Simultaneous computed tomography and seminal vesiculography in a patient with ejaculatory duct obstruction

A 32-year-old man presented with primary infertility. He had azoospermia with low volume ejaculate. Physical examination was normal. Transrectal ultrasonography [TRUS] revealed grossly dilated seminal vesicles. No other genitourinary tract abnormality was noted. He underwent TRUS-guided aspiration of the seminal vesicles with simultaneous instillation of contrast media and methylene blue dye into the seminal vesicles. The aspirate showed scanty sperms. Conventional radiograph [Figure 1] and simultaneous computed tomography [CT] and seminal vesiculogram images [Figure 2] were taken, which revealed the spectacular appearance of huge seminal vesicles and retrograde flow of contrast media into the proximally dilated system upto the epididymis. The dilated ejaculatory duct anatomy could be seen with exceptional clarity. The patient underwent transurethral resection of the ejaculatory ducts on the same day until free flow of methylene blue was noted from a wide open orifice [Figure 3]. Postoperatively, he developed seminal vesiculitis which was treated with oral ciprofloxacin. He showed a delayed return of sperms into the ejaculate at 9 months. Transrectal ultrasonography alone is insufficient for the diagnosis of ejaculatory duct obstruction.[1] Only about half of the patients with TRUS findings show confirmed obstruction on additional diagnostic evaluation such as examination of TRUS-guided aspirate, instillation of colored dye, and seminal vesiculography. [2] Computed tomography and seminal vesiculography may be combined easily at the time of contrast instillation and gives excellent anatomical detail. Further studies are needed to better elucidate the role of imaging with CT in patients with obstructive azoospermia

Role of testicular fine-needle aspiration cytology in infertile men with clinically obstructive azoospermia.

BACKGROUND: Azoospermia due to obstruction of the vaso-epididymal junction is one of the few surgically correctable causes of male infertility. In patients where all clinical and laboratory parameters suggest a vaso-epididymal junction block amenable to surgery, failure to find normal spermatogenesis on fine-needle aspiration cytology (FNAC) of the testis may necessitate a change in treatment modality to the more expensive intracytoplasmic sperm injection. We evaluated the validity of FNAC findings in predicting failure of surgical exploration when clinical parameters suggest otherwise. METHODS: Infertile, azoospermic men in whom the semen volume and fructose content, testis size, follicle-stimulating hormone level were normal and the vas deferens was palpable with no evident cause for obstruction, underwent FNAC of the testis to confirm the presence of normal spermatogenesis before surgical exploration. Men with hypospermatogenesis or maturation arrest on FNAC and a normal karyotype with absence of Y chromosome microdeletion were offered assisted reproduction or surgical exploration to identify a reconstructable obstruction. Men who chose surgery were included in the study and the findings on exploration were compared with the FNAC reports. RESULTS: Of the 10 men who satisfied the inclusion criteria, 6 had hypospermatogenesis and in 4 FNAC showed maturation arrest. On surgical exploration, none had sperm in the epididymis. A biopsy of the testis taken at the time of exploration confirmed the FNAC findings. CONCLUSION: Clinical parameters are insufficient for diagnosing obstructive azoospermia. FNAC can accurately evaluate the testicular pathology and predict whether or not surgical exploration should be undertaken.

Ultra-sonografia transretal no diagnóstico da obstruçäo ejaculatória em pacientes inférteis / Transrectal ultrasonography in the diagnosis of ejaculatory obstruction in infertile patients

A ultrasonografia transretal de próstata realizada em 47 pacientes inférteis foi anormal em 19 (40,45 por cento). Os achados foram anormais em 5 (55,5 por cento) de 9 pacientes azoospérmicos, em 6 (42,8 por cento) de 14 oligozoospérmicos e em 8 (33 por cento) de 24 normozoospérmicos. Näo havia diferença estatística significativa entre os volumes seminais dos pacientes com e sem anormalidades ultra-sonográficas. Cistos pélvicos únicos foram encontrados em 11 pacientes e associados a outras patologias em 2 outros; em 4 casos existiam apenas vesículas seminais anormais e os 2 últimos pacientes tinham somente anormalidades em dutos ejaculatórios. Conclui-se que a possibilidade de achados sujestivos de obstruçäo ejaculatória pelo exame ultra-sonográfico é mais esperada entre os azoospérmicos com volumes seminais baixos ou normais baixos, que entre os oligos e normozoospérmicos com essas mesmas características seminais