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

ABSTRACT

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