[Seminal vesiculoscopy in the treatment of refractory hemospermia and ejaculatory duct obstruction].

Objective: To summarize the experience in the diagnosis and treatment of refractory hematospermia and ejaculatory duct obstruction by seminal vesiculoscopy. METHODS: We retrospectively analyzed the clinical data about 42 cases of refractory hematospermia and 6 cases of ejaculatory duct obstruction with azoospermia. We investigated the diagnosis, treatment, and prognosis of the diseases. RESULTS: All the patients underwent pelvic MRI and seminal vesiculoscopy. MRI for the 42 refractory hematospermia patients showed that 21 (50.0%) had cystic dilatation in the uni- or bilateral seminal vesicles, 25 (59.5%) had abnormal internal signal intensity in the uni- or bilateral seminal vesicles, 12 (28.6%) had both the problems above, and 4 (9.52%) had no obvious abnormality in the seminal vesicle area. The bilateral seminal vesicles were <1 cm in width in 3 of the 6 cases of ejaculatory duct obstruction, and obviously enlarged in the other 3, but without abnormal internal signals. No recurrence was found during the 3－36 months follow-up. CONCLUSIONS: The history and physical examination play important roles in the diagnosis of refractory hemospermia, and MRI is more valuable than TRUS in the diagnosis of seminal vesicle diseases. Seminal vesiculoscopy is an effective option for the management of persistent hematospermia and ejaculatory duct obstruction.

Transurethral resection of the ejaculatory ducts: etiology of obstruction and surgical treatment options.

Ejaculatory duct obstruction is an uncommon but surgically correctable cause of male infertility. With the advent and increased use of high-resolution transrectal ultrasonography, anomalies of the ejaculatory ducts related to infertility have been well documented. 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 transrectal ultrasound (TRUS). Although additional larger prospective and comparative studies are needed, it appears that TRUS with aspiration is the most effective method for diagnosis. While intrusive, it is less invasive than vasography. The most robust and published evidence for treatment involves transurethral resection of ejaculatory duct (TURED). More recent experience with antegrade endoscopic approaches are promising and may also be considered. An alternative to surgeries for reversal of obstruction is sperm retrieval for in vitro fertilization/intracytoplasmic sperm injection. A thorough discussion of all alternatives, including risks and benefits, should be held with couples facing this uncommon condition to allow them to make informed decisions regarding management.

Etiology of 305 cases of refractory hematospermia and therapeutic options by emerging endoscopic technology.

To investigate the surgical outcomes of vesiculoscopy on refractory hematospermia and ejaculatory duct obstruction (EDO), the clinical data (including pelvic magnetic resonance imaging (MRI) examinations and the long-term effects of endoscopic treatment) from 305 patients were analyzed. Four main etiologic groups were found on MRI. We found that 62.0% (189/305) of patients showed abnormal signal intensity in MRI investigations in the seminal vesicle (SV) area. Cystic lesions were observed in 36.7% (112/305) of the patients. The third sign was dilatation or enlargement of unilateral or bilateral SV, which were observed in 32.1% (98/305) of the patients. The fourth sign was stone formation in SV or in an adjacent cyst, which was present in 8.5% (26/305) of the patients. The transurethral endoscopy or seminal vesiculoscopy and the related procedures, including fenestration in prostatic utricle (PU), irrigation, lithotripsy, stone removal, biopsy, electroexcision, fulguration, or transurethral resection/incision of the ejaculatory duct (TURED/TUIED), chosen according to the different situations of individual patients were successfully performed in 296 patients. Fenestrations in PU+ seminal vesiculoscopy were performed in 66.6% (197/296) of cases. Seminal vesiculoscopy via the pathological opening in PU was performed in 10.8% (32/296) of cases. TURED/TUIED + seminal vesiculoscopy was performed in 12.8% (38/296) of cases, and seminal vesiculoscopy by the natural orifices of the ejaculatory duct (ED) was performed in 2.4% (7/296) of cases. Electroexcision and fulguration to the abnormal blood vessels or cavernous hemangioma at posterior urethra were performed in 7.4% (22/296) of cases. Two hundred and seventy-one patients were followed up for 6-72 months. The hematospermia of all the patients disappeared within 2-6 weeks, and 93.0% of the patients showed no further hematospermia during follow-up. No obvious postoperative complications were observed. The transurethral seminal vesiculoscopy technique and related procedures are safe and effective approaches for refractory hematospermia and EDO.

Retrograde ejaculation: pathophysiologic aspects and report of two successfully treated cases.

The ejaculatory process consists of two stages. During the first stage the semen is pumped into the posterior urethra and during the second stage the semen is propelled via the urethra through the external meatus. A pathologic second stage may lead to retrograde ejaculation of the semen into the urinary bladder. Attempts to achieve fertility in such patients can be made in two ways; namely through procedures to restore antegrade ejaculation (mainly using alpha-sympathomimetic agents) and procedures to regain viable and fertile sperm from the urinary bladder after sexual intercourse, with subsequent artificial insemination. The latter way of treatment was used in two patients who were referred for infertility and in whom retrograde ejaculation had been diagnosed. Postcoital urinary specimens were obtained by micturition and centrifuged. In one patient the sediment was washed with a nutrient solution; the other patient received alkalizing agents prior to intercourse in order to neutralize the urinary pH. The wives were inseminated on appropriate days and conceived. Both delivered healthy babies after uneventful pregnancies.

Evaluation and treatment of ejaculatory duct obstruction in the infertile male.

OBJECTIVE: To evaluate the role of ejaculatory duct obstruction as a cause for male factor infertility and review the treatment of this condition. DESIGN: A retrospective study was carried out involving male patients diagnosed as having ejaculatory duct obstruction as a contributing cause for their subfertility. SETTING: Patients were evaluated and treated through a university-based male infertility clinic. PATIENTS, PARTICIPANTS: Patients were evaluated for the presence of ejaculatory duct obstruction if they suffered from decreased ejaculate volume, sperm density, and sperm motility but had normal physical examinations and otherwise normal laboratory evaluations. INTERVENTIONS: Patients were treated by transurethral resection of the ejaculatory ducts. MAIN OUTCOME MEASURES: Results of semen analysis and pregnancy rates. RESULTS: An alteration in semen quality was achieved in 79% of patients after transurethral resection. An increase in sperm density or motility was achieved in 50%, whereas 29% showed an increase in ejaculate volume only. Pregnancy rate postoperatively was 29%. CONCLUSIONS: Ejaculatory duct obstruction as a cause of male infertility is more common than was previously recognized, especially among nonazoospermic patients. In properly selected patients, transurethral resection of the ejaculatory ducts can result in marked improvement in semen quality with subsequent pregnancy.

[Obstructive aspermia. successful treatment by transurethral resection of the verumontanum. A case report (author's transl)]. / Erfolgreiche Behandlung einer Verschlussaspermie durch transurethrale Resektion des Colliculus seminalis.

After a barren marriage for 2 1/2 years the 22 years old male patient presented for consultation. The examinations confirmed obstructive aspermia with acceptable spermatogenesis. The site of obstruction involved the colliculus seminalis. Transurethral resection of the colliculus was performed. Following a protracted postoperative andrological treatment pregnancy ensued with uncomplicated delivery.

Diagnosis and management of ejaculatory duct obstruction.

Ejaculatory duct obstruction is a rare but important cause of male infertility. The differential diagnosis, evaluation and treatment of patients with suspected ejaculatory duct obstruction is described herein. New minimally invasive techniques that can be utilized in both the diagnosis and treatment of ejaculatory duct obstruction are described.

A rare case of obstructive azoospermia due to compression of the seminal vesicle and ejaculatory duct by a large lower ureteric stone.

Male infertility due to obstructive azoospermia is a well-known entity. It is characterised by obstruction to the outflow of sperms either in the epididymis, vas, seminal vesicles or the ejaculatory ducts. We describe a rare case of obstructive azoospermia due to compression of the ejaculatory duct and seminal vesicle by a large lower ureteric stone in a 30-year-old man who had infertility for the past ten years. The patient's azoospermia resolved after removal of the stone.

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.

Transurethral resection of the ejaculatory duct in a fertile man.

OBJECTIVE: To report a case of transurethral resection of the ejaculatory duct in a fertile man with normozoospermia. DESIGN: Case report. SETTING: Large federal hospital in Sao Paulo, Brazil. PATIENT(S): A 29-year-old man with normal semen analysis values who had recently fathered a healthy child, seen with complaint of scrotal pain and reduced ejaculate volume. INTERVENTION(S): Transurethral resection of the ejaculatory duct. MAIN OUTCOME MEASURE(S): Relief of the symptoms. RESULT(S): Successful relief of the scrotal pain and increase in ejaculate volume after correction of the partial ejaculatory duct obstruction. CONCLUSION(S): Fertile men with scrotal pain and reduced ejaculate volume may be seen with partial ejaculatory duct obstruction, and surgical transurethral resection of the ejaculatory duct may provide resolution of symptoms.

Treatment of anejaculation with electroejaculation.

Male infertility caused by anejaculation is common after spinal cord injury (SCI) and following retroperitoneal lymph node dissection (RPLND) for testicular cancer. Other conditions sometimes associated with neurogenic ejaculation loss are diabetes mellitus, multiple sclerosis, extensive pelvic surgery and adult myelodysplasia. Primary absence of ejaculation also has been described. Few treatment options exist for these patients, if they wish to father a child. With electroejaculation (EEJ), or the low-current stimulation of the ejaculatory organs via a rectal probe, emission of semen can be initiated in these men. In non-SCI-patients EEJ requires general anaesthesia. The collected semen is washed and the motile sperm fraction isolated before artificial insemination (AI) of the partner. At the University of Michigan 198 men have been treated between 1986 and December 1991. An ejaculate could be obtained from nearly all patients. A major obstacle to success is the severe asthenozoospermia and the poor functional quality of the obtained sperm samples. This can be caused by the EEJ-technique itself, as well as by the long anejaculatory status. A semen sample with at least 10 million progressively motile sperm cells, useful for AI, was obtained in 75% of the SCI men and in 87% of the men following RPLND. In the couples wishing insemination, 49 pregnancies were induced, accounting for an overall pregnancy rate of 35% per couple. Thirty five healthy babies have been born. Only three complications were encountered. At Hannover Medical School only few patients have been stimulated to date. We could obtain an adequate sperm sample for AI from all of them. No complications were seen. As the first couple has just entered the phase of AI with husband sperm, an analysis of these results would be premature. Electroejaculation combined with artificial insemination is an efficient and safe treatment of male infertility due to neurogenic anejaculation.

[Transient obstructive aspermia and transient obstructive oligospermia]. / Tranzitornaia obturatsionnaia aspermiia, tranzitornaia obturatsionnaia oligospermiia.

The article is a continuation of a series of papers dealing with changes of ejaculatory ducts associated with various diseases of the prostatic gland and posterior urethra. Clinical description of patients, earlier treated for aspermia or oligospermia is presented. In some of the patients with such clinical manifestations, complete or partial compression of the ejaculatory ducts by the inflamed prostate or seminal bulb may be the cause and the disorder may be transitory rather than continuous. Twenty-six cases of transitory aspermia are reported, with special reference to laboratory and instrumental findings and treatment results. A group of patients (43) with transitory oligospermia is also described, and the results of investigation and treatment are presented.

Functional voiding disturbances of the ampullo-vesicular seminal tract: a cause of male infertility.

We present herein six cases of male sterility due to purely functional ampullo-vesicular tract voiding disturbances, out of a series of 94 vasovesiculographies performed on selected patients with suspected obstructive azoo-or oligozoospermia. This pathology was suspected from the particular seminal vesicle ultrasonographic pictures (anechoic areas) and the absence or marked reduction of the vesicular component in the ejaculate. The non-anatomic cause of the ampullo-vesicular voiding disturbance was demonstrated by means of the vesiculographic images and by the finding of large amounts of spermatozoa in the fluid obtained by micturition or bladder catheterism after seminal tract washout during vasovesiculography. Until now and to the best of our knowledge, only four other such cases were described in Literature, although documented in a different way (Ichijo et al., 1981). We may suppose that this new syndrome, possibly due to a local neurological defect, could be a not so rare cause of male infertility. Therapeutical attempts are also described.

Transrectal ultrasound in the evaluation of men with low volume azoospermia.

The evaluation of the subfertile man has changed with the advent of noninvasive imaging techniques. We used high resolution transrectal ultrasound early in the evaluation of 25 men 24 to 35 years old with probable ductal obstruction represented by azoospermia or severe oligospermia (less than 1 million sperm per cc) and low volume ejaculate. Of these patients 13 were found to have a post-testicular obstructive cause including ejaculatory duct obstruction (5), voluminous seminal vesicle dilatation with obstruction (3), seminal vesicle aplasia (2), nonpalpable vas (2) or epididymal obstruction (1). The other 12 men had either a varicocele (8) or testicular failure (4). Except for vasal or epididymal pathology, the other causes of post-testicular azoospermia presented with an ejaculate volume consistently less than 1.0 cc. All 10 patients with low volume and an abnormal ultrasound had normal follicle stimulating hormone levels and testicular biopsy findings. Sonography not only was helpful in establishing the diagnosis but also in determining the distal extent of the obstruction. Transrectal ultrasound is an important noninvasive diagnostic tool that minimizes the need for more invasive studies in the evaluation of azoospermia, particularly when associated with low ejaculate volume.

Ausencia funcional de conductos eyaculadores / Functional absence of ejaculatory ducts

Se realizó un estudio retrospectivo de muestras de semen procedentes de 5 159 pacientes que se consultaron por infertilidad en un período de 8 años y 4 meses. En 188 casos se comprobó azoospermia (muestras seminales con ausencia de espermatozoides) y en 23 de los azoospérmicos se presentaron características seminales del síndrome de ausencia funcional de los conductos eyaculadores. Se compararon los valores bioquímicos del plasma seminal (fructosa, fosfatasa ácida, y glicerilfosforilcolina) de los pacientes con las características del síndrome con igual número de normozoospérmicos infértiles y azoospérmicos no obstructivos. Pudo comprobarse diferencia altamente significativa en los 3 indicadores (p < 0,005) entre los pacientes con el sídrome y los otros 2 grupos. Los resultados indican que estas determinaciones bioquímicas son útiles en el diagnóstico del síndrome sin necesidad de utilizar métodos quirúrgicos