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J Clin Ultrasound 24:437-453, October 1996
0 1996 by John Wiley & Sons, Inc.
CCC 0091-2751/96/080437-17
Role of Ultrasound in the Assessment of
Male Infertility
Edward D. Kim, MD, and Larry I. Lipshultz, MD
Abstract: The use of ultrasonography has become a n important component in the
evaluation and treatment of male reproductive tract disorders. From the use of color
flow Doppler ultrasonography for the assessment of varicoceles to transrectal ultrasonography combined with seminal vesiculography for the evaluation of ejaculatory duct
obstruction, ultrasonography has practical clinical applications. In this article, the
authors review the indications and use of ultrasonography in the assessment and treatment of the infertile male. The recent advances in diagnostic transrectal ultrasonography for ejaculatory duct obstruction, in particular, are emphasized. 0 1996 John
Wiley & Sons, Inc.
Indexing Words: Infertility ' Scrota1 ultrasonography . Transrectal ultrasonography . varicocele . TRUS
The role of ultrasonography in the evaluation of
the infertile male has expanded with advances in
ultrasound technology. The specialist in male reproductive tract disorders relies significantly on
scrotal and transrectal ultrasonography in the
evaluation of many patients. From the acceptance
and widespread use of color flow Doppler ultrasonography for the assessment of varicoceles t o
transrectal ultrasonography combined with seminal vesiculography for the evaluation of ejaculatory duct obstruction, ultrasonography has important clinical applications in reproductive
medicine. The purpose of this article is to review
the indications and use of ultrasonography in the
assessment and treatment of the infertile male.
SCROTALULTRASONOGRAPHY
Ultrasonography is the primary imaging modality for abnormalities within the scrotum. The
principal role is to confirm findings suspected on
physical examination, such as varicoceles and
testicular and epididymal parenchymal irregularities.
From the Scott Department of Urology, Baylor College of Medicine, Houston, Texas. For reprint requests contact Larry I.
Lipshultz, M.D., Baylor College of Medicine, 6560 Fannin,
Suite 2100, Houston, TX 77030.
VOL. 24, NO. 8,OCTOBER 1996
The examination is most comfortably performed in a warm room with the patient in the
supine position, with the penis resting on the
lower abdomen. High resolution, short-focused,
real-time imaging with a 7.5 MHz or 10 MHz
transducer is ideal, and may identify abnormalities as small as 0.5 mm. Both sagittal and transverse images are typically obtained.
Testis
The normal adult testis is approximately 3 cm to
5 cm in length, 2 cm to 3 cm in width, and 2 cm to
3 cm in anteroposterior depth, with a homogenous
echotexture of low to medium echogenicity. The
volume may be calculated using the formula:
length x width x anteroposterior depth
= volume in mL1
X
0.53
The normal, post-pubescent testis volume is 15
mL to 20 mL. The accuracy of ultrasonography is
within 10% of the actual volume and is better
than physical examination in detecting testicular
asymmetry.' Thus, scrotal ultrasonography can
be very helpful in detecting unilateral atrophy.
Up to 64% of men with male factor infertility
have an abnormality in testicular size.' Conditions associated with atrophy and male infertility
437
KIM AND LIPSHULTZ
FIGURE 1. Testicular ultrasound demonstrating seminoma (solid arrows). The contour of the normal testis is
highlighted with the open arrows. This patient presented with primary infertility and a history of cryptorchidism treated with an orchidopexy i n childhood. Palpation demonstrated an irregular contour of the testis, thus
prompting a scrota1 ultrasound examination. Cryptorchidism is related t o both testis tumors and infertility.
Note the Uniformly reduced reflectivity and decreased echogenicity of the tumor.
include varicoceles, cryptorchidism, post-pubertal
mumps, Klinefelter’s syndrome, and hepatic cirrhosis.
The issue of accurate testicular size determination becomes important in the adolescent varicocele patient. Although the necessity for varicocelectomy in the adolescent or in the male with
unknown fertility status is controversial, atrophy
of the testis is generally regarded as an absolute
indication. Although age-specific volume curves
have been established, the best way to assess testicular size and atrophy in adolescents is to compare size differences between testicle^.^ Semiannual ultrasound examinations by the same
operator are sensitive in quantifying progressive
atrophy.
Ultrasound has also been used to localize the
inguinal, undescended t e ~ t i c l e . ~
Because
’~
men
with either a unilaterally or bilaterally undescended testis, regardless of the timing of an orchidopexy, have semen of diminished quality
compared with that of fertile men, infertility is
common in this population.6 However, men with
438
infertility and an undescended testicle are offered
either orchiectomy or observation, depending on
age criteria.
Testicular irregularities on physical examination such as nodules, indurations, and masses
should prompt ultrasound evaluation because testicular tumors are most common in the age
groups presenting with infertility complaints.
Scrota1 ultrasound provides excellent differentiation between intratesticular and extratesticular
masses suspected on physical examination. In one
study of ultrasound examinations in 658 consecutive male infertility patients, malignant lesions
were identified in 4 (0.6%)( 3 seminoma, 1 carcinoma in sit^).^ The increased association between
testicular tumors and infertility is well-established.’
The ultrasound appearance of most testicular
tumors is that of a focal hypoechoic lesion within
the normally homogenous echotexture of the testis. Seminoma, the most common germ cell tumor, has a uniformly hypoechoic appearance and
is the most common tumor associated with cryptJOURNAL OF CLINICAL ULTRASOUND
US AND MALE INFERTILITY
FIGURE 2. Scrotal high resolution, real-time ultrasound imaging demonstrating a varicocele in transverse section. (A) This dilated vein of the
pampiniform plexus measures 3.2 mm in diameter at rest. (6) With the Valsalva maneuver, the size of the varicocele increases to 3.4 mm. The "+"
signs indicate the boundaries of the dilated vein, whereas the white arrowheads delineate the pampiniform plexus. Although the size criterion for
a varicocele is controversial, 3 m m in diameter with Valsalva maneuver has been commonly used. Scrotal ultrasound for varicocele is indicated
when uncertainty of diagnosis is present on palpation.
VOL. 24, NO. 8,OCTOBER 1996
439
KIM AND LIPSHULTZ
FIGURE 3. Color flow Doppler ultrasound demonstrating a varicocele in longitudinal orientation. (A) At rest. (B)
With Valsalva maneuver. Not only can the color flow Doppler ultrasound detect varicoceles based on size
criteria, but reversal of flow can be distinguished. Reversal of flow, indicated by the different colors i n the
serial images, is most prominent i n the central vein (arrow). Many ultrasound scanners have the capability of
recording these examinations in real-time.
orchidism, a condition clearly predisposing t o
male infertility (Figure 1).Cystic degeneration,
fibrosis, local hemorrhage, and necrosis are more
commonly seen with non-seminomatous germ cell
tumors.
Although most intratesticular lesions in men
of the age group concerned about fertility are malignant, benign lesions such as microlithiasis, intratesticular cysts, and old hematoma are some440
times f o ~ n d . ~Of” ~150 infertile men with
palpable scrota1 abnormalities, only 2 had microlithiasis. These intratubular concretions may
involve a significant proportion of the seminiferous tubules, but the relationship with infertility
is not common and not well understood. Small
intratesticular cysts may represent cysts of the
rete testis, but the relationship with infertility is
unclear. The mixed echogenicity of a hematoma
’’
JOURNAL OF CLINICAL ULTRASOUND
US AND MALE INFERTILITY
TABLE 1
Transrectal Ultrasound in Male Infertility
Absolute indications
Low volume azoosperrnia i n the absence of testicular atrophy
Low volume severe oligospermia (concentration <5 rnillionirnl)
Abnormal digital rectal examination
Relative indications
Normal volume azoospermia or severe oligospermia in the
absence of testicular atrophy
Severe motility defects with a normal physical examination and
hormonal profile
Ejaculatory abnormality
Anejaculation
Hematospermia
Painful ejaculation
Unexplained retrograde ejaculation
History suggestive of genital duct abnormality
Unilaterally nonfunctioning or absent kidney
History of severe hypospadias
resulting from earlier trauma often requires surgical exploration to exclude a tumor.
Paratesticular Structures
Vuricoceles. The adult varicocele is the most
common identifiable anatomic abnormality in
male factor infertility, being present in up t o 40%
of infertile men.” The approximate incidence of
varicoceles in a screening of healthy young men
was 13.4%.6 Most varicoceles are left-sided, but
they are bilateral in approximately 40% of infertile patients.
Scrotal ultrasonography is used for the diagnosis of a varicocele when results of a physical examination performed in a warm room are uncertain. This examination is best performed with the
patient in both the supine and upright positions,
with and without the Valsalva maneuver.
Venography is still considered the “gold standard’ for the detection of varicoceles, although in
several studies no venogenic reflux could be demonstrated in the presence of palpable lesion^.'^,^^
Because of the invasive nature of venography, alternative diagnostic methods have been pursued,
including radionuclide angiography, thermography, and ultrasonography. Because of the high
false-negative rate with radionuclide angiography and the widely variable results with scrotal
thermography, these tests have a very limited diagnostic r01e.l~
The ultrasonographic armamentarium of the
Doppler stethoscope, real-time ultrasonography,
and color flow Doppler imaging have all been
used for varicocele diagnosis. Hirshs experience
with the pencil-probe Doppler stethoscope demonstrated a significant false-positive rate as compared to results in 17 patients with venographiVOL. 24, NO.8, OCTOBER 1996
cally demonstrated varicoceles.16 Although the
role of the Doppler stethoscope has limitations, its
sensitivity may give it a place in the diagnosis of
patients with a clinically “suspicious” varicocele.
The presence of a prolonged venous flow augmentation or reflux, usually detected as a venous rush
during the Valsalva maneuver, is considered diagnostic. False positives may occur with the mild
and transient flow augmentation during Valsalva
in some normal men and with difficulties in probe
placement secondary to active cremasteric contractions. For this reason, we prefer high resolution ultrasound.
High resolution, real-time scrotal ultrasonography using a 7 MHz to 10 MHz probe defines a
varicocele as a hollow tubular structure that increases in size with the Valsalva maneuver (Figure 2). Although the exact size definition is controversial, we consider a vein 3 mm in diameter
or larger when the patient is at rest to be a varicocele. McClure defines a varicocele as the presence of 3 or more veins, with one having a minimum resting diameter of 3 mm, or an increase in
venous diameter with the Valsalva maneuver.17
Because others have used 2 mm to 3 mm as a
cutoff, comparison of results of these ultrasoundbased varicocelectomy studies has been difficult. 18,19
The importance of reversal of flow during the
Valsalva maneuver has been described.” Sigmund further developed this concept by using a
bidirectional Doppler ultrasound t o classify varicoceles as stop-type or shunt-type.” Using this
bidirectional apparatus in comparison with percutaneous retrograde venography, they were able
to distinguish the presence of retrograde flow
(stop-type) alone from both retrograde and orthograde venous blood flow (shunt-type). The
stop-type pattern was more frequently associated
with subclinical, mild varicoceles.
Color flow Doppler ultrasonography defines
the anatomic and physiologic aspects of varicoceles by employing real-time ultrasonography
and pulsed Doppler in the same scan. Blood flow
and direction within the varicocele are identified
by the color of the signal (Figure 3). The reversal
of flow characteristic of varicoceles is confirmed
TABLE 2
Ultrasound Charges”
Transrectal ultrasound (TRUS)
TRUS with SV puncture
Scrotal ultrasound, with and without color flow Doppler
Renal ultrasound
$357
$744
$265
5352
=As of February 1996, Scott Department of Urology, Houston,
Texas.
441
KIM AND LIPSHULTZ
FIGURE 4. (A) Normal transrectal ultrasound of the ampulla of the vas deferens (V) and seminal vesicles (SV) i n transverse section. The vas are
convoluted, tubular structures lying medial t o the seminal vesicles and cephalad t o the prostate. The rectal rnucosa is indicated by solid white
arrows (B) Ampulla of the vas (solid black arrows) with internal calcifications. Seminal vesicles are demonstrated with the open black arrows.
442
JOURNAL OF CLINICAL ULTRASOUND
US AND MALE INFERTILITY
TABLE 3
Causes of Ejaculatory Duct Obstruction in Subfertile Males
Etiology
Number
~~
Mullerian duct cyst
Wolffian duct malformation
Previous surgical trauma
Transabdominal excision of seminal vesicle cyst
Rectal surgery in childhood (e.g. imperforate anus)
Bullet wound
Bladder extrophy repair
Previous genital infection
Tuberculosis
Megavesicles
Carcinoma of the prostate
17
19
15
Total
87
19
8
8
1
Created from Pryor JP, Hendry WF: Ejaculatory duct obstruction in
subfertile males: analysis of 87 patients. Fertd Steril 56:725-730,
1991.
by prolonged flow augmentation within a colored
flow area appearing as reversing (i.e., changing
color) with real-time imaging.
Inguinal ultrasonography has also been reported as an accurate alternative to the scrotal
technique.22In one study, the authors reported on
20 clinical varicocele patients and 18 controls noting a mean diameter of the dominant draining
vein of 4.5 mm versus 2.2 mm at rest. and 5.7 mm
versus 2.7 mm during the Valsalva maneuver for
the two groups, respectively. They preferred the
inguinal location because of the longitudinal
alignment, rather than the convoluted, irregular
venous arrangement seen at the scrotal level.
Epididymis. Ultrasound examination of the
epididymis is most helpful for the confirmation of
a diagnosis of an epididymal cyst or spermatocele
in the infertility evaluation. These conditions are
usually asymptomatic and not typically the cause
of infertility, but an associated finding. In certain
situations, however, an epididymal cyst may become obstructive and result in oligoasthenospermia or azoospermia. Epididymal cysts are hypoechoic and circumscribed with good through
transmission and posterior wall enhancement.
Loculations may be present. Spermatoceles and
epididymal cysts are commonly found at the head
of the epididymis.
Although the criterion for identification of a
clinically thickened epididymis as determined by
ultrasound has been described as 12.1 mm mean
diameter in cross-section at the level of the caput,
a correlation with epididymal obstruction has not
been e~tablished.~
In comparison, normal epididymides measured 7.7 mm mean diameter in crosssection in the same study. Ultrasound does not
reliably provide the resolution to identify dilated
epididymal tubules, and thus is not helpful in the
evaluation of suspected epididymal obstruction.
VOL. 24, NO. 8, OCTOBER 1996
Chronic epididymal inflammation may lead t o
an enlarged, thickened epididymis with mixed
echogenicity. Calcification may ensue from the
inflammatory response. Acute epididymitis, a
clinical diagnosis, may be confirmed from the
findings of an enlarged epididymis with decreased echogenicity.
Tunica uaginalis. An ultrasound examination provides definition of the testis and epididymis in the infertile patient if these structures are
not palpable secondary to a hydrocele. The presence of a testicular tumor should be considered in
the evaluation of the infertile male with a hydrocele because many tumors have an associated
small hydrocele. The hydrocele is characterized
by a hypoechoic, fluid-filled tunical vaginalis sac
surrounding the testis. Hydroceles may be communicating or non-communicating, simple or loculated.
TRANSRECTALULTRASONOGRAPHY
Because of its excellent visualization of the seminal vesicles, prostate, and ejaculatory ducts,
transrectal ultrasound (TRUS) is an important
diagnostic tool in the evaluation of the infertile
male. The primary use of TRUS is to assess obstructions and to determine the absence or hypoplasia of the seminal vesicle and ejaculatory
ducts. Recently, TRUS has been combined with
seminal vesiculography to search for distal ejaculatory duct obstruction, thereby greatly reducing the need for the more invasive open vasograPhY *
Most urologists are familiar with the use of
TRUS for the assessment of prostatic malignancy.
TRUS for infertility purposes is performed similarly, with the patient most commonly in the lateral decubitus, knee to chest position. Use of the
dorsal lithotomy and sitting positions has also
been described. A high resolution 6.5 MHz to 7.5
MHz probe is used to obtain sagittal and transverse images. Performance of the procedure with
the bladder partially filled results in better imaging because of the acoustic window provided for
delineation of the bladder, perivesical fat, and the
seminal vesicles.
Ejaculatory Duct and Prostate
Men with ejaculatory duct obstruction typically
seek treatment initially because of primary infertility and azoospermia or severe oligoasthenospermia. Perineal pain and d i ~ c o m f o r t ,he~~
matospermia, pain with ejaculation, and epididymal pain have also been reported.24 Thus
443
KIM AND LIPSHULTZ
FIGURE 5. Ejaculatory duct calcification resulting in obstructive, low volume azoospermia. (A) Transverse TRUS image of the prostate demonstrating a 2.9 mm x 1.7 rnm calcification (long white arrow) at the confluence of the ejaculatory ducts. The anterior boundary of prostate gland
is indicated by black open arrows. (B) An image just cephalad to (A) shows the calcifications extending into each ejaculatory duct.
444
JOURNAL OF CLINICAL ULTRASOUND
US AND MALE INFERTILITY
FIGURE 5. (confinued)Ejaculatory duct calcification. [C) Afurther cephalad image shows dilated ejaculatory ducts (white arrowheads) in transverse
section. (D) Sagittal image demonstrating the ejaculatory duct (ED) calcification in relation t o the bladder neck (BN) and apex of the prostate (white
arrows).
VOL. 24, NO. 8,OCTOBER 1996
445
KIM AND LIPSHULTZ
FIGURE 5. (continued) Ejaculatory duct calcification. (E) Dilated seminal vesicles (RT, LT) are first imaged at the
base of the prostate (black arrows). IF) The right seminal vesicle (RT SV) is clearly dilated having a width of
18.6 m m (white "x" marks).
446
JOURNAL OF CLINICAL ULTRASOUND
US AND MALE INFERTILITY
FIGURE 6. Large ejaculatory duct cyst (white arrow) within the prostate. (A) Transverse diameter measuring 14 mm. (B) Sagittal diameter
measuring 16.2 mm.
VOL. 24, NO. 8, OCTOBER 1996
447
KIM AND LIPSHULTZ
FIGURE 7. lntraoperative use of TRUS for transurethral resection of the ejaculatory duct. (A) Sagittal image demonstrating relationship of
ejaculatory duct cyst to the rectum and resectoscopy loop. (6) After resection of the ejaculatory duct cyst (resectoscope indicated by arrowhead).
Note the communication between the cyst and the urethra (arrow). (From Honig SC: Use of ultrasonography in the infertile male. WorldJ Urol
11 :102-107, 1993, reproduced with permission.)
absolute indications for performing TRUS include
low volume azoospermia in the absence of testicular atrophy and low volume severe oligoasthenospermia, when (for both) retrograde ejaculation
is not present (Table 1). A caveat is that although
low volume ejaculates are often present, a low
normal volume ejaculate does not exclude an ejaculatory duct obstr~ction.’~
Another absolute indication for performing TRUS is the presence of a
midline cyst or asymmetry palpated on digital
rectal examination.
When an ejaculatory duct obstruction is suspected, TRUS is now considered the initial diagnostic modality.26Previously, vasography, which
448
is still considered the “gold standard test,” had
been the only reliable way to evaluate a distal
ductal obstruction. Clearly, the invasive nature of
vasography with its attendant risk for vasal scarring make TRUS the ideal screening test. Investigators have also used the endorectal coil MRI to
provide a highly detailed anatomic depiction of
However, because of lower costs
the
(Table 2) and wider availability, TRUS remains
the procedure of choice for imaging the ejaculatory ducts and prostate for detecting infertilityrelated pathology.
The ejaculatory duct measures approximately
4 mm to 8 mm in diameter with a 2 mm lumen,28
JOURNAL OF CLINICAL ULTRASOUND
US AND MALE INFERTILITY
FIGURE 8. Congenital absence of the vas deferens associated with absence of the seminal vesicle on the left side (black arrows demonstrate where
the seminal vesicle would be expected) in transverse TRUS imaging. The right seminal vesicle and the ampulla of the vas are easily visualized
(open arrow). These men require renal ultrasound examinations because of the risk of renal abnormalities.
and may be difficult to image in its typically nondilated state. The ejaculatory duct is formed by
the confluence of the seminal vesicle and the terminal ampullary portion of the vas deferens. The
ampulla of the vas deferens can be imaged in both
the transverse and sagittal planes. They appear
as a pair of oval, convoluted, tubular structures
medial to the seminal vesicles and cephalad t o the
prostate (Figure 4).
The obstructed lumen of the ejaculatory duct
may be best appreciated in sagittal images as a
hypoechoic tubular structure entering the urethra at the level of the verumontanum. When dilation is evident, imaging for possible causes of
obstruction is advisable (Table 3).28 Causes of obstruction as revealed in one of the largest series
are shown in Table 3. Ejaculatory duct cysts, ejaculatory duct calcification, ejaculatory duct dilation, and seminal vesicle dilation visualized on
TRUS are all consistent with ejaculatory duct obstruction (Figure 5A-F).
Intraprostatic cysts causing obstruction of the
ejaculatory duct may be of Mullerian duct, WolfVOL. 24, NO. 8,OCTOBER 1996
fian duct, or prostatic in origin. Also known as
utricular cysts, Mullerian duct cysts are midline
in location and do not contain sperm. In a series of
150 consecutive infertility patients, Jarow demonstrated an 11%incidence of Mullerian duct
cysts in contrast to 0% in the control
These were the only cysts significantly associated
with infertility and might have caused obstruction of the ejaculatory duct by external compression (Figure 6).
Wolffian duct cysts, also known as ejaculatory
duct diverticula, are also located in the midline.
These cysts do contain sperm, and may be produced by a distal obstruction of the ejaculatory
duct. Prostatic retention cysts are located in the
periphery of the prostate and do not contain
sperm. Jarow found these cysts in 4 of 150 infertility patients.
The prevalence of ejaculatory duct cystic dilation has been recorded by a prostate cancer
screening
Of 400 men examined, 21
(5.25%) were found to have dilated ejaculatory
ducts with a mean diameter of 7 mm. Interest449
KIM AND LIPSHULTZ
FIGURE 9. Seminal vesiculography using TRUS guidance. This KUB demonstrates needle guidance and instillation (needle indicated with open arrow) of 5 mL of non-ionic contrast into the left seminal vesicle. The
pelvic portion of the vas deferans is also visualized (arrowhead), as is filling of the bladder (curved arrow).
[From Reidenklau E, Buch JP, Jarow JP: Diagnosis of vasal obstruction with seminal vesiculography: an
alternative to vasography in select patients. Fertd Steri/64(6):1224-1229, 1995. Reproduced with permission
of the publisher, the American Society for Reproductive Medicine (The American Fertility Society).]
ingly, 8 (38%)of these 21 men had never had children, in contrast to only 13% of childless men
without cystic dilation. These data suggest that
ejaculatory duct cysts do cause infertility and are
not uncommon.
TRUS is indicated in men with severe oligospermia and a low volume ejaculate because a
partial ejaculatory obstruction may be present.31
Although a partial ejaculatory duct obstruction
can cause a low volume severe oligospermia, a
functional ampullo-vesicular seminal tract disorder must also be c o n ~ i d e r e dPatients
.~~
with partial ejaculatory duct obstructions treated with
transurethral resection of the ejaculatory ducts
(TURED) had improvement in semen quality in
72% of cases, with 54% of improved men initiating a pregnancy.33
450
TURED is the treatment of choice for men with
ejaculatory duct o b s t r ~ c t i o nIntraoperative
.~~
usage of TRUS is helpful in identifying the location
of an obstructing cyst and in determining the
depth of resection, which may require an incision
5 mm to 10 mm in depth35 (Figure 7). TRUS can
also provide a better demonstration than vasography of the exact distal extent of dilation and
level of obstruction in relation to the prostate.
After resection of the cyst, there is a communication between the ejaculatory duct and the urethra. Persistent azoospermia after TURED may
be a result of scarring at the site of the resection
or in the epididymis from a “blowout” following
long-term ejaculatory duct obstruction. The latter
will require a microscopic epididymovasostomy.
One caveat is that TRUS cannot exclude an
JOURNAL OF CLINICAL ULTRASOUND
US AND MALE INFERTILITY
obstruction of the ejaculatory duct proximal to
the region of the prostate and seminal vesicles. A
patient with clinical findings suggestive of obstruction with a normal TRUS still needs a vasography and a testis biopsy.
Seminal Vesicles
The seminal vesicles are paired, symmetric, saccular, elongated organs which lie cephalad to the
prostate and posterior to the bladder. Best visualized with transverse imaging and having a typical “bow-tie” appearance, they are homogenous
with a few fine internal echoes. Serving as reservoirs of seminal fluid, the seminal vesicles have
mean dimensions of 3.0 cm 2 0.8 cm in length, 1.5
cm 0.4 cm in width, and 13.7 mL k 3.7 mL in
change in volume
v o l ~ m e . ~ ~No
, ~significant
~,~’
has been demonstrated after e j a ~ u l a t i o n The
.~~
vasal ampullae have a mean diameter of 0.4 cm
0.1 cm and are best visualized in transverse section just medial to the seminal vesicles.28
Ejaculatory duct obstruction often, but not always, is associated with seminal vesicle dilation.
Although obstruction should be suspected in patients with a transaxial seminal vesicle width of
>1.5 cm,25,33,36 seminal vesicle dilation does not
occur in every patient. Asymmetry, however,
should raise suspicions for ejaculatory duct obstruction.
Men with congenital absence of the vas deferens (CAVD) should undergo TRUS, because as
many as 90% of these men with unilateral CAVD
may have aplasia of the ipsilateral seminal vesicle, and as many as 20% may have aplasia of the
contralateral seminal ve~icle.~’
In those men
with bilateral congenital absence of the vas deferens (CBAVD), 16% had bilateral aplasia of the
seminal vesicles, whereas 21% had unilateral
seminal vesicle aplasia and contralateral seminal
vesicle hypoplasia4’ (Figure 8). Hypoplasia has
been defined as a decrease in normal size of 30%
or more.
Renal ultrasound and cystic fibrosis testing are
also recommended for men with CAVD. In one
study, 85%of men with CAVD had abnormalities
of the upper urinary tract4’; in another study,
21% of men with CBAVD had renal malformat i o n ~ Overwhelmingly,
.~~
the most common abnormality was ipsilateral renal agenesis. Ipsilatera1 renal ectopia, crossed-fused renal ectopia,
and horseshoe kidneys have also been observed.
A recent advance has been TRUS-guided seminal vesiculography for patients with suspected
ejaculatory duct obstruction. The previous test of
choice was vasography, an open surgical tech-
*
*
VOL. 24,
NO,8, OCTOBER
1996
nique carrying a risk of iatrogenic vasal scarring.
An alternative was cystoscopic cannulation of the
ejaculatory ducts with retrograde infusion of contrast, a relatively difficult technique. An officebased procedure, TRUS-guided seminal vesiculography combined w i t h s e m i n a l vesicle
aspiration can effectively diagnose ejaculatory
duct obstruction with substantially lower risks of
vasal scarring.
The seminal vesicles may be aspirated using a
35 cm long, 21 gauge Williams needle (or a 30 cm,
17 gauge oocyte retrieval needle). The presence of
numerous motile sperm in the seminal vesicles is
highly suggestive of obstruction at the ejaculatory duct in men with azoospermia or severe olig ~ s p e r m i aSperm
. ~ ~ are not normally found in the
seminal vesicles.
Seminal vesiculography using methylene blue
and a dilute nonionic contrast may be performed
after transrectal aspiration. Fluoroscopy, combined with radiographs after instillation of 5, 10,
and 20 mL of contrast, provides ideal imaging.
We have found the use of intra-operative flexible
cystoscopy helpful in visualizing the egress of
methylene blue from the ejaculatory duct. A recent publication has noted that the pelvic and inguinal portions of the vas deferens may be seen in
some patients44 (Figure 9). Seminal vesiculography may also be performed using the perineal
route of contrast injection with TRUS guidance.45,46
CONCLUSION
Ultrasound is a critical, indispensable tool for everyday use in the evaluation and treatment of
male reproductive tract disorders. Scrotal, transrectal, and even renal ultrasonography have important applications for the confirmation and diagnosis of conditions ranging from varicoceles to
ejaculatory duct obstruction. Because the accuracy of ultrasonography is dependent on the examiner’s knowledge of the disease process, the
urologist must try to obtain direct, hands-on experience with the techniques involved. Close communication between the urologist and radiologist
are critical for the diagnosis and treatment of
male reproductive tract disorders.
REFERENCES
1. Costabile RA, Skoog S, Radowich M: Testicular
volume assessment in the adolescent with varicocele. J Urol 147:1348-1350, 1992.
2. McClure RD, Hricak H: Scrotal ultrasound in the
infertile man: detection of subclinical unilateral
451
KIM AND LIPSHULTZ
and bilateral varicoceles. J Urol 135:711-715,
1986.
3. Kass EJ: Evaluation and management of the adolescent with a varicocele. A U A Update Series ZX,
lesson 1289-96, 1990.
4. Wolverson MK, Houttuin E, Heiberg E, et al: Comparison of computed tomography with highresolution real-time ultrasound in the localization
of the impalpable undescended testis. Radiology
146:133-136, 1983.
5. Weiss RM, C a r t e r AK, Rosenfield A: Highresolution real-time sonography in the localization
of the undescended testis. J Urol 135936-938,
1986.
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