnancy rates, both naturally and by in vitro fertilization, as well as sperm count, motility and DNA fragmentation rates.

CONCLUSION

Whenever possible, the urologist should present the surgical options for improving male fertility to the ART team and to the couple, discussing the benefit/risk balance of the operation as part of a personalized approach.

Long-Term Success Durability of Transurethral Resection of Ejaculatory Duct in Treating Infertile Men with Ejaculatory Duct Obstruction

Objectives: The current study aimed to evaluate the long-term outcomes of TURED (transurethral resection of the ejaculatory duct) in treating male infertility due to ejaculatory duct obstruction (EDO) to the short-term follow-up. Methods: From 2000 to 2010, we retrospectively reviewed 30 men with infertility resulting from EDO who underwent TURED. Information on preoperative evaluation of patients was collected from the medical records. Standardized semen analysis was performed 6 weeks, 3 months, and 12 months postoperatively, as well as after a 7-year follow-up. Results: The average age of patients was 35.5 ± 2.6. All patients had low ejaculate volume and normal range of the mean serum hormone levels (gonadotropins and testosterone). Transrectal ultrasonography (TRUS) assessment revealed midline cysts in 46.7% (n = 14 cases), a seminal vesicle dilatation in 83.3% (25/30 cases), and ejaculatory duct dilatation in 76.7% (23/30 patients). In addition, two patients (6.6%) underwent MRI pelvis to confirm equivocal EDO by TRUS. After short-term and long-term follow-up, semen parameters improved significantly in 90% of cases vs 63.3% of cases, respectively, with statistically insignificant differences in all parameters (p ≥ 0.1). Based on subgroup analysis, semen parameters improved in all partial EDO and cystic EDO cases vs complete EDO and noncystic EDO, respectively. Spontaneous pregnancies were achieved in 10 (33.3%) vs 8 (26.6%) cases after short and long term, respectively. Regarding post-TURED complications, we reported 23.3% (n = 7). Conclusion: TURED is an effective treatment for EDO. It significantly improves all semen parameters and improves the symptoms related to EDO after short and long-term follow-up.

A systematic review of transurethral resection of ejaculatory ducts for the management of ejaculatory duct obstruction

OBJECTIVE

Ejaculatory duct obstruction (EDO) is an uncommon but potentially treatable cause of male factor infertility. However, there are limited data on transurethral resection of the ejaculatory ducts (TURED) as a treatment option. A systematic review was therefore conducted to assess its efficacy and identify patient subgroups that benefit from the procedure.

MATERIAL AND METHODS

A database search of PubMed, Embase, and Scopus (up to January 2019) and the World Health Organization trial registry was performed to identify all studies assessing infertile men with EDO undergoing TURED. The primary outcome measures included semen parameters and natural pregnancies. The secondary outcomes included complications, symptomatic improvement, and a change from in vitro fertilization to intrauterine insemination.

RESULTS

Of 3,277 articles screened, 29 studies with 634 patients were included in the study. Although outcomes varied considerably among studies, a general increase in all semen parameters postoperatively was observed. Semen volume (n=23 studies) improved in a median of 83.0% of patients (interquartile range [IQR]: 37.5). Sperm motility and concentration (n=10 and n=21 studies) improved in a median of 63.0% (IQR: 15.0) and 62.5% (IQR: 16.5) of patients, respectively. The natural pregnancy rate across the studies was a median of 25.0% (IQR: 15.7). Improvements in both the outcomes were greater in patients with congenital etiologies and partial EDO. Differences in surgical technique did not appear to affect outcomes.

CONCLUSION

TURED is associated with improvements in semen parameters and offers a chance of restoring fertility in previously subfertile men. Although results are promising, the current evidence remains limited owing to predominantly retrospective studies with small sample sizes.

A Schematic Overview of the Current Status of Male Infertility Practice

The practice of male infertility has dramatically evolved over the past few decades. This has been achieved after the realization of the important contribution the male counterpart holds in the couple's infertility. It is also supported by a number of breakthroughs in the diagnosis and treatment of this medical condition. Several tests to investigate sperm quality and function were introduced along with refinements and/or institution of novel surgical techniques that can correct several causes of infertility. This manuscript is aimed at highlighting the current state of male infertility practice in a robust, schematic method addressing a broader audience involved in the treatment of male infertility.

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.

Seminal vesicle sperm aspiration from wounded warriors

OBJECTIVE

To assess whether seminal vesicle sperm aspiration (SVSA) is an option for wounded warriors with severe genital and testicular injuries, with the goal of cryopreservation to use in future assisted reproductive technology (ART) cycles.

DESIGN

Retrospective case series.

SETTING

Tertiary care military hospital.

PATIENT(S)

Six wounded warriors.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Seminal vesicle fluid analysis after harvest, after thaw analysis, fertilization rates, pregnancy rates (PRs), live birth.

RESULT(S)

Six patients with lower extremity, pelvic, and genital injuries from dismounted improvised explosive devices underwent SVSA within 5-12 days of the initial injury. Sperm retrieved were analyzed (volume, 0.4-1.8 mL; concentration, 40-2,200 K; motility, 0-5%), washed, and cryopreserved. Two patients underwent IVF/intracytoplasmic sperm injection (ICSI) cycles using their samples. In one couple, fertilization rate was 38%. One grade V embryo was transferred with a negative pregnancy test. The second couple underwent two cycles. In their first cycle, fertilization rate was 44%, with one blastocyst transferred and a negative pregnancy test. In the second cycle, fertilization rate was 47%. Two blastocysts were cryopreserved due to ovarian hyperstimulation syndrome (OHSS) concerns. One blastocyst was later transferred in a frozen cycle resulting in a live birth.

CONCLUSION(S)

The SVSA is a reasonable option to retrieve sperm in wounded warriors or trauma patients with extensive genital injuries.

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.

Transurethral resection of ejaculatory duct in infertile men: outcome and predictors of success

OBJECTIVES

To evaluate the outcome of transurethral resection of the ejaculatory duct (TURED) in the treatment for ejaculatory duct obstruction (EDO) and define predictors of success.

MATERIALS AND METHODS

We retrospectively evaluated 23 infertile men between 2006 and 20011, who were diagnosed as having EDO. Inclusion criteria were azoospermia or oligozoospermia, low ejaculate volume, low ejaculate PH, little or no fructose in seminal plasma with normal serum levels of gonadotropins and testosterone and evidence of obstruction on transrectal ultrasonography (TRUS) or magnetic resonance images (MRI). Seventeen patients were diagnosed as complete EDO, and the remaining 6 were considered as having partial EDO. All patients were treated by TURED.

RESULTS

Midline cysts were diagnosed in seven cases, and the remaining 16 patients had postinflammatory obstruction of ejaculatory ducts (ED). Overall, a significant improvement of semen quality was achieved after surgery. All patients with partial EDO showed improvements in semen parameters after TURED compared to 23.5% (4/17) in those with complete EDO. Improvement in sperm count was 71.5% and 31% for patients with midline cysts and patients with non-cystic causes of EDO, respectively. Six (26%) patients developed complications including epididymo-orchitis in 2, watery ejaculate in 3 and conversion to azoospermia in 1. Spontaneous pregnancies were achieved in 3 (13%) cases: 2 (33.3%) men with partial and 1 (5.9%) with complete obstruction.

CONCLUSION

Partial EDO, whatever the etiology, has an excellent outcome after TURED. Complete EDO due to cysts appears to respond better than postinflammatory obstruction to TURED.

An update on the clinical assessment of the infertile male. [corrected]

Male infertility is directly or indirectly responsible for 60% of cases involving reproductive-age couples with fertility-related issues. Nevertheless, the evaluation of male infertility is often underestimated or postponed. A coordinated evaluation of the infertile male using standardized procedures improves both diagnostic precision and the results of subsequent management in terms of effectiveness, risk and costs. Recent advances in assisted reproductive techniques (ART) have made it possible to identify and overcome previously untreatable causes of male infertility. To properly utilize the available techniques and improve clinical results, it is of the utmost importance that patients are adequately diagnosed and evaluated. Ideally, this initial assessment should also be affordable and accessible. We describe the main aspects of male infertility evaluation in a practical manner to provide information on the judicious use of available diagnostic tools and to better determine the etiology of the most adequate treatment for the existing condition.

Novel methods for the diagnosis and treatment of ejaculatory duct obstruction

OBJECTIVES

• To investigate a new method of vas deferens radiography for ejaculatory duct obstruction (EDO). • To evaluate the effect of a procedure involving dilation of the ejaculatory duct by F9 seminal vesicoscopy.

PATIENTS AND METHODS

• Twenty-two patients with EDO were diagnosed using semen analysis, semen fructose measurement, transrectal ultrasonography (TRUS) and vas deferens radiography. • Of these, 18 patients were successfully treated by dilation of ejaculatory duct using F9 seminal vesicoscopy and four patients, whose treatment was unsuccessful, were treated by transurethral resection of the ejaculatory ducts (TURED). • All patients were followed up for at least 3 months after treatment.

RESULTS

• Semen analyses in all 22 patients showed oligoasthenozoospermia or azoospermia, low semen volume (0-1.9 mL), low pH level (5.6-7.0) and absent or low semen fructose. TRUS and radiography showed pure dilated seminal vesicles on both sides in three patients, partial dilated seminal vesicles in one patient, dilation of both the ejaculatory duct and seminal vesicles in ten patients, dilated seminal vesicles and a prostatic cyst in four patients, and dilated ejaculatory duct or cystic lesions without dilated seminal vesicles in the remaining four patients. • At >3-month follow-up after dilation or TURED, the semen characteristics of 18 patients were improved and sperm were present in the semen in 13 cases. Normal semen analyses were found in 7 patients and 6 patients had conceived. • Voiding urethral radiography showed that no patients who had undergone dilation by seminal vesicoscopy had urine reflux into the ejaculatory duct. Only one patient showed urine reflux into the seminal vesicle after TURED. • All patients felt that their symptoms had improved after treatment.

CONCLUSIONS

• The approach to vas deferens radiography using vas deferens aspiration has proved to be an effective and safe method for EDO diagnosis. • The procedure involving the dilation of the ejaculatory duct using F9 seminal vesicoscopy is equally effective but has fewer postoperative complications than TURED.

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.

Porcine vas deferens luminal pH is acutely increased by systemic xylazine administration

Data are accumulating to demonstrate that pH regulation in the male reproductive tract has a vital role in modulating sperm cell fertilizing capacity, and therefore male fertility. Bicarbonate uptake by sperm cells is required for the achievement of motility levels required for fertilization. Vas deferens epithelial cells can carry out measurable bicarbonate secretion, but the available literature to date reports that the vas deferens luminal content is typically acidic. This study aimed to determine pH in the boar vas deferens lumen and whether modulatory mechanisms exist for regulation of pH in this compartment of the male reproductive tract. A fiberoptic pH probe was used to assess pH in the vas deferens of anesthetized adult boars. The mean pH, derived from multiple measurements at variable positions along the vas deferens lumen, was 7.39 +/- 0.09. Furthermore, administration of xylazine, an alpha-2 adrenergic receptor agonist rapidly (<10 min) alkalinized the vas deferens lumen in most cases. Because the duct was transected proximal to the site of measurements, the observations rule out the possibility that alkalinization resulted from secretion in more proximal portions of the duct. These results indicate that the boar vas deferens lumen can be alkaline, and they suggest that porcine vas deferens epithelia increase net bicarbonate secretion in vivo after systemic alpha-2 adrenergic stimulation. This secretory response greatly changes the luminal environment to which sperm cells are exposed, which will initiate or enhance motility, and is expected to modulate male fertility.

Testosterone upregulates anion secretion across porcine vas deferens epithelia in vitro

Testosterone induces and maintains prostaglandin endoperoxide synthase 2 (PTGS2, also known as cyclooxygenase 2) expression in vas deferens epithelial cells, but it remains unknown whether this has a physiological role in the context of male reproductive biology. Prostaglandins induce concentration-dependent increases in anion secretion in porcine vas deferens epithelial cell (1 degrees PVD) monolayers, where bicarbonate contributes to cAMP-stimulated anion secretion. Moreover, bradykinin induces anion secretion across 1 degrees PVD monolayers that is indomethacin sensitive, and both PTGS2 and PTGS1 are expressed in this model system. Therefore, it was hypothesized that testosterone modulates anion secretion across vas deferens epithelia via PTGS-dependent pathways and prostaglandin synthesis. Porcine vas deferens epithelial cells were isolated and cultured as monolayers on permeable supports until assayed in modified Ussing chambers. RNA and protein were isolated concurrently for semiquantitative expression analysis. Testosterone upregulated basal and bradykinin-induced short-circuit current across 1 degrees PVD monolayers, indicative of anion secretion. Testosterone also induced greater transepithelial electrical resistance. Increases in anion secretion were associated with preferential upregulation of PTGS2 at the mRNA and protein levels. In addition, testosterone induced greater basal and bradykinin-induced anion secretion across vas deferens epithelial cells isolated from the distal segment of the duct. Taken together, these results suggest that testosterone upregulates epithelial responsiveness to acute modulations of anion secretion (likely bicarbonate secretion), which ultimately modifies the environment to which sperm are exposed.

Evaluation of the azoospermic male

The purpose of this Technical Bulletin is to review the current methods of diagnosis and strategies for treatment of men with azoospermia.

Transurethral resection of ejaculatory ducts in the treatment of complete ejaculatory duct obstruction

OBJECTIVES

To evaluate the value of transurethral resection of the ejaculatory duct (TURED) in the treatment of complete ejaculatory duct obstruction (EDO) as a treatable cause of male factor infertility.

MATERIALS AND METHODS

We retrospectively evaluated 12 azoospermic infertile men who were diagnosed as having complete EDO. The mean age of the patients was 32 years (range 24-40). Inclusion criteria were EDO in patients with azoospermia, normal serum levels of gonadotropins and testosterone and evidence of obstruction on transrectal ultrasonographic (TRUS) images. The definitive diagnosis was based on the absence of an efflux of methylene blue injected through the seminal vesicles during cystoscopy. All patients were treated by TURED.

RESULTS

Before TURED, all patients were azoospermic and had been considered as candidates for in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI). Following the operation, sperms were seen in the ejaculates of 11/12 patients. After a mean follow-up period of 12 (range 4-36) months, five (41.6%) pregnancies were noted (three spontaneous, one with intrauterine insemination and one with IVF/ICSI).

CONCLUSION

Transurethral resection was found to be a safe and somewhat effective approach for the treatment of EDO. After TURED, a significant improvement was achieved in semen parameters, and spontaneous pregnancy resulted in three cases. In addition, TURED can reduce the need for expensive procedures such as IVF/ICSI as this modality allows IVF/ICSI to be performed with ejaculated instead of surgically retrieved sperm.

Comparison of transrectal ultrasonography and transrectal ultrasonography-guided seminal vesicle aspiration in the diagnosis of the ejaculatory duct obstruction

OBJECTIVE

To compare transrectal ultrasonography (TRUS) and TRUS-guided seminal vesicle aspiration in the diagnosis of ejaculatory duct obstruction (EDO).

DESIGN

A retrospective case-controlled study comparing the findings of TRUS and TRUS-guided seminal vesicle (SV) aspiration.

SETTING

Clinics of Urology and Radiology.

PATIENT(S)

Seventy patients with suspected EDO (complete in 10, partial in 60 patients) on clinical evaluation.

INTERVENTION(S)

Each SV was punctured transrectally using a 20-gauge Chiba needle within 2 hours after ejaculation.

MAIN OUTCOME MEASURE(S)

In SV aspirates, greater than three sperm per high-power microscopic field was considered a positive result for EDO.

RESULT(S)

Fifty-five (78.6%) patients had evidence of EDO on diagnostic TRUS. However, obstruction on TRUS was confirmed in 49.1% (27 of 55) of the patients with SV aspiration. Higher sperm positivity rates were achieved in patients with SV dilation (11 of 13, 84.6%) and prostatic midline/ED cyst (12 of 16, 75.0%). Stepwise logistic regression analysis revealed that the incidence of SV dilation was significantly higher, whereas that of chronic inflammatory findings in the prostate was significantly lower in the positive SV aspirate group.

CONCLUSION(S)

TRUS alone is not a reliable tool for the diagnosis of EDO. For this reason, SV aspiration should be used as an adjunctive technique in patients with SV dilation or a prostatic midline/ED cyst to confirm the diagnosis before surgery.

Technetium Tc 99m sulphur colloid seminal vesicle scintigraphy: a novel approach for the diagnosis of the ejaculatory duct obstruction

OBJECTIVES

To define a novel technique in the diagnosis of partial and complete ejaculatory duct obstruction (EDO).

METHODS

Twenty men with suspected EDO were initially evaluated by transrectal ultrasound (TRUS). Subsequently, all patients underwent TRUS-guided seminal vesicle (SV) scintigraphy. Technetium Tc 99m sulphur colloid solution was injected into each SV under TRUS guidance and patients were immediately evaluated by scintigraphy. After patients ejaculated scintigraphy was repeated. The difference between 2 measurements in respect to technetium Tc 99m count was used to measure the percentage of emptying.

RESULTS

In the first group, TRUS revealed 11 patients with findings suggestive of EDO, whereas no abnormality was found in 9. Scintigraphic measurement in first group of patients showed a mean emptying ratio for the right and left SVs of 16.6% +/- 2.22 (2.2 to 30.6) and 17.1% +/- 2.34 (1.4 to 32.5), respectively. The mean percent of emptied technetium Tc 99m from right and left SVs in patients with no pathologic findings on TRUS was 30.9% +/- 4.3 (10.1 to 44.2) and 33.9% +/- 5.81 (13.6 to 68.1), respectively. Statistically significant difference was determined between 2 groups (P = 0.037). Initially, TRUS examination revealed no pathologic findings in 3 patients; however, SV scintigraphy showed less than 30% emptying and revealed an additional 33% of patients to be obstructed in our series.

CONCLUSIONS

TRUS, the static anatomic imaging modality, may not be sufficient to distinguish functional from complete obstruction. Seminal vesicle scintigraphy is unique that incorporates physiologic aspect of ejaculation into a diagnostic intervention, of which we believe that is especially important in diagnosis of functional EDO.

Clinical and radiological evaluation of ejaculatory duct obstruction

Ejaculatory duct obstruction (EDO) is a rare but surgically correctable cause of male infertility. With the advent and increased use of transrectal ultrasonography and magnetic resonance imaging, abnormalities of the ejaculatory duct (ED) related to infertility have been diagnosed more frequently. Recently, with the increased awareness of functional obstruction of ED, reports have been focusing on the diagnosis of partial or functional EDO. We present 2 review of the ED pathologies, imaging modalities and treatment options.

Ejaculatory duct obstruction caused by a right giant seminal vesicle with an ipsilateral upper urinary tract agenesia: an embryologic malformation

OBJECTIVE

To report our experience with TURED in infertile men with EDO associated with abnormal development of the mesonephric or Wolffian duct, causing a contemporary malformation of the ipsilateral upper urinary tract.

DESIGN

Retrospective clinical study.

SETTING

Infertile men in an hospital environment.

PATIENT(S)

Seven patients affected by Zinner syndrome, from March to September 2005, were selected.

INTERVENTION(S)

Underwent TURED.

MAIN OUTCOME MEASURE(S)

Semen analysis, endocrine profile, transrectal ultrasonography and seminal vesicles aspiration, excretory urography, computerized tomography (CT), or magnetic resonance imaging (MRI).

RESULT(S)

Before surgery, the patients experienced a decreased intensity and force of ejaculation and a low motile sperm count. The detection of the ipsilateral upper urinary tract malformation by the patients was incidental. After surgery, all patients reported having a projectile ejaculation, an increase in the average postoperative volume, and of the total motile sperm count.

CONCLUSION(S)

A seminal vesicle cyst combined with ipsilateral renal agenesis, described as Zinner syndrome, is a rare urological anomaly. It is frequently asymptomatic or else characterized by infertility, symptoms of bladder irritation, or pain in the scrotum and perineum. In selected patients, TURED can improve semen quality with subsequent ability to impregnate. The upper urinary tract malformation should be treated in symptomatic cases only.

Management of ejaculatory duct obstruction: etiology, diagnosis, and treatment

Abnormalities of the distal ejaculatory ducts related to infertility have been well-documented. Although there are no specific findings associated with ejaculatory duct obstruction, several clinical findings are highly suggestive. A diagnosis of ejaculatory duct obstruction is suggested in an infertile male with oligospermia or azoospermia with low ejaculate volume, normal secondary sex characteristics, testes, and hormonal profile, and dilated seminal vesicles, midline cyst, or calcifications on TRUS. Other causes of infertility may be concomitantly present and need to be evaluated and treated. Trans urethral resection of ejaculatory ducts (TURED) has resulted in marked improvement in semen parameters, and pregnancies have been achieved. Proper patient selection and surgical experience are necessary to obtain optimal results. In case of testicular dysfunction, chances of success are minimal. Extended follow-up periods are needed after TURED to examine the long-term effects of this procedure. Better understanding of the anatomy and pathology of the ejaculatory ducts will continue to refine diagnostic and therapeutic procedures for this disorder.

Hematospermia: imaging findings

Hematospermia is an anxiety provoking but otherwise generally benign and self-limited condition that is infrequently associated with significant underlying pathology, and is most often considered to be idiopathic in nature. Management with routine clinical evaluation, watchful waiting, and reassurance generally suffice without further diagnostic workup or treatment. Noninvasive imaging may play an important role in the diagnostic workup of men with hematospermia, particularly in those who are >40 years old, have other associated symptoms or signs of disease, or have persistence of hematospermia. Many entities may be encountered in association with hematospermia at imaging, and specific therapeutic interventions may be used if certain treatable underlying pathologies are coincidentally detected. In this comprehensive review, we discuss the potential etiologies, diagnostic workup, imaging techniques, relevant male pelvic anatomy, imaging appearance of specific associated pathologies, and treatment for hematospermia.

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.

Effects of sildenafil citrate on ejaculation latency, detumescence time, and refractory period: placebo-controlled, double-blind, crossover laboratory setting study

OBJECTIVES

To evaluate whether sildenafil citrate (SC) prolongs ejaculation latency and detumescence time and shortens the refractory period in a laboratory setting.

METHODS

Two successive double-blind, placebo-controlled, crossover laboratory studies were performed with 30 different healthy volunteers in each study (total of 60). In the first study, the subject ingested placebo or SC. Real-time penile tumescence and rigidity monitoring and audiovisual sexual stimulation was performed. When the subject had his best erection, he applied vibratory stimulation until he ejaculated, and then audiovisual sexual stimulation was stopped. Monitoring was continued until he lost rigidity. The test was repeated with the second medication in 7 to 15 days. In the second study, another group of 30 volunteers were tested, as in the first study, and audiovisual sexual stimulation was continued for an additional hour after ejaculation.

RESULTS

In the first study, the time to ejaculation with vibratory stimulation was 2.23 and 3.89 minutes (P = 0.01) and the time to minimal tip rigidity after ejaculation was 1.93 and 3.1 minutes (P <0,001) in the placebo and SC groups, respectively. In the second study, the time to ejaculation with vibratory stimulation was 2.23 and 4.91 minutes (P = 0.006), the time to best tip rigidity after ejaculation was 19.10 and 15.66 minutes (P = 0.242), and the area under the curve of tip rigidity in 3 minutes after ejaculation was 73.61 and 144.05 (P <0.001) in the placebo and SC groups, respectively.

CONCLUSIONS

In this laboratory setting, SC seemed to prolong the ejaculation latency time. The detumescence time was also longer, with better quality. However, we did not show that SC shortens the refractory period after ejaculation.

Phosphodiesterase 5 Inhibitors in Rapid Ejaculation

Rapid (premature) ejaculation (RE) is a very common sexual disorder. This condition may be primary or secondary to underlying disease. Control of RE has been primarily focused on behavioural therapy, topical anaesthetics, tricyclic antidepressants and selective serotonin reuptake inhibitors; however, an approved treatment does not exist. Recently, a number of clinical trials have studied the potential effectiveness of the phosphodiesterase (PDE)-5 inhibitor sildenafil in the treatment of RE. Results of most of these studies have been encouraging. Available data indicate that there is clinical, anatomical, physiological, pharmacological and genetic evidence to explain the efficacy of PDE5 inhibitors in RE. The rationale for the use of PDE5 inhibitors in the treatment of RE could be due to possible peripheral and central mechanisms. Possible peripheral ejaculation retarding capabilities may include modulation of the contractile response of the vas deferens (VD), seminal vesicles (SV), prostate and urethra, induction of a state of peripheral analgesia, and prolongation of the total duration of erection. Possible central mechanisms may involve lessening of the central sympathetic output. Furthermore, there is evidence from knockout mice to explain the efficacy of PDE5 inhibitors in RE. Mice lacking the gene for endothelial nitric oxide synthase develop a condition similar to RE. On the other hand, mice lacking the gene for heme oxygenase-2 develop a condition similar to delayed ejaculation. This review also discusses the findings against the use of these agents in RE. In conclusion, a review of the literature suggests the potential usefulness of PDE5 inhibitors as a promising line of therapy in RE but further studies are needed.

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

PURPOSE

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.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Causes of azoospermia and their management

Azoospermia may occur because of reproductive tract obstruction (obstructive azoospermia) or inadequate production of spermatozoa, such that spermatozoa do not appear in the ejaculate (non-obstructive azoospermia). Azoospermia is diagnosed based on the absence of spermatozoa after centrifugation of complete semen specimens using microscopic analysis. History and physical examination and hormonal analysis (FSH, testosterone) are undertaken to define the cause of azoospermia. Together, these factors provide a >90% prediction of the type of azoospermia (obstructive v. non-obstructive). Full definition of the type of azoospermia is provided based on diagnostic testicular biopsy. Obstructive azoospermia may be congenital (congenital absence of the vas deferens, idiopathic epididymal obstruction) or acquired (from infections, vasectomy, or other iatrogenic injuries to the male reproductive tract). Couples in whom the man has congenital reproductive tract obstruction should have cystic fibrosis (CF) gene mutation analysis for the female partner because of the high risk of the male being a CF carrier. Patients with acquired obstruction of the male reproductive tract may be treated using microsurgical reconstruction or transurethral resection of the ejaculatory ducts, depending on the level of obstruction. Alternatively, sperm retrieval with assisted reproduction may be used to effect pregnancies, with success rates of 25–65% reported by different centres. Non-obstructive azoospermia may be treated by defining the cause of low sperm production and initiating treatment. Genetic evaluation with Y-chromosome microdeletion analysis and karyotype testing provides prognostic information in these men. For men who have had any factors potentially affecting sperm production treated and remain azoospermic, sperm retrieval from the testis may be effective in 30–70% of cases. Once sperm are found, pregnancy rates of 20–50% may be obtained at different centres with in vitro fertilisation and intracytoplasmic sperm injection.

Ejaculatory duct obstruction

PURPOSE OF REVIEW

We surveyed the growing literature on ejaculatory duct obstruction and provide suggestions regarding its diagnosis and management.

RECENT FINDINGS

Ejaculatory duct obstruction is a rare cause of male infertility. With the advent of the high resolution transurethral ultrasound (TRUS) technology, there has been an increase in diagnosis of this disorder. As for the treatment, it appears that central cystic lesions and partial obstructions respond best to transurethral resection of the ejaculatory ducts (TURED).

SUMMARY

Ejaculatory duct obstruction is a rare but surgically correctable cause of male infertility. Although there are no pathognomonic findings associated with ejaculatory duct obstruction, the diagnosis should be suspected in an infertile male with oligospermia or azoospermia with low ejaculate volume, normal secondary sex characteristics, testes, and hormonal profile, and dilated seminal vesicles, midline cyst, or calcifications on TRUS. In select cases, TURED has resulted in marked improvement in semen parameters, and pregnancies have been achieved. More studies are needed in the areas of diagnosis and long-term surgical outcome.

The diagnosis and treatment of the azoospermic patient in the age of intracytoplasmic sperm injection

Microsurgical reconstruction remains the treatment of choice for men with reconstructable obstructive azoospermia. Sperm retrieval techniques performed with ICSI are highly effective for men in whom reconstruction is not feasible. In men with nonobstructive azoospermia, the optimization of spermatogenesis with hormonal therapy and, when appropriate, microsurgical varicocelectomy can result in the appearance of adequate sperm in the ejaculate for ICSI. In men with persistent nonobstructive azoospermia, TESE with ICSI has provided encouraging results. Caution must be used when this ART is applied in couples in whom genetic aberrations are detected given certain inheritance of these anomalies, as the genetic consequences of this procedure have not been thoroughly elucidated. Just as the possibility of ICSI was thought to be inconceivable several decades ago, the advent of future sentinel discoveries will present the possibility for realization of achievements that now seem incredulous.

Diagnosis and treatment of ejaculatory dysfunction

The normal ejaculatory process requires complex coordination and integration of neurologic, physiologic, anatomic, and psychologic events. An understanding of these processes is critical to evaluate properly and manage patients with ejaculatory dysfunction. With the advent of improved techniques to treat patients, some men with ejaculatory dysfunction are being offered the opportunity to reproduce. Further research on the ejaculatory process and associated dysfunctional states should continue to improve treatment for patients presenting with ejaculatory disorders.

Ultrasound and infertility: diagnostic and therapeutic uses

Ultrasound has become essential in the diagnosis and management of the infertile male. Scrotal ultrasonography provides a detailed examination of the testes and assesses the presence or absence of varicoceles and can identify other abnormalities of the scrotal contents and the spermatic cord. Transrectal ultrasonography can "visualize" the excurrent ejaculatory ductal system, including the ejaculatory ducts, seminal vesicles, and vas deferens. The expansion of these ultrasonographic techniques has provided the urologist with non- or minimally invasive techniques with which to evaluate the infertile male. These advancements consequently have led to innovative surgical and radiologic treatments.

Does response to treatment of ejaculatory duct obstruction in infertile men vary with pathology?

OBJECTIVE

To describe the pathology-specific response to transurethral resection of ejaculatory ducts (TURED) in patients with complete or partial ejaculatory duct obstruction and to evaluate the role of TURED in light of powerful assisted reproductive technologies.

DESIGN

Retrospective clinical study.

SETTING

University hospital.

PATIENT(S)

Thirty-eight infertile men with obstruction of the ejaculatory ducts.

INTERVENTION(S)

Diagnosis by transrectal ultrasonography or magnetic resonance imaging, and treatment with TURED.

MAIN OUTCOME MEASURE(S)

Changes in semen variables, pregnancy outcomes, and complication rates were analyzed before and after surgery.

RESULT(S)

Improvement in semen variables was significantly better in patients with partial obstruction (94%) of ducts than in those with complete obstruction (59%) (P=.04). Cystic obstruction, especially midline and eccentric cysts, responded best to TURED. Before surgery, all patients were candidates for IVF/ICSI; after surgery, 32% of azoospermic men and 81% of oligospermic men conceived spontaneously or were referred for IUI instead of IVF/ICSI.

CONCLUSION(S)

Ejaculatory duct obstruction due to cysts appears to respond best to TURED. In addition, TURED may decrease the need for IVF/ICSI as primary treatment in many cases. Finally, TURED may allow IVF/ICSI to be performed with ejaculated rather than surgically retrieved sperm.

Ejaculatory physiology and dysfunction

The sequence of events encompassing ejaculation has been well described. Multiple disease processes can result in ejaculatory dysfunction. Evaluation and subsequent treatment of ejaculatory dysfunction is possible using behavioral, mechanical, and medical and surgical modalities. Further elucidation of ejaculation is now taking place at the molecular level.

Surgical therapy in infertile men with ejaculatory duct obstruction: technique and outcome of a standardized surgical approach

In severe oligozoospermia or azoospermia, low ejaculate volume, low ejaculate pH and little or no fructose in seminal plasma suggest an obstruction of the seminal pathways at the level of the prostate gland, when vasal aplasia and ejaculatory disorders are excluded. We report on our standardized surgical approach in 16 consecutive patients with this condition after clinical evaluation, semen analysis, endocrine assessment, testicular biopsy and transrectal ultrasonography. Pre-operatively, sperm analysis demonstrated typical low-volume ejaculates with azoospermia in 12 and severe oligozoospermia in four cases. Ultrasonography demonstrated seven central (Müllerian) and five lateral cystic lesions. Four cases with central obstruction revealed no ultrasonographic pathology. After intra-operative vasopuncture and vasography for definite localization of the level of obstruction, transurethral incision and/or resection of ejaculatory ducts (TURED) was performed. Patency was proven in 15 out of 16 cases by 'intra-operative chromotubation'. In nine out of 12 patients, spermatozoa could be harvested intra-operatively from the vas. During the follow-up of 12 months, post-operative ejaculates showed persistent patency in six out of seven Müllerian cysts with concomitant improvement of sperm quality. Only three of the other nine cases remained patent with the worst results in lateral cystic lesions. Only two of the patients with Müllerian cysts have fathered a child so far. The data provide evidence for the effectiveness of surgical treatment of ejaculatory duct obstruction, especially in the case of central cystic lesions. The combination of surgery, cryostoring of spermatozoa retrieved intra-operatively and the possible storage of ejaculated spermatozoa post-operatively creates the possibility of subsequently using reproductive techniques if pregnancy is not achieved.

Seminal vesicle sperm aspiration in the diagnosis of ejaculatory duct obstruction

OBJECTIVE

To determine the effectiveness of seminal vesicle aspiration in the diagnosis and treatment of patients with ejaculatory duct obstruction.

PATIENTS, SUBJECTS AND METHODS

Between March 1998 and February 1999, 10 infertile men with ejaculatory duct obstruction (EDO, mean age 32.7 years, range 25-47) and 10 fertile volunteers (mean age 33.2 years, range 25-42) underwent transrectal ultrasonography (TRUS) and TRUS-guided seminal vesicle aspiration. The volume of and presence of motile sperm in the aspirate was compared with the TRUS findings for both groups.

RESULTS

From TRUS of the patients with EDO, the mean (sd, range) transverse diameter of the right and left seminal vesicles were 1.97 (0.54, 0.8-2.6) cm and 1.93 (0.53, 0.9-2.6) cm; the corresponding values in the control group were 1.03 (0.15, 0.8-1.3) cm and 1.0 (0. 12, 0.8-1.4) cm, respectively (P<0.001). In all, 20 aspirate samples were obtained from the patients with EDO by bilateral seminal vesicle aspiration and only one (10%) had no sperm within the aspirate fluid. Of these 10 patients, two had immotile sperm and the remaining seven (14 samples) had a mean motile sperm count of 0.63 (0.45, 0.1-1.0)x106 /mL, whereas seven of eight men assessed in the control group had no motile sperm (one patient had immotile sperm within the aspirate fluid); this difference was significant (P<0.01).

CONCLUSIONS

The aspiration of significant numbers of motile sperm from the seminal vesicles suggests the presence of distal obstructions of the ejaculatory duct and enables infertile couples to be candidates for assisted reproduction. However, there is a need for further research to determine the use of this technique in the diagnosis of partial EDO.