- Email: [email protected]
Transurethral resection for ejaculatory duct stenosis and oligospermia*
Vol. 41, No.3, Maroh 1984 Printed in U.S.A.
FERTILITY AND STERILITY Copyright c 1984 The American Fertility Society
Transurethral resection for ejaculatory duct stenosis and oligospermia*
Culley C. Carson, M.D.t Department of Surgery,.Duke University Medical Center, Durham, North Carolina
Infertility caused by bilateral ejaculatory duct obstruction is rare. 1 -3 Obstruction of the ejaculatory duct seminal emission may be congenital or acquired. Acquired obstructions are more common and are caused by any agent that produces posterior urethral inflammation. 1 , 2 Four cases of profound oligospermia are presented with diagnostic and management criteria. MATERIALS AND METHODS
Four patients, 28, 33, 38, and 40 years of age, were evaluated for profound oligospermia and were fOllnd to have sperm counts of < 5 million on two semen analyses. All patients had semen volumes of < 1.5 ml, semen pH averaged 6.8, and seminal fructose was negative. Diminished semen coagulation was noted in 5 of 11 specimens. All patients had normal serum testosterone, luteinizing hormone, and follicle-stimulating hormone. Physical examinations were unremarkable except for a boggy, tender prostate in one patient. One patient had a history of prolonged Foley catheterization after abdominal trauma, and two patients had histories of prostatitis and gonococcal urethritis, while the remaining patient had only a history of prostatitis.
Patients underwent testis biopsy and unilateral vasogram using 5 ml of diatrizoate meglumine. Preliminary films revealed prostatic calculi in one patient but were unremarkable in all others. The criterion for a patent vasal system is visualization of contrast media in the posterior urethra after injection of 5 ml using a fine needle for cannulating the vas deferens. 4 Distinct obstruction could be seen in all patients, with the column of contrast media ending at the ejaculatory duct (Fig. lA). Repeat films after further injection of contrast media confirmed the obstruction of the ejaculatory duct .. Testis biopsies were normal in all patients. During subsequent cystourethroscopy, no fluid was seen flowing from the ejaculatory ducts in any patient. Recently, 3 ml of indigo carmine diluted 1:4 with saline was injected before cystoscopy confirming obstruction visually. With a resectoscope, a small area of the prostate lateral to the verumontanum was resected; care was taken to avoid penetrating the prostatic capsule or injuring the external urethral sphincter. The vesical neck must be preserved to avoid retrograde ejaculation. In all cases, contrast or indigo carmine could be seen flowing from resected ejaculatory ducts and confirmed radiographically with a repeat vasogram (Fig_ IB). RESULTS
Received September 13, 1983; revised and accepted November 14, 1983. *Presented at the World Infertility Congress, June 27 to 30, 1983, Dublin, Ireland. tReprint requests: Culley C. Carson, M.D., Assistant Professor of Urology, Department of Surgery, Duke University Medical Center, Box 3274, Durham, North Carolina 27710. 482
Carson Communications-in-brief
Semen analyses were evaluated monthly after surgery for 6 to 12 months; the longest follow-up was 36 months. Three patients had sperm in their ejaculates with return of normal semen volume and fructose (Table 1). One patient remained azoospermic after resection despite a patent vasoFertility and Sterility
DISCUSSION
While infertility and azoospermia caused by ejaculatory obstruction is rare, vasography performed at the time of testis biopsy can be diagnostic of this condition. Patients with azoospermia, low semen volume, absent fructose, and poor semen coagulation are at higher risk for obstruction and benefit from investigation. Causes of ejaculatory obstruction include inflammatory conditions such as prostatitis, tuberculosis, and gonococcal urethritis. Urethral trauma, indwelling urethral catheters, urethral foreign bodies, or transurethral surgery can also produce ejaculatory duct obstruction. Whereas restoration of fertility after transurethral resection of ejaculatory ducts is unlikely because of epididymal blow-outs or restenosis, return of even minimal sperm transport may allow artificial insemination or in vitro fertilization. Surgical resection must be carried out with great care to avoid complications such as retrograde ejaculation, incontinence, or restenosis. Failure to restore fertile semen specimens in our series and others! probably results from stenosis beyond the level of the verumontanum. Our successfully treated patient had obstruction related not to chronic inflammation but to the local trauma of a urethral catheter. Despite the minimal success of this procedure, the low morbidity, lack of other treatment modalities, and hope for use of sperm in artificial insemination for these patients support the use of t:ransurethral resection for ejaculatory duct obstruction.
Figure 1 (A), Obstruction of the ejaculatory duct in a patient after urethral trauma from an indwelling catheter and prostatitis. (B), Normal ejaculatory duct patency after transurethral resection.
gram. Sperm counts were restored to fertile levels in only one patient with post-Foley catheter obstruction whose counts varied from 15 to 25 millionlml with 55% motility. This patient reported a pregnancy 8 months after surgery. Two remaining patients had counts varying from 4 to 18 million/ml, with motility varying from 10% to 25%.
SUMMARY
Four patients with oligospermia were treated for ejaculatory obstruction after diagnosis by semen analysis and vasography. Ejaculatory obstruction was caused by urethral catheterization or infection in all cases. Transurethral resection
Table 1. Results of Surgery for Ejaculatory Duct Obstruction Patient
Age
Diagnosis
Sperm count/motility Preoperative
Postoperative
Semen volume Preoperative
x 106
1
28
2
33
3
38
4
40
Vol. 41, No.3, March 1984
Indwelling catheter and trauma Prostatitislhistory of gonorrhea Prostatitislhistory of gonorrhea Prostatitis
Postoperative ml
Azoospermic
22/55%
0.5
4.5
Azoospermic
8/25%
0.5
2.5
2110%
18/22%
1.0
3.0
Azoospermic
Azoospermic
1.0
1.5
Carson Communications-in-brief
483
of the posterior prostatic urethra produced fertile levels of sperm in the semen in one patient. While success rates are low, low morbidity and possible use of sperm for in vitro fertilization make investigation and treatment of these patients worthwhile.
2. Pomerol JM: Obstructions of the seminal duct. Int J Androl (Suppl 1):50, 1978 3. Wagenknecht LV: Obstruction in the male reproductive tract. In Treatment of Male Infertility, Edited by J Bain, W Schill, L Schwarzstein. New York, Springer-Verlag, 1982, p 221 4. Ford K, Carson CC III, Dunnick NR, Osborne D, Paulson DF: The role of seminal vesiculography in the evaluation of male infertility. Fertil Steril 37:552, 1982
REFERENCES
1. Amelar RD, Dubin L: Ejaculatory duct obstruction. In Current Therapy of Infertility, Edited by RD Amelar, L Dubin. Trenton, BC Decker, 1982, p 80
484
Carson Communications-in-brief
Fertility and Sterility
FERTILITY AND STERILITY Copyright c 1984 The American Fertility Society
Transurethral resection for ejaculatory duct stenosis and oligospermia*
Culley C. Carson, M.D.t Department of Surgery,.Duke University Medical Center, Durham, North Carolina
Infertility caused by bilateral ejaculatory duct obstruction is rare. 1 -3 Obstruction of the ejaculatory duct seminal emission may be congenital or acquired. Acquired obstructions are more common and are caused by any agent that produces posterior urethral inflammation. 1 , 2 Four cases of profound oligospermia are presented with diagnostic and management criteria. MATERIALS AND METHODS
Four patients, 28, 33, 38, and 40 years of age, were evaluated for profound oligospermia and were fOllnd to have sperm counts of < 5 million on two semen analyses. All patients had semen volumes of < 1.5 ml, semen pH averaged 6.8, and seminal fructose was negative. Diminished semen coagulation was noted in 5 of 11 specimens. All patients had normal serum testosterone, luteinizing hormone, and follicle-stimulating hormone. Physical examinations were unremarkable except for a boggy, tender prostate in one patient. One patient had a history of prolonged Foley catheterization after abdominal trauma, and two patients had histories of prostatitis and gonococcal urethritis, while the remaining patient had only a history of prostatitis.
Patients underwent testis biopsy and unilateral vasogram using 5 ml of diatrizoate meglumine. Preliminary films revealed prostatic calculi in one patient but were unremarkable in all others. The criterion for a patent vasal system is visualization of contrast media in the posterior urethra after injection of 5 ml using a fine needle for cannulating the vas deferens. 4 Distinct obstruction could be seen in all patients, with the column of contrast media ending at the ejaculatory duct (Fig. lA). Repeat films after further injection of contrast media confirmed the obstruction of the ejaculatory duct .. Testis biopsies were normal in all patients. During subsequent cystourethroscopy, no fluid was seen flowing from the ejaculatory ducts in any patient. Recently, 3 ml of indigo carmine diluted 1:4 with saline was injected before cystoscopy confirming obstruction visually. With a resectoscope, a small area of the prostate lateral to the verumontanum was resected; care was taken to avoid penetrating the prostatic capsule or injuring the external urethral sphincter. The vesical neck must be preserved to avoid retrograde ejaculation. In all cases, contrast or indigo carmine could be seen flowing from resected ejaculatory ducts and confirmed radiographically with a repeat vasogram (Fig_ IB). RESULTS
Received September 13, 1983; revised and accepted November 14, 1983. *Presented at the World Infertility Congress, June 27 to 30, 1983, Dublin, Ireland. tReprint requests: Culley C. Carson, M.D., Assistant Professor of Urology, Department of Surgery, Duke University Medical Center, Box 3274, Durham, North Carolina 27710. 482
Carson Communications-in-brief
Semen analyses were evaluated monthly after surgery for 6 to 12 months; the longest follow-up was 36 months. Three patients had sperm in their ejaculates with return of normal semen volume and fructose (Table 1). One patient remained azoospermic after resection despite a patent vasoFertility and Sterility
DISCUSSION
While infertility and azoospermia caused by ejaculatory obstruction is rare, vasography performed at the time of testis biopsy can be diagnostic of this condition. Patients with azoospermia, low semen volume, absent fructose, and poor semen coagulation are at higher risk for obstruction and benefit from investigation. Causes of ejaculatory obstruction include inflammatory conditions such as prostatitis, tuberculosis, and gonococcal urethritis. Urethral trauma, indwelling urethral catheters, urethral foreign bodies, or transurethral surgery can also produce ejaculatory duct obstruction. Whereas restoration of fertility after transurethral resection of ejaculatory ducts is unlikely because of epididymal blow-outs or restenosis, return of even minimal sperm transport may allow artificial insemination or in vitro fertilization. Surgical resection must be carried out with great care to avoid complications such as retrograde ejaculation, incontinence, or restenosis. Failure to restore fertile semen specimens in our series and others! probably results from stenosis beyond the level of the verumontanum. Our successfully treated patient had obstruction related not to chronic inflammation but to the local trauma of a urethral catheter. Despite the minimal success of this procedure, the low morbidity, lack of other treatment modalities, and hope for use of sperm in artificial insemination for these patients support the use of t:ransurethral resection for ejaculatory duct obstruction.
Figure 1 (A), Obstruction of the ejaculatory duct in a patient after urethral trauma from an indwelling catheter and prostatitis. (B), Normal ejaculatory duct patency after transurethral resection.
gram. Sperm counts were restored to fertile levels in only one patient with post-Foley catheter obstruction whose counts varied from 15 to 25 millionlml with 55% motility. This patient reported a pregnancy 8 months after surgery. Two remaining patients had counts varying from 4 to 18 million/ml, with motility varying from 10% to 25%.
SUMMARY
Four patients with oligospermia were treated for ejaculatory obstruction after diagnosis by semen analysis and vasography. Ejaculatory obstruction was caused by urethral catheterization or infection in all cases. Transurethral resection
Table 1. Results of Surgery for Ejaculatory Duct Obstruction Patient
Age
Diagnosis
Sperm count/motility Preoperative
Postoperative
Semen volume Preoperative
x 106
1
28
2
33
3
38
4
40
Vol. 41, No.3, March 1984
Indwelling catheter and trauma Prostatitislhistory of gonorrhea Prostatitislhistory of gonorrhea Prostatitis
Postoperative ml
Azoospermic
22/55%
0.5
4.5
Azoospermic
8/25%
0.5
2.5
2110%
18/22%
1.0
3.0
Azoospermic
Azoospermic
1.0
1.5
Carson Communications-in-brief
483
of the posterior prostatic urethra produced fertile levels of sperm in the semen in one patient. While success rates are low, low morbidity and possible use of sperm for in vitro fertilization make investigation and treatment of these patients worthwhile.
2. Pomerol JM: Obstructions of the seminal duct. Int J Androl (Suppl 1):50, 1978 3. Wagenknecht LV: Obstruction in the male reproductive tract. In Treatment of Male Infertility, Edited by J Bain, W Schill, L Schwarzstein. New York, Springer-Verlag, 1982, p 221 4. Ford K, Carson CC III, Dunnick NR, Osborne D, Paulson DF: The role of seminal vesiculography in the evaluation of male infertility. Fertil Steril 37:552, 1982
REFERENCES
1. Amelar RD, Dubin L: Ejaculatory duct obstruction. In Current Therapy of Infertility, Edited by RD Amelar, L Dubin. Trenton, BC Decker, 1982, p 80
484
Carson Communications-in-brief
Fertility and Sterility