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337
Abnormalities of the Seminal Tract Causing Infertility: Diagnosis with Endorectal
Patricia
L. Abbmtt1
Laurence
Watson2
Stuart
Howards3
Endorectal prostatic
Sonography
sonography,
carcinoma,
developed
should
primarily
for use in the diagnosis
be the first imaging
technique
and staging
used in the evaluation
of
of an
infertile man with low semen volume in whom either a hypoplastic or obstructed seminal tract is suspected. Endorectal sonography allows visualization of the seminal vesicles, which are otherwise difficult to examine. We used endorectal sonography to evaluate six young men, five of whom were being evaluated for azoospermia and infertility. One patient had no identifiable seminal vesicle on either side. Four patients had unilateral absence of the seminal vesicles. Of these four, three had a sonographically normal-
appearing
seminal
system
vesicle
on the contralateral
side, and the fourth
had an obstructed
contralaterally.
The sixth patient had a hypoplastic system on the left and an obstructed system on the right. The delineation of an obstructed or agenetic seminal vesicle and seminal tract on endorectal sonography allows decisions to be made regarding treatment and prognosis.
157:337-339,
AJR
August
The seminal tract such as vasography primarily
1991
is difficult to evaluate clinically, and traditional enhanced studies are invasive. Although endorectal sonography was developed
for the diagnosis
and
staging
of prostatic
carcinoma,
it provides
excellent
visualization of the seminal vesidles [1 , 2]. After retrograde ejaculation has been excluded as a cause of low ejaculate volume, endorectal sonography should be used in the infertile man in whom congenital absence or obstruction of the spermatic ductal system (vasa deferentia) and/or the seminal vesicles is suspected. We describe patients in whom endorectal sonography identified congenital abnormalities of the vas deferens or seminal vesicles.
Materials
and Methods
Five men (24-34 years old) were being evaluated for infertility. old, was studied after no left-sided vas deferens could be identified Received September revision March 25, 1991 1
Department
21
,
of Radiology,
College of Medicine, ville, FL 3261 0-0374.
1990; accepted
after
.
University of Florida
Box J-374, JHMHC, GainesAddress reprint requests to
P. L. Abbitt. 2
Department
Health 3
Sciences
Department
levels were was
Center,
lkiiversity
Charlottesville,
of Urology,
University
0361-803X/91/1572-0337 American Roentgen
of Virginia
tested
present
urinalysis of Radiology,
Health Sciences Center, Charlottesville, C
All five infertile men had had multiple semen absent or very few sperm. Testicular biopsy, normal spermatogenesis. Luteinizing hormone,
Each
VA 22908.
uld
of Virginia
deferens
VA 22908.
are not palpable,
five
be palpated
(Clark
and were three
normal
patients.
in three
Retrograde
patients.
Seminal
ejaculation
was
very low volumes with either of the six patients, revealed hormone, and testosterone fluid fructose
was tested
excluded
postejaculatory
by
and
in two patients. of the
was
All six patients Ray Society
in
analyses showing performed in two follicle-stimulating
A sixth patient, 36 years at the time of vasectomy.
Medical
patients
had
physical
in one patient.
present
There
in the remaining
were
not palpable
were
studied
Technology,
examination
was four
some patients.
of the
genital
question
region.
as to whether
The seminal
vesicles,
No vas
deferens
or not the vas which
generally
in any of the patients.
in the lithotomy
San Diego,
position
by using
CA) with a multiplanar
a Diasonics
7.5-MHz
Urovue-200
transrectal
probe.
unit
338
ABBITT
Downloaded from www.ajronline.org by NYU Langone Med Ctr-Sch of Med on 06/24/15 from IP address 128.122.253.228. Copyright ARRS. For personal use only; all rights reserved
Results Figure 1 is a schematic drawing illustrating possible abnormalities ofthe seminal tract. The normal sonographic anatomy is shown
in Figure
2.
One of our six patients had no identifiable on either side. Four patients had unilateral seminal
vesicle
(Figs.
3 and 4). Of these,
seminal absence
three
vesicle of the
had ipsilateral
renal agenesis. Of the four patients with an absent seminal vesicle on one side, one had an obstructed seminal tract on the opposite side. The other three had a sonographically normal-appearing
system
patient had a diminutive an obstructed system performed
on the
opposite
side.
The
sixth
hypoplastic system on one side and on the other. Scrotal sonography,
in all patients,
demonstrated
normal
testes
bilat-
erally.
ET
AL.
AJR:157, August
1991
In four of the patients, no surgical remedy could be devised from the information obtained with endorectal sonography.
One patient underwent surgical exploration, and the findings identified on endorectal sonography were confirmed. The sixth patient, the patient with no identifiable left-sided vas deferens at vasectomy, was confirmed by sonography to have unilateral absence of the seminal vesicle and vas deferens.
Discussion Although congenital genitourinary malformations affect approximately 10-1 4% of the overall male population [3], congenital abnormalities of the seminal vesicles or lower genital ductal system may often be unsuspected until a boy reaches reproductive
the lower
age.
Men
genitourinary
who
tract
have
congenital
are often
abnormalities
asymptomatic.
of
They
may present in the reproductive years with vague symptoms of perineal discomfort, or may have palpable masses on rectal examination. Infertility is rarely the presenting problem. Delayed recognition of congenital lower genitourinary abnormalties may occur because of the relatively nonspecific symptoms and the difficulty and nonspecificity of the clinical examination of the seminal vesicles and vas deferens. Normal
seminal vesicles are usually easily seen on endorectal sonography (Fig. 2). They can be evaluated for their presence, symmetry, and evidence of obstruction. In infertile men with low semen volumes in whom retrograde ejaculation has been excluded, endorectal sonography may clarify
dorectal
anatomic
abnormalities
sonography
responsible
is easily performed
for
infertility.
and should
En-
be the
initial imaging technique used if seminal vesicle disease considered [2]. CT and MR imaging should be reserved
Fig. 1.-Schematic system
tourinary
for sperm
illustration transport
shows
and shared
tract that may result In agenesis
abnormal
lower
embryogenesis
in both areas.
genital with upper
conduit geni-
is
for situations that require a larger field of view in the pelvis and lower abdomen, as may be true with more complex malformations [3-5]. The information provided by endorectal sonography can be used to determine if surgery is feasible and can determine the prognosis in patients with hypoplastic or agenetic ductal systems.
Fig. 2.-Normal patient. A, Axial sonogram shows symmetry of seminal vesicles (arrows). B, Longitudinal sonogram shows normal relationship of seminal vesicle (arrow) to prostate.
Downloaded from www.ajronline.org by NYU Langone Med Ctr-Sch of Med on 06/24/15 from IP address 128.122.253.228. Copyright ARRS. For personal use only; all rights reserved
AJA:157,
August
1991
SONOGRAPHY
Fig. 3-Sonogram of a 26-year-old infertile man shows cystic-appearing seminal vesicle (arrowhead) on right side. No seminal vesicle or kidney was identified on the left
OF SEMINAL
W, Kutz AB. State-of-the-art: endorectal sonography of the prostate gland. AJR 1990;154:691-700 2. Carter SSC, Shinohare K, Lipshultz L. Transrectal ultrasonography in disorders of the seminal vesicles and ejaculatory ducts. Urol Clin North Am 1989;i6:773-790
339
ABNORMALITIES
Fig. 4.-A and B, Sonograms of a 24-year-old on right side (A ) and a short, cystic one (arrows)
REFERENCES
1 . Rifkin MD, Dahnert
TRACT
infertile
man show no seminal
vesicle
(arrowhead)
on left side (B).
3. Malatinsky E, Labady F, Lepies P, Zajac A, Jancar M. Congenital anomalies of the seminal ducts. !nt Urol Nephrol 1987; 1 9 : 1 89-i 94 4. Kenney PJ, Leeson MD. Congenital anomalies of seminal vesicles: spectrum of computed tomographic findings. Radiology 1983;149:247-251 5. Kaneti J, Lissmer L, Smailowitz Z, Sober I. Agenesis of kidney associated with malformations of the seminal vesicle. Various clinical presentations. Int Urol Nephrol 1988;20:29-33
337
Abnormalities of the Seminal Tract Causing Infertility: Diagnosis with Endorectal
Patricia
L. Abbmtt1
Laurence
Watson2
Stuart
Howards3
Endorectal prostatic
Sonography
sonography,
carcinoma,
developed
should
primarily
for use in the diagnosis
be the first imaging
technique
and staging
used in the evaluation
of
of an
infertile man with low semen volume in whom either a hypoplastic or obstructed seminal tract is suspected. Endorectal sonography allows visualization of the seminal vesicles, which are otherwise difficult to examine. We used endorectal sonography to evaluate six young men, five of whom were being evaluated for azoospermia and infertility. One patient had no identifiable seminal vesicle on either side. Four patients had unilateral absence of the seminal vesicles. Of these four, three had a sonographically normal-
appearing
seminal
system
vesicle
on the contralateral
side, and the fourth
had an obstructed
contralaterally.
The sixth patient had a hypoplastic system on the left and an obstructed system on the right. The delineation of an obstructed or agenetic seminal vesicle and seminal tract on endorectal sonography allows decisions to be made regarding treatment and prognosis.
157:337-339,
AJR
August
The seminal tract such as vasography primarily
1991
is difficult to evaluate clinically, and traditional enhanced studies are invasive. Although endorectal sonography was developed
for the diagnosis
and
staging
of prostatic
carcinoma,
it provides
excellent
visualization of the seminal vesidles [1 , 2]. After retrograde ejaculation has been excluded as a cause of low ejaculate volume, endorectal sonography should be used in the infertile man in whom congenital absence or obstruction of the spermatic ductal system (vasa deferentia) and/or the seminal vesicles is suspected. We describe patients in whom endorectal sonography identified congenital abnormalities of the vas deferens or seminal vesicles.
Materials
and Methods
Five men (24-34 years old) were being evaluated for infertility. old, was studied after no left-sided vas deferens could be identified Received September revision March 25, 1991 1
Department
21
,
of Radiology,
College of Medicine, ville, FL 3261 0-0374.
1990; accepted
after
.
University of Florida
Box J-374, JHMHC, GainesAddress reprint requests to
P. L. Abbitt. 2
Department
Health 3
Sciences
Department
levels were was
Center,
lkiiversity
Charlottesville,
of Urology,
University
0361-803X/91/1572-0337 American Roentgen
of Virginia
tested
present
urinalysis of Radiology,
Health Sciences Center, Charlottesville, C
All five infertile men had had multiple semen absent or very few sperm. Testicular biopsy, normal spermatogenesis. Luteinizing hormone,
Each
VA 22908.
uld
of Virginia
deferens
VA 22908.
are not palpable,
five
be palpated
(Clark
and were three
normal
patients.
in three
Retrograde
patients.
Seminal
ejaculation
was
very low volumes with either of the six patients, revealed hormone, and testosterone fluid fructose
was tested
excluded
postejaculatory
by
and
in two patients. of the
was
All six patients Ray Society
in
analyses showing performed in two follicle-stimulating
A sixth patient, 36 years at the time of vasectomy.
Medical
patients
had
physical
in one patient.
present
There
in the remaining
were
not palpable
were
studied
Technology,
examination
was four
some patients.
of the
genital
question
region.
as to whether
The seminal
vesicles,
No vas
deferens
or not the vas which
generally
in any of the patients.
in the lithotomy
San Diego,
position
by using
CA) with a multiplanar
a Diasonics
7.5-MHz
Urovue-200
transrectal
probe.
unit
338
ABBITT
Downloaded from www.ajronline.org by NYU Langone Med Ctr-Sch of Med on 06/24/15 from IP address 128.122.253.228. Copyright ARRS. For personal use only; all rights reserved
Results Figure 1 is a schematic drawing illustrating possible abnormalities ofthe seminal tract. The normal sonographic anatomy is shown
in Figure
2.
One of our six patients had no identifiable on either side. Four patients had unilateral seminal
vesicle
(Figs.
3 and 4). Of these,
seminal absence
three
vesicle of the
had ipsilateral
renal agenesis. Of the four patients with an absent seminal vesicle on one side, one had an obstructed seminal tract on the opposite side. The other three had a sonographically normal-appearing
system
patient had a diminutive an obstructed system performed
on the
opposite
side.
The
sixth
hypoplastic system on one side and on the other. Scrotal sonography,
in all patients,
demonstrated
normal
testes
bilat-
erally.
ET
AL.
AJR:157, August
1991
In four of the patients, no surgical remedy could be devised from the information obtained with endorectal sonography.
One patient underwent surgical exploration, and the findings identified on endorectal sonography were confirmed. The sixth patient, the patient with no identifiable left-sided vas deferens at vasectomy, was confirmed by sonography to have unilateral absence of the seminal vesicle and vas deferens.
Discussion Although congenital genitourinary malformations affect approximately 10-1 4% of the overall male population [3], congenital abnormalities of the seminal vesicles or lower genital ductal system may often be unsuspected until a boy reaches reproductive
the lower
age.
Men
genitourinary
who
tract
have
congenital
are often
abnormalities
asymptomatic.
of
They
may present in the reproductive years with vague symptoms of perineal discomfort, or may have palpable masses on rectal examination. Infertility is rarely the presenting problem. Delayed recognition of congenital lower genitourinary abnormalties may occur because of the relatively nonspecific symptoms and the difficulty and nonspecificity of the clinical examination of the seminal vesicles and vas deferens. Normal
seminal vesicles are usually easily seen on endorectal sonography (Fig. 2). They can be evaluated for their presence, symmetry, and evidence of obstruction. In infertile men with low semen volumes in whom retrograde ejaculation has been excluded, endorectal sonography may clarify
dorectal
anatomic
abnormalities
sonography
responsible
is easily performed
for
infertility.
and should
En-
be the
initial imaging technique used if seminal vesicle disease considered [2]. CT and MR imaging should be reserved
Fig. 1.-Schematic system
tourinary
for sperm
illustration transport
shows
and shared
tract that may result In agenesis
abnormal
lower
embryogenesis
in both areas.
genital with upper
conduit geni-
is
for situations that require a larger field of view in the pelvis and lower abdomen, as may be true with more complex malformations [3-5]. The information provided by endorectal sonography can be used to determine if surgery is feasible and can determine the prognosis in patients with hypoplastic or agenetic ductal systems.
Fig. 2.-Normal patient. A, Axial sonogram shows symmetry of seminal vesicles (arrows). B, Longitudinal sonogram shows normal relationship of seminal vesicle (arrow) to prostate.
Downloaded from www.ajronline.org by NYU Langone Med Ctr-Sch of Med on 06/24/15 from IP address 128.122.253.228. Copyright ARRS. For personal use only; all rights reserved
AJA:157,
August
1991
SONOGRAPHY
Fig. 3-Sonogram of a 26-year-old infertile man shows cystic-appearing seminal vesicle (arrowhead) on right side. No seminal vesicle or kidney was identified on the left
OF SEMINAL
W, Kutz AB. State-of-the-art: endorectal sonography of the prostate gland. AJR 1990;154:691-700 2. Carter SSC, Shinohare K, Lipshultz L. Transrectal ultrasonography in disorders of the seminal vesicles and ejaculatory ducts. Urol Clin North Am 1989;i6:773-790
339
ABNORMALITIES
Fig. 4.-A and B, Sonograms of a 24-year-old on right side (A ) and a short, cystic one (arrows)
REFERENCES
1 . Rifkin MD, Dahnert
TRACT
infertile
man show no seminal
vesicle
(arrowhead)
on left side (B).
3. Malatinsky E, Labady F, Lepies P, Zajac A, Jancar M. Congenital anomalies of the seminal ducts. !nt Urol Nephrol 1987; 1 9 : 1 89-i 94 4. Kenney PJ, Leeson MD. Congenital anomalies of seminal vesicles: spectrum of computed tomographic findings. Radiology 1983;149:247-251 5. Kaneti J, Lissmer L, Smailowitz Z, Sober I. Agenesis of kidney associated with malformations of the seminal vesicle. Various clinical presentations. Int Urol Nephrol 1988;20:29-33
