Bruce R. Gilbert, M.D.,Ph.D.
Clinical Assistant Professor of Surgery (Urology)
in SURGERY OF MALE INFERTILITY
edited by Marc Goldstein,M.D.
INTRODUCTION
Until recently, relatively few surgical options have existed for
the man with an impaired semen quality. Varicoceles have been
and remain the most common surgically treatable condition associated
with male subfertility. Technical advances have markedly improved
the prognosis for men with obstructive azoospermia (1). Historically,
men with azoospermia or severely oligospermia have been successfully
treated with transurethral resection of a portion of the prostate.
However, this has required a formal microsurgical vasotomy and
vasogram to identify obstruction of the ejaculatory ducts (2)(3)(4)(5)(6)(7)(8)(9)(10)(11).
In addition, men presenting with a severely impaired semen quality,
a markedly decreased number of forwardly progressive spermatozoa,
pyospermia or hematospermia have had only expectant therapy. With
the widespread use of transrectal ultrasonography many cases of
partial genital duct obstruction have been identified [Pryor,
1991 #16](12)(13). This has made the previously rare finding of
obstruction of the ejaculatory duct a much more common and treatable
cause of male factor subfertility. In addition, 'partial' ductal
obstruction can be identified and treated.
This chapter will discuss the diagnosis and treatment of ejaculatory
duct obstruction. A particular emphasis on the diagnostic modalities
will be made since identification of the pathology is as important
as the skill of the surgeon in its repair.
Diagnostic Techniques
Clinical History and Physical Examination
The history and physical examination of the infertile man should
include factors associated with obstruction of the ejaculatory
ducts. These include a decline in ejaculatory volume, a history
of genitourinary tract infection or injury as well as perineal
pain or discomfort. Use of a questionnaire facilitates the accumulation
of necessary information in an expeditious manner. The questionnaire
that we use has been previously published(14). The history should
initially include classification of the prior fertility of the
man. Has he previously contributed to a pregnancy in this partner
or a previous partner? If this is true, then information regarding
any infections or traumatic injuries should be obtained. After
delineation of primary or secondary infertility for the man, a
careful sexual history should be obtained. This not only directs
the physical examination but also yields insight as to the couples
timing of relations. The couple needs to have an understanding
of the menstrual cycle and the importance of the appropriate frequency
of intercourse, without use of anti-sperm agents such as lubricants
and avoidance of douching after intercourse. Brief assessment
of the infertility evaluation of the female partner should be
obtained so that inappropriate intervention is not entertained
for the man when fertility is not possible for the women (e.g.,
ovulatory failure).
A history directed toward the general physical health and hormonal
status of the man should also be performed with specific attention
to factors that impair male fertility potential. Childhood illnesses
associated with infertility include cryptorchidism and postpubertal
mumps orchitis. The timing of pubertal landmarks and characteristics
of secondary sexual development should be noted (onset of axillary
& pubic hair, start of shaving, density of beard relative to male
siblings). Operative intervention on the bladder neck (including
Y-V plasty for UTI or vesicoureteral reflux) may be associated
with retrograde ejaculation. Retroperitoneal Iymph node dissection
for testis tumor and other retroperitoneal surgery may disrupt
sympathetic pathways necessary for emission and antegrade ejaculation.
Medical conditions such as diabetes or medications taken for diseases
such as hypertension may affect ejaculation. The neuropathy associated
with diabetes can affect bladder neck closure and antegrade ejaculation.
Sympathomimetic drugs or electroejaculation may be used for treatment
of these patients.
Prescription as well as "recreational" drugs may also
impair ejaculatory function (15)(16) (TABLE 1). A detailed
history of all medications is needed to assess their potential
effect on ejaculatory function as well as fertility. Medications
that interfere with preganglionic and postganglionic autonomic
function have the potential to interfere with both emission and
ejaculation. Male sexual function has been associated with almost
every antihypertensive agent available. The alpha-adrenergic blocking
agents phenoxybenzamine and phentolamine are common causes of
ejaculatory inhibition (17),(15). This effect was found by Kedia
and Persky (18) o be due to absent seminal emission and not retrograde
ejaculation.
Use of many psychotropic agents, like the antihypertensives, have
been reported to causes ejaculatory dysfunction. The major tranquilizers
Thioridazine (Mellaril), Chlorpromazine (Thorazine) and Mesoridazine
(Serentil) have all been reported to inhibit or reduce ejaculation.
Thioridazine in particular inhibits ejaculation in up to 49% of
men using this medication(18). This effect of Thioridazine is
likely due to its significant peripheral alpha-adrenergic blocking
action. The antidepressants (both tricyclic antidepressants and
monamine oxidase inhibitors) have both peripheral and central
effects (17). The minor tranquilizers (including the benzodiazepines)
have been implicated in ejaculatory dysfunction (19) although
the mechanism is not well defined (17).
Blood alcohol level is associated with a decreased arousal and
an increased ejaculatory latency (20). Prolonged use of both cocaine
and amphetamines has been reported to cause a decreased libido
and ejaculatory difficulty(17). Androgenic drugs, such as anabolic
steroids, can inhibit function of the hypothalamic-pituitary-testicular
axis, leading to hypogonadism as well as possible alterations
in seminal vesicle fluid volume.
The physical examination of the infertile man should be complete
and thorough, since any significant medical condition may adversely
affect testicular function. A warm room is critical to allow adequate
relaxation of the scrotum to facilitate examination of the scrotal
contents. A global assessment of androgen action should initially
be performed. Temporal balding requires DHT action. Normal axillary
and pubic hair distribution are related to androgen action. Gynecomastia
results from excessive estrogen action or an imbalance between
androgens and estrogens. The general appearance of men with recognized
syndromes (e.g., Kallmann's syndrome: anosmia, lack of sexual
secondary characteristics, long arms, short 4th metacarpals, etc.)
should be considered, although a definitive diagnosis of idiopathic
hypogonadotropic hypogonadism requires serum hormone evaluation.
Specific attention to the genitourinary examination is necessary.
The penis should be evaluated for lesions, curvature and Peyronie's
plaques. Location of the urethral meatus should be noted, and
assessed relative to the ability of the patient to place the ejaculate
deep within the vagina during intercourse for hypospadiac men.
The abdomen should be palpated for abdominal masses and the inguinal
regions closely inspected for scars.
The scrotal exam is most easily performed in a warm room. Scrotal
evaluation should asses the spermatogenic potential of the testes
and the presence of potentially obstructing lesions. Initially
the patient is examined supine. The consistency of the testis
can be best evaluated in this position, including the presence
of any testicular masses. Testicular examination should carefully
assess the volume and consistency of the testis which directly
correlates to the spermatogenic potential of the testis. Induration
of the epididymis may be associated with inflammation and epididymal
obstruction. Post-epididymal obstruction of the reproductive tract
may result in fullness" of the epididymis. If clinically
indicated a scrotal ultrasound should be performed to define the
intratesticular and peri-testicular structures.
The presence of vasa deferentia bilaterally should be confirmed
by palpation. Vascular engorgement of the spermatic cords should
be assessed and the size of varicoceles recorded. Large bilateral
varicoceles or a varicocele that does not decompress with the
patient supine may suggest a fixed obstruction in the retroperitoneum
and should be further evaluated with ultrasonography and possibly
computed tomography of the abdomen. Hernias in the inguinal region
should also be assessed. Rectal examination should be performed
to assess for prostatic irregularities, bogginess or tenderness.
When indicated (see below) a transrectal ultrasound examination
should be performed to evaluate the prostate, seminal vesicles
and ejaculatory ducts. Routine digital rectal assessment for masses
as well as guaiac testing of stool from the examining glove is
also performed.
Laboratory Evaluation
Urinalysis
Urinalysis can detect urinary tract infections, retrograde ejaculation
and medical renal disease all of which can be related to an impaired
ejaculatory or semen quality. The urinalysis should include a
dip stick analysis of leukocytes, pH, protein, glucose, ketones,
blood and hemoglobin. I routinely obtain a post ejaculate urine
(PEU) after a semen specimen is given. The entire contents of
the bladder should be evacuated, the volume measured and concentrated
if too large a volume is obtained. The total number of sperm in
the specimen is determined. The spun specimen should be evaluated
microscopically (preferably by phase contrast microscopy) and
the number of sperm, round cells, bacteria and crystals quantified.
Chlamydia is a common pathogen that impairs both female and male
fertility. Simplified kits for evaluation of Chlamydia in a voided
urine specimen (Kodak SureCell) are readily available and easily
incorporated into the routine evaluation.
Semen analysis
Semen analysis is usually the first test performed in male factor
evaluation. There are many excellent reviews that detail the procedure(21),(22),(23).
There are factors to consider in evaluation of partial or complete
obstruction of the male genital ductal system. (1) Multiple analyses
separated by 3-4 week intervals are needed to document volume
and/or motility. (2) It is important to provide patients with
clearly written instructions on how to produce a
specimen and as to the type of container to use. Routinely we
ask for 48-72 hours of abstinence. When the specimen is received
in the laboratory it is placed in an incubator at 370C. We note
the time of collection, the time that we evaluate it and whether
it is a complete sample or whether some loss occurred during collection.
We also ask for a post-ejaculate urine to be given at this time.
In men with a low volume specimen a post-ejaculate urine
is essential to eliminate retrograde ejaculation as the etiology.
The physical characteristics such as liquefaction, viscosity,
volume, color and pH are noted and recorded. A microscopic examination
is then performed. The parameters recorded are concentration,
total sperm count, motility and forward progression and morphology.
If no sperm are seen, and/or the volume is less than 1.5 cc, a
fructose test should be done to confirm the presence of seminal
vesicle fluid, as well as a post ejaculate urine, to rule out
retrograde ejaculation. If motility is less than 50% a viability
stain is done using Eosin Y with Nigrosin as a counterstain. Greater
then 50% of the sperm should be viable (i.e., non-stained). Morphology
is the most subjective parameter measured in the semen analysis.
The two standard atlases are the WHO laboratory manual (21)
and the Atlas of Human Sperm Morphology (22).
Hormonal evaluation
An appropriate hormonal milieu must exist for the reproductive
organs to produce, mature and transport the highly specialized
male gamete to the ejaculatory duct. Our routine blood studies
include testosterone, FSH, LH, prolactin and estradiol. FSH is
usually elevated when seminiferous tubular function is impaired.
However, the secretory functions of the prostate and seminal vesicles
is regulated primarily by androgens (24). Testosterone production
by the Leydig cell provides locally high intratesticular concentrations
of this hormone that stimulates spermatogenesis. However, it is
the circulating levels of androgens that are important in seminal
vesicle and prostatic secretions. Testosterone concentrations
in peripheral blood of men change dramatically during man's aging.
Testosterone reaches a maximum concentration during the second
or third decade of life, then reaches a plateau, and declines
thereafter. Additionally, annual and daily rhythms in testosterone
concentration occur, typically with a testosterone peak in the
early morning. Other, irregular fluctuations in testosterone concentration
may also be detectable in peripheral blood. Within 2 - 14 days
following castration seminal plasma production ceases resulting
from a de-activation of both RNA and protein synthesis (25). Therefore,
LH, prolactin and estradiol, all of which might have an effect
of androgen function need to be evaluated.
Transrectal Ultrasound Evaluation
The use of high resolution and high frequency (5-7 MHz) transducers
has allowed superb imaging of the prostate, seminal vesicles and
ejaculatory ducts. Vasography (chapter ) is presently the gold
standard. However, vasography requires a microsurgical procedure
and carries the risk of scarring of the vas deferens. Transrectal
ultrasound (TRUS) on the other hand, is a relatively non invasive
technique that offers superb resolution of the prostate seminal
vesicles and ampulla of the vas deferens and is a technique well
known to most Urologists. It is also less costly than either CT
scan or MRI and therefore is more cost effective in following
resolution of a pathologic lesion after medical or surgical intervention.
In evaluating the subfertile male TRUS has become increasingly
important (26),(27),(28),(29). Meacham et al (13) have used TRUS
for evaluation of men with low ejaculate volumes (1.5 cc). reduced
sperm density and/or motility with FSH levels that were not greater
than three times normal. Indications for TRUS in evaluating the
subfertile male include:
1) Azoospermia
2) Abnormal digital rectal examination
3) Retrograde ejaculation
4) Suspicion of partial obstruction
( volume 1.5cc, motility 20% or a forward progression 2)
5) Hematospermia or Pyospermia
6) History of rectal injury, pelvic fracture or genital trauma
In the azoospermic patient, seminal vesicle and ejaculatory
duct obstruction can be documented. Formally, only vasography
was able to delineate ductal obstruction. However, the advent
of high resolution ultrasonography using transrectal solid state
probes has made the TRUS exam one of the first tests to be done
in the evaluation of the azoospermic male. The presence of seminal
vesicle dilation (presently defined as a seminal vesicle cross-sectional
width greater than 1.5cm (12), ejaculatory duct obstruction (defined
as an internal ductal diameter of greater than 0.2mm) with or
without a calcification is diagnostic. The echo texture of the
seminal vesicles is also suggestive of altered function. When
the normal homogenous appearance of the seminal vesicle is replaced
by a heterogenous appearance with hypoechoic regions and dilation
(Figure 1), careful inspection of the ejaculatory ducts
and prostate might uncover an obstructive lesion (Figure 1).
In addition, the diagnosis of agenesis of the distal portions
of the vas deferens can be suspected by absence or atresia of
the ampulla of the vas deferens. Agenesis of the vas deferens
is often associated with abnormalities of the seminal vesicles.
An abnormal digital rectal examination in the subfertile
man also needs to be examined by TRUS. Chronic prostatitis, utricular
or ejaculatory duct cysts or other mass lesions can be suspected
by palpation but can be identified by TRUS (Figure 1).
The ability to confirm our suspicions by TRUS has allowed us to
make a diagnosis and formulate a treatment plan. This has often
eliminated the need to perform a formal microsurgical vasotomy
and vasogram.
Occasionally , in patients with retrograde ejaculation
anatomic abnormalities might exist. These often can be diagnosed
by transrectal ultrasonography (Figure 2). In many of these
anomalies the ejaculatory ducts and seminal vesicles can be found
to enter intravesically or at the bladder neck . Thus treatment
with sympathomimetics would not be expected to be effective.
In the patient with a low volume ejaculate ( 1.5cc), poor motility
(20%) and/or poor forward progression (2) a partial obstruction
of the ejaculatory duct is suspected. These are important
indications for transrectal ultrasonography in the subfertile
male. Prostatic calcifications (Figure 3), cystic masses
(Figure 4) and inflammatory lesions all can obstruct the
transit of seminal plasma and spermatozoa and can readily be identified
by TRUS. Resolution of the lesion and the effectiveness of treatment
can be evaluated post operatively.
The presence of hematospermia and/or pyospermia have long
eluded diagnostic evaluation. In male factor subfertility, clinical
and subclinical infections of the male genitourinary tract are
routinely evaluated by seminal fluid and urine cultures when indicated.
When pyospermia or hematospermia is found in evaluation of the
subfertile male with an impaired semen profile, TRUS should performed
to identify correctable lesions. These included obstruction of
the ejaculatory duct or seminal vesicles as well as prostatic
or ejaculatory duct calcifications (Figure 1) .
TREATMENT OF EJACULATORY DUCT OBSTRUCTION
Medical Therapy
The diagnosis of an anatomic obstruction is paramount since surgical
intervention is not initial therapy for functional obstructions
(i.e., the absence of an anatomic obstruction) of the ejaculatory
ducts. The most common functional obstructions seen in male factor
subfertility are retrograde ejaculation and anejaculation either
secondary to diabetes or surgical intervention (e.g., retroperitoneal
lymph node dissection). Treatment of retrograde ejaculation usually
begins with a trial of a medication containing alpha-sympathomimetic
properties (Table 2)(30),(31),(32). If medical therapy
fails to produce an antegrade ejaculate then retrieving sperm
from the post ejaculate urine after systemic alkalinization, followed
by sperm processing and intrauterine insemination(33)(34) ,has
been used with good results . Electroejaculation is often successful
in patients with anejaculation after retroperitoneal lymph node
dissection(35),(36),(37). Surgical therapy for functional obstruction
usually consists of aspiration of epididymal or vasal sperm with
assisted reproductive technology incorporating microinsemination.
Surgical Therapy
The ejaculatory ducts are paired structures approximately 2 cm
in length. They are formed by the union of the medially positioned
ampulla of the vas deferens and the laterally placed duct of the
seminal vesicle (Figure 5). These ducts extend from the
base of the prostate and run within the central zone of the prostate(38),(39)
in an antero-inferior direction (Color Plate). They terminate
just within or lateral to the prostatic utricle. The thin wall
of the ejaculatory duct is composed of three layers (40): (1)
the outer fibrous layer disappears as the ejaculatory ducts
enter the prostate, (2) an inner layer of muscular fibers consisting
of a thin outer circular layer and an inner longitudinal layer
and (3) a mucus membrane covered with columnar epithelium.
The proximity of the ducts to each other together with their thin
walls is the reason why bilateral obstruction might result from
a single local lesion. The physiology of the ejaculatory ducts
is not well defined. It is thought that the basal tones tends
to keep the walls of the ejaculatory duct coapted. Thus imaging
of the long axis of normal ejaculatory duct yields two slightly
echogenic lines (representing the muscular layer) separated by
no more than a 2 mm hypoechoic line (representing the epithelial
layer) (Figure 6,7)(41).
The goal of surgical therapy is to eliminate the obstruction while
minimizing complications
(e.g., ductal scarring, bladder neck injury, rectal injury). Classically,
treatment of ejaculatory duct obstruction was only suspected prior
to surgery. Therefore, the protocol that was followed in the operating
room, was to first localize the obstruction by vasotomy and vasography.
Cannulation of the of the distal (abdominal) end of the vas deferens
together with vasal injection of a dye (indigo carmine or methylene
blue) then allowed visual confirmation of patency of the ejaculatory
duct during resection. Intraoperative vasography prior to resection
documents the obstruction while intraoperative dye injection confirms
patency. This approach often requires repositioning of the patient
from a supine position needed for microsurgical vasotomy and cannulation
of the ductus deferens to the dorsal lithotomy position necessary
for transurethral resection.
Recently, the availability and experience with transrectal ultrasonography
has changed this classic approach. With transrectal ultrasonography
seminal vesicle obstruction or seminal vesicle cysts (Figure
8), ejaculatory duct obstruction, cysts or calculi (Figure
9) and utricular cysts (Figure 10) can be defined both
preoperatively and intraoperatively. Intraoperative sonography
allows confirmation as to the depth of the resection and elimination
of the obstructing pathology. It does not however, document elimination
of the obstruction as does visualization of dye emanating from
the ejaculatory duct after resection of the obstruction. Operative
vasography is still required when obstruction cannot be documented
preoperatively by transrectal ultrasonography. In addition, failure
of transurethral resection might be due to inadequate resection,
a secondary epididymal obstruction, testicular failure or a functional
obstruction. Therefore, in men with azoospermia and/or severe
oligozoospermia a testicular biopsy is done to document spermatogenesis
prior to transurethral resection. A 'wet prep' can be done at
the time of transurethral resection to document the presence of
mature spermatozoa. Several types of 'wet prep' have been described
((42),(43),(44),(45). My preference is that prescribed by Jow
et al (42). In this technique after a portion of testicular parenchyma
is sent in Bouins' solution for formal pathologic evaluation a
second portion of testicular parenchyma is placed on a glass slide.
A drop of lactated Ringers is placed on top together with a cover
slip. The margins of the compressed tissue specimen is then viewed
immediately under phase contrast microscopy. The presence of spermatozoa
with tails confirms spermatogenesis. The presence of motile sperm
suggests obstruction of the ductal system (42).
Operative Technique
Transurethral Incision (TUI) and transurethral resection (TUR)
are the primary surgical techniques used to treat these obstructions.
TUI is used primarily for incising short strictures of the ejaculatory
ducts and for the initial opening (prior to TUR) of ejaculatory
ducts visualized by a dye vasogram. For lesions easily visualized
by TRUS, I routinely use intraoperative transrectal ultrasonography
in lieu of a formal vasotomy and vasogram In addition, all cystoscopic
procedures are performed under video guidance. If a biopsy had
not been done previously a bilateral testicular biopsy is done
and placed in Bouin's solution for formal sections.
With the patient in a dorsal lithotomy position cystourethroscopy
is performed. Particular emphasis is given to the region just
lateral to the verumontanum. It often is here that one can visualize
the opening to at least one ejaculatory duct. Particularly in
cases of secondary subfertility following a prostatic infection
the ejaculatory duct will be blocked proximal to these openings.
A resectoscope with a 24f loop is used. The lesion is localized
by TRUS (Figure 11A) while the resectoscope is in place.
This allows for measurement of the depth of resection necessary.
By simultaneous observation of both the video monitor for cytoscopy
and the TRUS monitor, the length, depth and location of the lesion
is determined. Resection is then done with a pure cutting current
(to prevent injury to the ejaculatory duct). The removal of the
lesion (or opening of the cyst) is confirmed both by TRUS and
by video documentation (Figure 11B). Resection usually
involves removal of the verumontanum and occasionally requires
relatively deep resection in a small gland (Figure 12).
This is often unnerving to the most seasoned resectionist. Intraoperative
TRUS is invaluable in making this a safe and effective procedure.
In addition, external sphincter injury is avoided by keeping the
tip of the resectoscope at the level of the external sphincter
and advancing the resectoscope loop from this anchored position.
Large bleeding vessels are fulgurated with great care being taken
to identify the ejaculatory ducts (and to keep clear of them)
during fulguration. The patient is discharged to home the day
of the procedure usually with an indwelling catheter for 24 to
48 hours. He is placed on an oral quinolone antibiotic and begun
on a non-steroidal anti-inflammatory agent 24 hours after the
procedure.
Patients are followed with semen analyses monthly. Improvement
in seminal fluid volume is seen by the first month. Oftentimes
improvement in semen quality (count, motility and morphology)
will require 3 to 6 months. As mentioned previously, failure of
transurethral resection might be due to inadequate resection,
a secondary epididymal obstruction, testicular failure or a functional
obstruction. If the seminal fluid volume improves with little
or no improvement in semen quality and the biopsy suggests good
spermatogenesis (better than 20 mature spermatids per seminiferous
tubule with a minimum of ten tubules counted per testis (46))
then a secondary obstruction probably at the level of the epididymis
is likely and repair indicated.
COMPLICATIONS
The potential for complications exists with all transurethral
procedures (47), (48). Injury can occur not only to the urinary
tract but also to adjacent organ systems. Most often treatment
of ejaculatory duct obstruction requires only limited resection.
However, the small size of the glands in these young patients
and/ or the need for deeper resection might predispose these men
to complications.
Impairment of semen quality
Patients should always be informed that worsening of semen quality
is possible after surgical resection. Scarring and possible recurrent
obstruction of the ejaculatory ducts is possible post operatively.
This can be minimized by limiting fulguration of bleeding sites
near the ejaculatory ducts and ensuring a widely patent and obliquely
transected duct prior to completion of the procedure. In addition,
a secondary obstruction at the level of the epididymis is common.
Bilateral testis biopsy either prior to, or at the time of resection,
will help identify a secondary epididymal obstruction.
Retrograde ejaculation
Occasionally extensive resection is required to uncover ejaculatory
ducts obstructed proximal to their course through the central
zone (Color Plate). In these cases resection at the level of the
bladder neck may be necessary, possibly resulting in retrograde
ejaculation. Post operatively, if the post ejaculate urine has
a significant amount of sperm, medical therapy may be attempted
(see above). If retrograde ejaculation persists, then recovery
of sperm from the post ejaculate urine after systemic alkalinization
or instillation of a buffer is usually successful.
Anatomic Abnormalities
Phimosis, meatal stenosis and urethral stricture may be present
prior to transurethral surgery or occur after the procedure. Dilation
with urethral sounds prior to introduction of the resectoscope
may not adequately dilate the urethral passage. In the case of
phimosis a circumcision (or a limited dorsal slit) might be required.
Urethral strictures might require an internal urethrotomy or urethrostomy
to allow passage of the resectoscope. These anatomic abnormalities
are usually known pre-operatively and planned for at the time
of the procedure. Injury to the urethra might also occur as a
result of the surgery. These complications are usually avoided
by proper technique and use of the smallest size sheath possible
(24 Fr).
Post operative bleeding
Bleeding in the post operative period can be minimized by meticulous
intraoperative hemostasis. However, as mentioned above this is
occasionally counterproductive and might result in re scarring
of the ducts. An indwelling catheter left for one to two day postoperatively
will usually limit this residual postoperative bleeding. The patient
is usually discharged to home with the indwelling catheter and
placed on an oral broad spectrum antibiotic.
Injury due to transurethral resection
Rectal injury, sphincteric injury resulting in incontinence, urethral
injury, bladder neck contracture and erectile dysfunction including
corporal fibrosis have all been described after transurethral
resections (47), (48). The incidence of these complications after
transurethral resection of ejaculatory duct obstruction will only
be known after a large series of patients undergoing this procedure
are evaluated. The limited resection necessary for correction
of the obstructed ejaculatory duct together with the use of intraoperative
transrectal ultrasound scanning for localization of the lesion
and identification of the depth of the resection, likely limits
the occurrence of these injuries. However, the patient should
be informed pre operatively that these are possible complications
of this surgery.
Results
Interpretation of data from prior studies has been difficult due
to the limited number of cases reported upon. In case reports
limited to single case presentations (2)(3)(11) all have documented
and improvement in semen quality and pregnancy. Two of these men
had been treated by transurethral resection (2)(3) and one by
urethrotome (11). While reports that have had series ranging from
2 to 9 patients (4)(5)(6)(49)(8)(9) , improvement in semen quality
occurred in 41% of patients while pregnancy occurred in 21% of
men treated for their partial obstruction with transurethral resection.
In the largest series to date, Meacham et al (13) recently reported
on 22 subfertile male patients with various abnormalities noted
on transrectal ultrasound (Table 3). Patients were treated
with transurethral resection which unroofed the obstructed ejaculatory
ducts (Figure) and placed in one of three groups dependent upon
postoperative results. 55% of patients had an improvement in sperm
density and/or sperm motility (Group I). 27% had improvement in
ejaculate volume only (Group II) and 18% had no improvement in
seminal parameters (Group III). Eleven of these patients had partial
obstruction of the ejaculatory duct (not azoospermic) 9 of these
11 achieved an improvement in sperm density or motility postoperatively
and 6 went on to achieve a pregnancy.
Ejaculatory duct obstruction is a much more common and treatable
cause of male subfertility then previously described. This is
due, in large part to the widespread use of transrectal ultrasound
technology. The relatively non-invasive method of diagnosis and
excellent results of therapy support the use of transrectal ultrasound
examination as part of the initial evaluation in many men with
male factor subfertility.
TABLE 1
Pharmacologic Agents Associated with Impaired Ejaculation
(after Murphy et al,(16))
Antihypertensives
Bethanidine
Guanethidine sulfate
Hexamethonium
Phenoxybenzamine hydrochloride
Phentolamine
Prazosin hydrochloride
Reserpine
Thiazides
Antipsychotics (major tranquilizers)
Chlorpromazine
Chlorprothixene
Haloperidol
Perphenazine
Thioridazine
Trifluoperazine hydrochloride
Amitriptyline
Clomipramine
lmipramine hydrochloride
Pargyline
Phenelzine sulfate
Alcohol
Baclofen
Chlordiazepoxide
Epsilon aminocaproic acid
Methadone
Naproxen
TABLE 2
Treatment of Retrograde Ejaculation
(after Murphy et al, (16))
Alkalinization (monitor urine pH)
Sodium bicarbonate 650 mg q.i.d. 2 days before & day of collection
Sympathomimetic Agents (initially as a 2-week trial)
Pseudoephedrine hydrochloride 60 mg q.i.d.
Ephedrine sulfate 25-50 mg q.i.d.
Phenylpropanolamine hydrochloride 75 mg b.i.d.
Imipramine hydrochloride 25 mg b.i.d., 50 mg h.s.
TABLE 3
Abnormalities Noted on Transrectal Ultrasonography Among Patients in Each Treatment
Response Group (after Meacham et al, (13)
Group 1* Group 2** Group 3***
Ejaculatory duct cyst 4 3 1
Dilated seminal vesicle 4 2 1
Dilated vasal ampullae or
ejaculatory ducts 3 0 0
Calcification of ejaculatory
ducts 1 1 1
Non-diagnostic ultrasound 0 0 2~
*Postoperative improvement in sperm density and/or motility.
**Improvement in ejaculate volume only.
***No postoperative improvement in semen parameters.
~Two patients did not Undergo preoperative ultrasonography.
FIGURE LEGENDS
Figure 1 Transrectal ultrasound image in a patient with secondary subfertility.
Patient had a protracted course of prostatitis just after the birth of their
first child. Top: transverse view of prostate demonstrating increased
echogenicity in the region of the ejaculatory ducts bilaterally. Bottom:
transverse image of dilated seminal vesicles which measure greater than 1.5
cm in anterior-posterior dimension and demonstrating a heterogenous echogenic
pattern.
Figure 2 Transverse TRUS image (left) and axial view (right) of a 26
year old patient with retrograde ejaculation. Cystoscopy demonstrated a patulous
bladder neck. Note the open bladder neck (large arrow) and seminal vesicle cyst
(arrow head).
Figure 3 Transverse TRUS image (left) and axial view (right) of a patient
with secondary subfertility and a fructose positive specimen with a volume of
0.2 cc, a total sperm count of 400,000 sperm, a 46% motility with a forward
progression of 1-2. Note the calcification at the level of the verumontanum
(large arrow) and the ejaculatory duct entering the calcification (arrowheads).
Intraoperative TRUS at the time of resection is shown in Figure 11.
Figure 4 Transverse TRUS image near the apex (top image) and base (lower
image) of the prostate in a patient with a large midline (utricular) cyst.
Figure 5 Schematic representation of the prostate, seminal vesicles and
ampulla of the vas deferens. The ejaculator ducts usually enter the prostatic
urethra just lateral and proximal to the prostatic verumontanum. However, variation
is great and oftentimes the ejaculatory duct orifice cannot be visualized at
the time of cystoscopy..(From Oates (50); copyright Medical Economics Publishing,
Inc., used with permission)
Figure 6 A neurovascular fibrous stroma surrounds each ejaculatory duct.
The wall of the ejaculatory duct consists of a layer of muscular fibers consisting
of a thin outer circular layer and an inner longitudinal layer.(From Oates (50);
copyright Medical Economics Publishing, Inc., used with permission)
Figure 7 The ejaculatory duct is shown in this axial view as two slightly
echogenic lines.
Figure 8 Transverse and axial TRUS image of a seminal vesicle cyst (arrows).
Figure 9 Markedly dilated ejaculatory duct (arrows) is shown in these
axial views.
Figure 10 A midline (utricular) cyst is shown in transverse projection
at the level of the mid prostate (top) and verumontanum (lower left) and in
axial projection (lower right).
Figure 11A Intraoperative transverse image of case presented in Figure
3. The location and depth of the calcification (arrows) from the resectoscope
(arrowhead) is easily determined.
Figure 11B Intraoperative transverse image after resection. Note the
calcification has been removed and a cystic region (arrows) identified. The
resectoscope is in place (arrowheads).
Figure 12 Resection of the verumontanum is oftentimes all that is required
for unroofing ejaculatory duct cysts or removing calcifications located at the
distal end of the ejaculatory ducts. However, more proximal obstructions and/or
cysts might require deeper and more lateral resection from the bladder neck
to the verumontanum. Intraoperative transrectal ultrasound is particularly valuable
in these cases. (From Meacham RB et al(13) Reproduced with permission of the
publisher, The American Fertility Society)
Color Plate: Normal prostate gland based on McNeal's morphology provides
the orientation for longitudinal ultrasound scanning. TZ=transition zone, CZ=central
zone, PZ = peripheral zone, AFS = anterior fibromuscular stroma, PPS=pre prostatic
sphincter, POPS=post prostatic sphincter, v=verumontanum, LSM=longitudinal smooth
muscle, PUG=periurethral glands. (From Kaye, KW (51), copyright Medical Economics
Publishing, Inc., used with permission)
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