Imaging Ejaculatory Disorders and Hematospermia

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Oliver Haynes
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1 ATHENS 4-6 October 2018 European Society of Urogenital Radiology Imaging Ejaculatory Disorders and Hematospermia Parvati Ramchandani, MD Professor, Radiology and Surgery University of Pennsylvania Medical Center Philadelphia, PA, USA 2nd ESUR Teaching Course Multimodality Imaging Approach to Scrotal and Penile Pathologies

2 Why is Ejaculatory Tract imaging important? Symptoms of ejaculatory tract dysfunction are nonspecific imaging may show a cause Imaging studies, particularly Pelvic MRI may show incidental, unsuspected ejaculatory tract abnormalities

3 Symptoms of Ejaculatory Tract nonspecific Abnormalities perineal and lower abdominal pain Hematospermia Infertilityazoospermia with normal testicular biopsy

4 Imaging The Ejaculatory Tract What study is this? Is it still performed? Why not?? Is it normal?

5 Ejaculatory Tract Anatomy Vas deferens SV Vas deferens SV Ejaculatory duct Ejac duct VD Vasogram T2 W Coronal MR

Convoluted tubes Size Length- 3-8 cm Width - 1-2.

6 Convoluted tubes Size Length- 3-8 cm Width cm Androgen dependent sex glands largest in men >60 Seminal vesicles

7 Seminal vesicles Secrete fluid that constitutes 2/3 of ejaculate volume Fluid contains fructose, fibrinogen and prostaglandins which help activate sperm seminal vesicles are large and prominent in the human and rat but are not present in either the cat or the dog

8 Ejaculatory Tract Imaging MRI- modality of choice Endorectal coil (E-coil) MRI provides best anatomic resolution TRUS CT Vasoseminal vesiculography - almost never performed currently

9 Normal Seminal Vesicle - MRI T1W intermediate SI T2W Bright convoluted tube, superior to prostate

10 Vas Deferens - MRI Ampulla of vas is dark on T2W due to thick muscular wall

12 TRUS MHZ transducers Normal SV are hypoechoic, less echogenic than prostate

13 SV VD - ampulla

15 Vasoseminal Vesiculography (Vasogram) In the past, was the best study to demonstrate lumen of vas deferens Performed in infertile men suspected of having obstructive azoospermia MR and US are now preferred techniques

16 Azoospermic after inguinal herniorraphy Normal?

17 Seminal Vesicle Pathology Congenital agenesis cysts Inflammatory, including calculi Neoplasms

18 Right renal agenesis with ectopic ureteral insertion into a dilated right seminal vesicle

19 Congenital Seminal Vesicle Pathology Frequent association with urinary tract anomalies because seminal vesicles,vas deferens and ureter all derived from mesonephric (Wolfian) duct

20 Walsh: Textbook of Urology

21 Seminal Vesicle Agenesis Unilateral- Associated with ipsilateral renal agenesis (79% of cases), other renal abnormalities (12%), or normal kidney (9%) Bilateral - associated with cystic fibrosis gene mutation (64-73%), bilateral vas deferens agenesis, have normal kidneys

22 99% of men with cystic fibrosis have azoospermia due to bilateral vas deferens agenesis (due to mutation of the transmembrane conductance gene) Mutation of this gene is seen in 2/3 of patients with bilateral VD agenesis

23 Seminal Vesicle Cysts Strong association with renal anomalies (2/3 cases), ectopic ureteral insertion Present in young adulthood Cysts contain viscous brownish fluid with dead sperm Bilateral cysts- occur in 44-60% of patients with with autosomal dominant polycystic kidney disease

contain viscous brownish fluid with dead sperm Bilateral cysts- occur

24 Seminal Vesicle Cysts Strong association with renal anomalies (2/3 cases), ectopic ureteral insertion Present in young adulthood Cysts contain viscous brownish fluid with dead sperm Bilateral cysts- occur in 44-60% of patients with with autosomal dominant polycystic kidney disease

25 31 year old man with hematospermia

26 Right SV cyst, absent left SV, small prostate

27 Left megacalyces and megaureter

28 40 y.o. with pelvic pain T1 T2 Right SV cyst

29 61 year old, E-coil MRI for prostate CA staging Absent left seminal vesicle

30 Hematospermia (blood in ejaculate) Peak incidence in yr olds Brownish or red discoloration of ejaculate >80% have repeated episodes

31 T1W MRI in hematospermia T1W- Bright signal in portions of ejac tract Normal Blood in midline cyst and left SV with fluid levels

32 T2W MRI in hematospermia T2 W - blood low signal, but signal can vary depending on age of blood T2W T1W

33 Hematospermia T1 Normal T1 T2 T2 Normal

34 Cystic Lesions in Male Pelvis Cysts arise from SV Vas deferens Mullerian duct Ejaculatory duct Prostatic utricle Prostatic cysts

35 60 year old asymptomatic man with CA prostate

36 Mullerian duct cyst midline, extends above prostate

37 30 y.o. with hematospermia and perineal pain Mullerian duct cyst with ejac duct obstruction

38 Dr. Francesco Lotti- Urologist- ESUR 2018, Barcelona

39 Dr. Francesco Lotti- Urologist- ESUR 2018, Barcelona

40 Dr. Francesco Lotti- Urologist- ESUR 2018, Barcelona

41 Dr. Francesco Lotti- Urologist- ESUR 2018, Barcelona

42 45 y.o. male with hematospermia Ejaculatory duct cyst

43 Ejaculatory duct cyst Midline or para-midline, within prostate

44 Ejaculatory duct cyst with dilated sv

45 Hematospermia Men < 40 years usually due to inflammation in prostate, SV, epidydimis, or testicle SV cysts or calculi Rarely malignant or benign tumors e.g. urethral hemangioma

46 Stones and Inflammatory Disease

47 40-y.o. male with 3 years of hematospermia and hematuria Also, hypoplastic left SV T1W Axial T2W Axial

48 T1W Coronal T2W Coronal

49 Blood in midline cyst, left SV Stones and debris

50 Hematospermia Men > 40 years Benign causes predominate 5-10% may be due to CA prostate, bladder or SV

51 Hematospermia Work up if Persistent Associated with pain or hematuria MR is imaging modality of choice

52 Inflammatory Diseases Seminal vesiculitis usually associated with prostatitis May present with hematospermia Clinically obvious Can progress to abscess Predisposing factors- Instrumentation, diabetes, UTI

53 Aspergillus prostate abscess post liver transplant

54 Prostate and seminal vesicle abscess

55 Neoplasms Seminal vesicle - usually secondary involvement by prostate, rectal, or bladder cancer - primary tumors are rare Prostate Ca can rarely present with hematospermia

56 Hematospermia post prostate biopsy T1 T1 T2

57 23 y.o. with left SV mass-sarcoma

58 Coronal T2W Prostate Ca invading both seminal vesicles

59 T2W images - Bright intensity of normal tubules replaced by low Intensity foci and tubular thickening SV replaced by tumor Normal

60 Conclusions Imaging may reveal a specific etiology in patients with suspected ejaculatory tract abnormality such as hematospermia E-coil MR is imaging modality of choice but TRUS has a role in the initial diagnosis and management of these patients

61 Thank You

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Genitourinary Radiology In-Training Test Questions for Diagnostic Radiology Residents March, 2013 Sponsored by: Commission on Education Committee on Residency Training in Diagnostic Radiology 2013 by American