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Aspermia Owing to Obstruction of Distal Ejaculatory Duct and Treatment by Transurethral Resection
0022-5347/78/1191-0141$02.00/0 THE JOURNAL OF UROLOGY Copyright © 1978 by The Williams & Wilkins Co.
Vol. 119, January Printed in U.SA.
ASPERMIA OWING TO OBSTRUCTION OF DISTAL EJACULATORY DUCT AND TREATMENT BY TRANSURETHRAL RESECTION PHILLIP P. PORCH, JR.
ABSTRACT
A case of a young aspermic male patient with bilateral atresia of the terminal ejaculatory duct is reported. He was treated successfully by transurethral resection of the prostate gland in the area of the ejaculatory ducts. He was hospitalized in January 1975 and underwent bilateral scrotal exploration, left spermatocelectomy, testicular biopsies and vasograms. No abnormality of the epididymis or vas deferens was noted. The vas deferens was cannulated with a No. 25 needle bilaterally and vasograms were made (part A of figure). The vasograms demonstrated slight dilata-
Surgical procedures for the correction of obstructions of the seminal tract are common but the majority of them deal with obstruction in the proximal portion of the tract. There are a number of reports on congenital anomalies of the ejaculatory ducts and seminal vesicles in association with cystic fibrosis of the pancreas but few reports on fertility have appeared in
A, operative vasogram shows dilated ejaculatory ducts. B, right ejaculatorry duct catheterized at time of transurethral resection demonstrates patency.
the literature. Girgis and associates reported 1 case of unilateral atresia of the ejaculatory duct but did not indicate any attempt at surgical treatment. 1 Mohsenian, in a series of more than 13,000 patients evaluated for seminal tract obstruction, lists ejaculatory duct obstruction as a cause of aspermia but reports no surgical treatment. 2 A review of the world literature during the last 10 years has failed to reveal a case similar to the one presented herein. CASE REPORT
A 29-year-old man was referred for fertility evaluation in November 1974. He had been married for 9 years and there had been no pregnancies. There was no history of any inflammatory disease or injury of the genital or urinary tract. Growth, development and onset of puberty had been normal. His general physical condition was good. The vas deferens was palpable bilaterally and there was a 2 cm. spermatocele on the left side. The prostate was normal in size, shape and consistency. The seminal vesicles were not palpable. The volume of the ejaculate was 1 ml. and appeared to be pure prostatic fluid containing numerous lecithin bodies but no sperm. The ejaculate did not coagulate and the patient stated that it had always looked thin and watery. Accepted for publication September 23, 1977.
tion of the seminal vesicles and ejaculatory ducts. There was no discharge of contrast material into the prostatic urethra. Bilateral testicular biopsies indicated normal spermatogenesis. Since there was no history of any inflammatory disease it was believed that the obstruction of the terminal ejaculatory ducts was owing to congenital atresia. On March 25 the patient was rehospitalized and a limited transurethral resection was done, slightly proximal and lateral to the verumontanum. The resection opened into a duct on both sides, which proved to be the ejaculatory ducts after injection of contrast material through a ureteral catheter (part B of figure). One month postoperatively the patient stated that sexual intercourse seemed to be more satisfying and fulfilling, and that the semen seemed to be thicker and in larger volume. On June 24 the first semen analysis showed a volume of 1.5 cc, 5,000,000 sperm per cc and 60 per cent motility. On January 8, 1976 semen analysis showed a volume of 2.6 ml. with a count of 49,000,000 sperm per ml. and 50 per cent motility. In December his wife delivered a normal female newborn. COMMENT
The thin, watery, non-coagulating, azoospermic semen was the first indication that this patient could have an obstruction of the ejaculatory duct or absence of the seminal vesicles. The 141
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vasogram confirmed this suspicion. It was thought that the terminal ejaculatory ducts would be close enough to the urethral lumen to allow opening by transurethral resection. In the absence of any history of inflammatory disease it was assumed that this was a congenital problem. It was surprising that the testicular biopsy showed remarkably normal spermatogenesis. It was explained to the patient preoperatively that there was the possibility of epididymitis occurring if the dilated ejaculatory ducts were opened. This did occur 1 time about 3 months postoperatively but there have been no recurrences. Infertility owing to distal obstruction of the ejaculatory ducts is undoubtedly rare. This one experience has renewed my interest in vasograms at the time of testicular biopsy.
V asograms should be done in those patients with semen lacking seminal vesicular fluid or in which fructose is deficient.
1921 Hayes St., Nashville, Tennessee 37203. REFERENCES 1. Girgis, S. M., Etriby, A., El-Hafnawy, H. and Kahil, S.: Asper-
mia: a survey of 49 cases. Fertil. Steril., 19: 580, 1968. 2. Mohsenian, M.: Surgical treatment of male sterility. Report on 1500 cases of epididymo-vasostomy. Fertility and Sterility. Proceedings of VII World Congress, Tokyo and Kyoto, Japan, October 17-25, 1971. Amsterdam: Excerpta Medica, p. 214, 1973.
Vol. 119, January Printed in U.SA.
ASPERMIA OWING TO OBSTRUCTION OF DISTAL EJACULATORY DUCT AND TREATMENT BY TRANSURETHRAL RESECTION PHILLIP P. PORCH, JR.
ABSTRACT
A case of a young aspermic male patient with bilateral atresia of the terminal ejaculatory duct is reported. He was treated successfully by transurethral resection of the prostate gland in the area of the ejaculatory ducts. He was hospitalized in January 1975 and underwent bilateral scrotal exploration, left spermatocelectomy, testicular biopsies and vasograms. No abnormality of the epididymis or vas deferens was noted. The vas deferens was cannulated with a No. 25 needle bilaterally and vasograms were made (part A of figure). The vasograms demonstrated slight dilata-
Surgical procedures for the correction of obstructions of the seminal tract are common but the majority of them deal with obstruction in the proximal portion of the tract. There are a number of reports on congenital anomalies of the ejaculatory ducts and seminal vesicles in association with cystic fibrosis of the pancreas but few reports on fertility have appeared in
A, operative vasogram shows dilated ejaculatory ducts. B, right ejaculatorry duct catheterized at time of transurethral resection demonstrates patency.
the literature. Girgis and associates reported 1 case of unilateral atresia of the ejaculatory duct but did not indicate any attempt at surgical treatment. 1 Mohsenian, in a series of more than 13,000 patients evaluated for seminal tract obstruction, lists ejaculatory duct obstruction as a cause of aspermia but reports no surgical treatment. 2 A review of the world literature during the last 10 years has failed to reveal a case similar to the one presented herein. CASE REPORT
A 29-year-old man was referred for fertility evaluation in November 1974. He had been married for 9 years and there had been no pregnancies. There was no history of any inflammatory disease or injury of the genital or urinary tract. Growth, development and onset of puberty had been normal. His general physical condition was good. The vas deferens was palpable bilaterally and there was a 2 cm. spermatocele on the left side. The prostate was normal in size, shape and consistency. The seminal vesicles were not palpable. The volume of the ejaculate was 1 ml. and appeared to be pure prostatic fluid containing numerous lecithin bodies but no sperm. The ejaculate did not coagulate and the patient stated that it had always looked thin and watery. Accepted for publication September 23, 1977.
tion of the seminal vesicles and ejaculatory ducts. There was no discharge of contrast material into the prostatic urethra. Bilateral testicular biopsies indicated normal spermatogenesis. Since there was no history of any inflammatory disease it was believed that the obstruction of the terminal ejaculatory ducts was owing to congenital atresia. On March 25 the patient was rehospitalized and a limited transurethral resection was done, slightly proximal and lateral to the verumontanum. The resection opened into a duct on both sides, which proved to be the ejaculatory ducts after injection of contrast material through a ureteral catheter (part B of figure). One month postoperatively the patient stated that sexual intercourse seemed to be more satisfying and fulfilling, and that the semen seemed to be thicker and in larger volume. On June 24 the first semen analysis showed a volume of 1.5 cc, 5,000,000 sperm per cc and 60 per cent motility. On January 8, 1976 semen analysis showed a volume of 2.6 ml. with a count of 49,000,000 sperm per ml. and 50 per cent motility. In December his wife delivered a normal female newborn. COMMENT
The thin, watery, non-coagulating, azoospermic semen was the first indication that this patient could have an obstruction of the ejaculatory duct or absence of the seminal vesicles. The 141
142
PORCH
vasogram confirmed this suspicion. It was thought that the terminal ejaculatory ducts would be close enough to the urethral lumen to allow opening by transurethral resection. In the absence of any history of inflammatory disease it was assumed that this was a congenital problem. It was surprising that the testicular biopsy showed remarkably normal spermatogenesis. It was explained to the patient preoperatively that there was the possibility of epididymitis occurring if the dilated ejaculatory ducts were opened. This did occur 1 time about 3 months postoperatively but there have been no recurrences. Infertility owing to distal obstruction of the ejaculatory ducts is undoubtedly rare. This one experience has renewed my interest in vasograms at the time of testicular biopsy.
V asograms should be done in those patients with semen lacking seminal vesicular fluid or in which fructose is deficient.
1921 Hayes St., Nashville, Tennessee 37203. REFERENCES 1. Girgis, S. M., Etriby, A., El-Hafnawy, H. and Kahil, S.: Asper-
mia: a survey of 49 cases. Fertil. Steril., 19: 580, 1968. 2. Mohsenian, M.: Surgical treatment of male sterility. Report on 1500 cases of epididymo-vasostomy. Fertility and Sterility. Proceedings of VII World Congress, Tokyo and Kyoto, Japan, October 17-25, 1971. Amsterdam: Excerpta Medica, p. 214, 1973.