Transrectal ultrasonography of infertile men

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1 FERTILITY AND STERILITY Copyright" 1993 The American Fertility Society Printed on acid-free paper in U. S. A. Transrectal ultrasonography of infertile men Jonathan P_ Jarow, M.D.* Department of Urology, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, North Carolina Objective: To determine normal transrectal ultrasonographic anatomy in young men and the frequency of abnormalities in the infertile population. Design: Transrectal ultrasonography was performed upon 30 fertile volunteers and 150 consecutive men referred for male factor infertility. Setting: A male fertility center. Results: Transrectal ultrasonography was normal in 60% of controls and 53 % of infertile group. The frequency of hyperechoic lesions within the prostate was similar in controls (40%) and infertile men (39%). Mullerian duct cysts were present in 11 % of the infertile men and none of the volunteers. Rectal exam was normal in all of the men. Conclusions: Transrectal ultrasonography is more sensitive at detecting abnormalities of the seminal vesicles and prostate than rectal exam. Hyperechoic lesions within the prostate is frequently a normal finding. Mullerian duct cysts are more frequently observed in infertile men and may be a cause of ejaculatory duct obstruction. Fertil Steril 1993;60: Key Words: Transrectal ultrasonography, ejaculatory ducts, seminal vesicle, infertility Recent reports suggest that transrectal ultrasonography is useful in the evaluation of infertile men (1-6). Vasography has been the traditional test for patency of the distal male genital tract: vas deferens, seminal vesicles, and ejaculatory ducts (7). However, this is an invasive test and has the potential risk of vasal scarring. Noninvasive imaging modalities, including computerized tomography (8), magnetic resonance imaging (9), and transrectal ultrasonography, have been used to detect abnormalities of the distal male reproductive system. Transrectal ultrasonography is fast becoming the most popular alternative to vasography because it is readily available to the urologist and it is inexpensive. In azoospermic patients with low ejaculate volume, the findings of massively dilated seminal vesicles or absent seminal vesicles on transrectal ultrasonography are pathognomonic for ejaculatory duct obstruction or seminal vesicle agenesis, respectively (10). Patients can be confidently managed on the basis of the results of this single study in this clinical setting. However, the interpretation of transrectal ultrasonography in the oligospermic or asthenospermic infertile patient suspected to have partial or unilateral obstruction is much more complex (11). Earlier reports have demonstrated hyperechoic and cystic lesions within the prostates of infertile men and suggested that these lesions may be causing partial obstruction ofthe ejaculatory ducts. In the absence of the appropriate controls and confirmatory diagnostic studies, it is unclear whether these ultrasonographic lesions are a cause of infertility or just an incidental finding (2, 4, 11). The purpose of this study was to characterize the normal transrectal ultrasonographic anatomy of young men and determine the frequency of abnormal findings in a group of infertile men. Received May 5, 1993; revised and accepted August 2, * Reprint requests: Jonathan P. Jarow, M.D., Department of Urology, Bowman Gray School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina MATERIALS AND METHODS Transrectal ultrasonography was performed upon 150 consecutive men referred for male factor infer- Jarow Transrectal ultrasonography 1035

Bladder Seminal vesicle diameter Rectum Symphysis pubis Rectum Figure 1 Transaxial (A) and sagittal (B) trans rectal ultrasonographic view of normal seminal vesicles and vas deferens demonstrating

2 Bladder Seminal vesicle diameter Rectum Symphysis pubis Rectum Figure 1 Transaxial (A) and sagittal (B) trans rectal ultrasonographic view of normal seminal vesicles and vas deferens demonstrating method of obtaining measurements. tility and 30 fertile volunteers (with internal review board approval) using a Hitachi EUB 450 ultrasound unit with a 6.5 MHz biplanar transducer (Hitachi Ltd., Tokyo, Japan). All ultrasound studies were performed with the subject in the lateral decubitus position after a defined period of sexual abstinence of <1 day. All of the patients and controls had a digital rectal exam and none received a bowel preparation before transrectal ultrasonography. Ultrasonography was not performed in a blinded fashion. Images were obtained in both the trans axial and sagittal planes. Seminal vesicle length and width were measured in the transaxial plane (Fig. la). Seminal vesicle area was calculated by multiplying length times width. The diameter of the vas deferens was also measured in the transaxial plane. Ejaculatory duct diameter was measured in the sagittal plane (Fig. IB). Ultrasonographic guided needle aspiration of cyst fluid was performed in patients with cystic lesions and the cyst fluid was examined for sperm under phase microscopy. Semen analyses were not performed upon the fertile volunteers. Statistical analysis was performed using Student's t-test and Fisher's exact test. RESULTS The mean age of the 30 fertile controls (29 ± 5 years) was significantly lower than the 150 patients 1036 J arow Transrectal ultrasonography Fertility and Sterility

Table 1 Measurements of Vas Deferens, Ejaculatory Ducts, and Seminal Vesicles* Vas deferens diameter (cm) Ejaculatory duct diameter (cm) Seminal vesicle width (cm) Seminal vesicle length (cm) Seminal

3 Table 1 Measurements of Vas Deferens, Ejaculatory Ducts, and Seminal Vesicles* Vas deferens diameter (cm) Ejaculatory duct diameter (cm) Seminal vesicle width (cm) Seminal vesicle length (cm) Seminal vesicle area (cm 2 ) * Values are means ± SD. Controls (n = 30) 0.4 ± ± ± ± ± 0.9 Patients (n = 150) 0.4 ± ± ± ± ± 1.5 (34 ± 6 years) (P < 0.01). The incidence of prior prostatitis, hematospermia, or urethral instrumentation was not significantly different between controls and patients. Rectal examination was normal in all patients and controls. Bilateral vasal agenesis was present in six infertile patients. One patient had normal seminal vesicles, one patient had unilateral seminal vesicle agenesis, and four had bilateral seminal vesicle agenesis. There was no significant difference in mean seminal vesicle, vas deferens, and ejaculatory duct size between the 30 fertile controls and 150 patients (Table 1). The normal distribution of each parameter was defined as the mean ± 2 SD ofthe control population. Thus normal seminal vesicle width is from 0.4 to 1.4 cm. Normal seminal vesicle length is 1.9 to 4.1 cm. Mean ejaculatory duct diameter was 0.06 cm with a normal range of 0.04 to 0.08 cm. The mean diameter of the vas deferens was 0.40 cm with a normal range of 0.26 to 0.54 cm. The mean seminal vesicle area (length X width) was 2.8 cm 2 for both patients and controls without significant difference between right and left seminal vesicles. The mean difference between right and left seminal vesicle area was cm 2 with a normal range of up to 1 cm 2 difference. There was a significant but weak correlation between combined seminal vesicle area (left + right) and ejaculate volume (r = 0.34, P < ). Transrectal ultrasonography of the prostate was completely normal in 60% of the controls and 53 % of the patients (Table 2). Hyperechoic lesions of the prostate were observed in 40% of controls and 39% of patients. Hypoechoic lesions of the prostate were seen in 1 % of the patients and none of the controls. Mullerian duct cysts, midline prostatic cysts without sperm in the cyst fluid (12), were found in 11 % of patients and none of the controls (P < 0.05). Ejaculatory duct diverticula, midline prostatic cysts with sperm present in the cyst fluid (12), were found in 3% of the patients and none of the con- trois. Prostatic retention cysts, peripherally located prostatic cysts without sperm in the fluid (12), were seen in 4 % of patients. Of the infertility patients, 18% had some type of prostatic cyst whereas none were found in the controls. The mean ejaculatory duct diameter or seminal vesicle size was not significantly different between those infertile patients with cystic lesions versus those without. We did not observe any abnormalities of the seminal vesicles other than size in either the patients or the controls. DISCUSSION This study demonstrates that transrectal ultrasonography is much more sensitive than rectal examination in detecting both gross and subtle lesions of the prostate and seminal vesicles. Yet it is still unclear whether all of the abnormalities detected by trans rectal ultrasonography in the infertile group are specifically related to their infertility or are just a coincidental finding. The normal values for seminal vesicle size, ejaculatory duct, and vas deferens diameter determined by our control population were similar to the mean of the infertile group and the results reported by previous investigators (2, 4, 13, 14). This finding suggests that the majority of infertile men do not have significant abnormalities of the distal genital tract. Previous investigators have recommended performing transrectal ultrasonography upon patients with abnormal semen analyses who do not have overt signs of testicular failure such as an elevated serum follicle stimulating ho:mone or testicular atrophy (4). Unfortunately, we were unable to identify a specific pattern on semen analysis that was predictive of an abnormal transrectal ultrasound exam other than low ejaculate volume. Therefore, we cannot recommend any new specific indications for the use of transrectal ultrasonography in the euvolemic infertile patient population on the basis of this study. Table 2 Ultrasonographic Findings Within the Prostate* Normal Hyperechoic lesions Hypoechoic lesions Mullerian duct cyst Ejaculatory duct diverticulum Prostatic retention cyst Controls (n = 30) o o * Values are percentages. t Significantly different from controls, P < Patients (n = 150) l1t 3 4 Jarow Transrectal ultrasonography 1037

r Pelvic cystic lesions have been classified on the basis of location and presence of sperm within the cyst fluid (12). We observed three types of intraprostatic cysts in the infertile population.

4 r Pelvic cystic lesions have been classified on the basis of location and presence of sperm within the cyst fluid (12). We observed three types of intraprostatic cysts in the infertile population. Midline cysts without sperm are of Mullerian duct origin and are called Mullerian duct cysts or utricular cysts. These lesions may cause obstruction of the ejaculatory ducts by external compression and were observed in 11 % ofthe infertile population and in none of the controls. Midline intraprostatic cysts containing sperm are of W olffian duct origin and have been called ejaculatory duct diverticula. These lesions may be produced by distal obstruction ofthe ejaculatory duct and are an infrequent finding. Peripherally located prostatic cysts do not contain sperm and are called prostatic retention cysts. Prostatic cysts were observed much more frequently in the infertile group compared with the fertile controls, suggesting that these lesions may playa causative role in infertility rather than being just an incidental finding. Cystic lesions ofthe seminal vesicles have been associated with ectopic ureters and either absent or dysplastic ipsilateral kidneys (15-18). This lesion should be differentiated from cystic dilation of the seminal vesicles due to obstruction of the ejaculatory ducts. We did not observe any cystic lesions ofthe seminal vesicles in this group of 150 consecutive infertile men but had previously reported a patient seen before the initiation of this study who had cystic dilation of the seminal vesicles (2). Hyperechoic lesions within the prostate gland were a common finding in both the control population and the infertile group. Hyperechogenicity is normally observed at the veru in association with the distal ejaculatory duct. We also observed hyperechoic lesions within the parenchyma of the prostate near the route of the ejaculatory duct, which may represent corpora amylacea. Fornage (19) reported finding hyperechoic lesions of the prostate in 55% of 2,000 men aged 30 to 40 years. Therefore, it does not appear that these hyperechoic lesions within the prostate are specifically related to infertility. Theoretically, obstruction ofthe ejaculatory duct should be associated with dilation of the seminal vesicle. Previous authors have suggested that obstruction should be suspected in patients with transaxial seminal vesicle width> 1.5 cm (1, 11, 20). This correlated well with our normal range of 0.4 to 1.4 cm. However, one of the infertile patients in this study had documented ejaculatory duct obstruction by vasography. His transrectal ultrasound study re- vealed normal-sized seminal vesicles (maximal width of 1.1 cm) and hyperechogenicity within the prostate at the veru. Therefore, seminal vesicle dilation does not appear to occur in every patient with ejaculatory duct obstruction. We observed a weak correlation between combined seminal vesicle area, which is an approximation of seminal vesicle size, and ejaculate volume. Therefore, one might suspect obstruction in patients who have a discrepancy between ejaculate volume and seminal vesicle size. However, seminal vesicle area was not an accurate enough predictor of ejaculate volume upon which clinical management decisions can be made, except in those patients with extremely low ejaculate volumes ( <1 ml). We also found symmetry in seminal vesicle area in our control population. The mean difference between right and left seminal vesicle area was 0.1 cm 2, with a normal difference of up to 1.0 cm 2 Seminal vesicle width and length were not always symmetrical because of occasional folding of the seminal vesicle upon itself. Therefore, obstruction should be suspected in patients with seminal vesicle size asymmetry. The results of this study demonstrate that transrectal ultrasonography will frequently detect abnormalities of the prostate and seminal vesicles in men with normal rectal exams. Transrectal ultrasound findings of cystic dilation of the seminal vesicles in a patient with abnormally low ejaculate volume is pathognomonic for ejaculatory duct obstruction. However, the more subtle signs of partial obstruction, such as prostatic cysts, mild dilation of the seminal vesicles (transaxial width> 1.5 cm), asymmetry of the seminal vesicles, or lack of correlation between seminal vesicle area and ejaculate volume are not always reliable signs of obstruction. Patients with these transrectal ultrasonographic abnormalities should undergo a confirmatory study, such as vasography, before considering treatment with transurethral resection ofthe ejaculatory duct. REFERENCES 1. Carter SSC, Shinohara K, Lipshultz LI. Transrectal ultrasonography in disorders of the seminal vesicles and ejaculatory ducts. Urol Clin North Am 1989;16: Patterson L, Jarow JP. Transrectal ultrasonography in the evaluation of the infertile man: a report of 3 cases. J Urol 1990;144: Kuligowska E, Baker CE, Oates RD. Male infertility: role of transrectal US in diagnosis and management. Radiology 1992;185: Hellerstein DK, Meacham RB, Lipshultz LI. Transrectal ultrasound and partial ejaculatory duct obstruction in male infertility. Urology 1992;39: Jarow Transrectal ultrasonography Fertility and Sterility

5 5. Belker AM, Steinbock GS. Transrectal prostate ultrasonography as a diagnostic and therapeutic aid for ejaculatory duct obstruction. J Urol 1990;144: Takatera H, Sugao H, Sakurai T. Ejaculatory duct cyst: the case for effective use of transrectallongitudinal ultrasonography. J UroI1987;137: Pryor JP, Hendry WF. Ejaculatory duct obstruction in subfertile males: analysis of 87 patients. Fertil Steril 1991;56: Stanley RJ, Sagel SS, Fair WR. Computed tomography of the genitourinary tract. J Urol 1978;119: Schnall MD, Pollack HM, Van Arsdalen K, Kressel HY. The seminal tract in patients with ejaculatory dysfunction: MR imaging with an endorectal surface coil. Am J RoentgenoI1992;159: Jarow JP. Evaluation and treatment of the azoospermic patient. Curr Probl Urol 1992;2: Meacham RB, Hellerstein DK, Lipshultz LI. Evaluation and treatment of ejaculatory duct obstruction in the infertile male. Fertil Steril1993;59: Shabsigh R, Lerner S, Fishman IJ, Kadmon D. The role of trans rectal ultrasonography in the diagnosis and management of prostatic and seminal vesicle cysts. J Urol 1989;141: Hernandez AD, Urry RL, Smith JA Jr. Ultrasonographic characteristics of the seminal vesicles after ejaculation. J Urol 1990;144: Fuse H, Okumura A, Satomi S, Kazama T, Katayama T. Evaluation of seminal vesicle characteristics by ultrasonography before and after ejaculation. Urol Int 1992;49: Beeby DI. Seminal vesicle cyst associated with ipsilateral renal agenesis: case report and review of literature. J Urol 1974;112: Carvalho HA, Paiva JLB, Santos VHV, Andrade M, Galvao-Teles A. Ultrasonic recognition of a cystic seminal vesicle with ipsilateral renal agenesis. J UroI1986;135: Schwartz ML, Kenney PJ, Bueschen AJ. Computed tomographic diagnosis of ectopic ureter with seminal vesicle cyst. Urology 1988;31: Kaneti J, Lissmer L, Smailowitz A, Sober I. Agenesis of kidney associated with malformations of the seminal vesicle. Various clinical presentations. Int Urol Nephrol 1988;20: Fornage BD. Normal ultrasound anatomy of the prostate. Ultrasound Med BioI 1986;12: Littrup PJ, Lee F, McLeary RD, Wu D, Lee A, Kumasaka GH. Transrectal US of the seminal vesicles and ejaculatory ducts: clinical correlation. Radiology 1988;168: Jarow Transrectal ultrasonography 1039

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