- Email: [email protected]
Urethrography: Its Value in the Study of Male Fertility and Sterility
Urethrography Its Value in the Study of Male Fertility and Sterility
M. Leopold Brodny, M.D.
THE
of genital pathology which may interfere with the proper progress of spermatozoa from the cervix to the tubal ostium is an important step in evaluating female infertility. A roentgenographic method, hysterosalpinography, is used to investigate these factors and is recognized as a valuable procedure for determining tubal patency and for the diagnosis of gynecologic conditions which affect or influence the degree of fertility. Pathologic changes which modify the ejaculate and interfere with the free passage of spermatozoa may also occur in the urethra and the accessory organs of reproduction, but it is not so well known that a roentgenographic method, urethrography, is available for a comparative purpose in the male. The male urethra and its appendages serve to furnish an adequate channel for the passage of semen, to provide propulsive power for the proper deposition of the ejaculate, and to secrete media for the protection and nutrition of spermatozoa. Alterations in these mechanisms can lower fertility or produce infertility. It is the purpose of this paper to present urethrography as a simple and safe procedure for the diagnosis of urethral factors which interfere with ejaculation, and for the visualization of adenexal factors which modify the ejaculate. I propose to describe the topographic changes observed on the urethrograms of patients with fertility problems and to correlate these findings with the qualities of their semen. Urethroscopy can be employed for studying the urethral anatomy but it is inadequate in many respects. The lens limits the examination to transitory DETECTION
From the Fertility Clinic of the Beth Israel Hospital, Boston, Massachusetts. Presented at the First World Congress on Fertility and Sterility, May 26, 1953. 386
Vol. 4, No.5, 1953]
URETHROGRAPHY
387
views of many small anatomic areas and the data are recorded by verbal descriptions which vary in perspective and completeness. The urethrogram permits the systematic study of groups of patients with similar lesions and provides a permanent topographic record from which disturbed sexual functions and seminal changes can be interpreted on an anatomic physiologic basis. The added psychologic advantages of this procedure lies in its freedom from pain and discomfort, its ease of performance, and the absence of complications. The technic of urethrography employing a specially designed urethragraphic instrument has been described in an earlier paper. 2 Various opaque media such as Lipiodol, Iodochloral, sodium iodide, Skiodan, acacia, and Rayopaque have been used. We now employ a new substance, Medopaque U, * which is superior to the iodized oils for urethrocystographic use. This medium mixes with water and urine, :flows easily, is well tolerated by the mucous membranes, and produces a homogeneous shadow with sharply defined outlines. The opacity of Medopaque U can be controlled by dilution with water. The medium does not break up into globules when mixed with urine in the bladder. Instruments and catheters are easily cleaned. A report on Medopaque U will shortly be in print. ROENTGENOGRAPHIC ANATOMY OF THE MALE URETHRA
The male urethra begins at the internal sphincter of the bladder, perforates the prostate in a slightly concave curve from the base to the apex, passes through the triangular ligament and continues along the ventral surface of the penis to the tip of the glans (Fig. 1). The urethra is arbitt·arily divided by the triangular ligament into an anterior cavernous portion and a posterior muscular portion. The roentgenologic interpretation of the urethrogram requires a thorough knowledge of the appearance of the normal urethra. In the relaxed state the base of the bladder is slightly convex and lies at the level of the upper border of the pubic bones. There are three normal areas of narrowing in the urethral canal: the vesical neck; the external sphincter; and the urethral meatus. There are also three normal areas of dilatation: the collicular portion of the prostatic urethra; the bulbous part of the anterior urethra; and the fossa navicularis. The prostatic portion of the urethra is, in the midline, about 3 em. in length. It is a fusiform structure beginning at the bladder as a narrow area *Furnished by the Bell-Craig Company, New York.
BRODNY
388
[Fertility & Sterility
produced by the so-called internal sphincter and terminating as a narrow constriction which represents the external sphincter. In the widest portion of the prostatic urethra is an ovoid area of increased radiance produced by the elevation of the verumontanum. The membranous portion of the urethra is wedge-shaped with the apex at the external sphincter and the distal portion terminating at the bulb. In the anteroposterior view there appears at the bulbous portion of the urethra a denser shadow than the rest of the
Fig. 1.
Normal urethrogram; anteroposterior and oblique views.
urethra. This is due to the penile-scrotal curve of the urethra producing overlapping of shadows. The anterior urethra is best visualized in its entirety in the oblique view. Its outline is regular, and the canal narrows as it terminates at the meatus. Urethrography is indicated in the study of all males with infertility problems and especially when the following conditions are present: ( 1) congenital urogenital anomalies; 7 • 17 • 18 ( 2) ejaculatory dysfunctions; ( 3) sexual disturbances; ( 4) endocrine diseases; ( 5) systemic diseases with neurogenic manifestations; 13 ( 6) persistent or recurrent prostatitis or urethritis; 6 (7) abnormal findings on rectal examination of the prostate and vesicles; ( 8) modified seminal qualities. This report has been divided into four sections for the sake of clarity and efficient presentation. The problems discussed in these arbitrary divisions are not distinct entities but often occur concomitantly.
Vol. 4, No. 5, 1953]
URETHROGRAPH¥
389
ANATOMIC FACTORS PRODUCING VARIATIONS OF NORMAL SEMEN U rethrography is valuable as a routine procedure for the evaluation of standards of male fertility. Many of the intensive studies on male fertility reported in the past two decades have been concerned primarily with determining what constitutes a normal semen and which factors in the seminal quality are most important in determining the degree of fertility. Marked discrepancies have been found in similar studies of normal semen conducted by different investigators. It was invariably taken for granted that the genital status of the donors in these groups was normal and this was especially considered so if the donor had a previous child or his wife was pregnant at the time of examination. It must be remembered that the index of fertility should be based not solely on the eventual production of a pregnancy in a fertile woman but on the number of properly inseminated ovulations which failed to take and on the number of pregnancies which did not go to term. Usually the normality of the male was determined by the clinical history, and if a urologic survey was conducted, it consisted of a local external examination of the genitalia, rectal palpation of the prostate and seminal vesicles, and microscopic examination of the expressed secretion and the urinary sediment. Urethroscopy was seldom routinely employed because of the objection of the patient. A wide variety of urologic and sexual disorders are silent and primarily or secondarily affect ejaculation and the ejaculate. Many of these disturbances are difficult to detect by routine history and local examination. As a result much of the theorizing which attempted to account for these variations has been derived from the study of males in whom the status of the urethra and its adenexal glands was inadequately determined. The influence of hidden urethral factors in determining the normal volume of semen is a case in point. Studies of the normal semen volume conducted by Hotchkiss, by Farris, and by MacLeod have not produced comparative results. MacLeod observed in referring to this factor, "There must be basic reasons for the different values reported by various authors." The answer often lies in unrecognized changes in the accessory sexual organs which influence their secretory output and in genital lesions which by distorting, constricting or disrupting the urethral lumen diminish the amount or the force of the ejaculate or cause seminal reflux into the bladder.
390
BRODNY
[Fertility & Sterility
A correlation of the urethral topography as visualized in the urethrogram with the ejaculatory findings in a large group of supposedly normal males would disclose many anatomico-pathologic reasons for some of the significant variables in seminal standards.
EJACULATORY FACTORS AFFECTING FERTILITY There is observed in many couples an inconsistency between the number of spermatozoa present in a semen specimen produced by masturbation and the number that should be found in the postcoital cervical secretion. The absence or small numbers of spermatozoa in the cervical secretion is usually attributed to secretory hostility or to local genital pathology of the female but often it is due to faulty deposition. Improper coital technic is well recognized as a cause of faulty deposition but disturbances in ejaculation as an etiologic factor is frequently overlooked. The following factors producing ejaculatory dysfunctions can be visualized on the urethrogram.
1. Obstructive Factors There is clinical evidence that in certain patients some of the semen is prevented from reaching the external environment by obstructions in the urethral canal. It is not possible to visualize the mechanisms of ejaculation but since the peristaltic action of ejaculation is of such short duration and the ejaculate is so thick and viscous, a urethral narrowing must cause some degree of ejaculatory stasis. If the strictured urethra is energetically milked into a glass jar ~hortly after intercourse, the amount of retained fluid can be noted. This maneuver was done in the case of M.R. who among some minor urinary symptoms also complained of "satisfactory relations but very little discharge." He had a history of a periurethral abscess and chronic prostatic infection many years ago. He obtained only 1.5 cc of ejaculate by coitus interruptus into a glass container and was able to milk 1.8 cc into a second jar a few minutes later. The urethrogram (Fig. 2) visualized the anatomicopathologic factors which mechanically produced retention of the ejaculate and thereby lowered the external seminal volume. There is a wide variety of disorders which constrict, distort, or disrupt the urethral lumen in the male. It is not feasible to present a complete urologic and roentgenographic discussion of all the lesions which produce
Vol. 4, No. 5, 1953]
URETHROGRAPHY
391
these anatomic alterations in a report primarily concerned with fertility. However, the incidence of such conditions in the general male population is not negligible and the incidence in males with poor fertility may be higher than suspected.
Fig. 2. M.R., age 49. Note the constricted area in the bulbous urethra and the small sinus tract about 2 em. long. The verumontanum is elongated and compressed. The trigone is displaced anteriorly by a distended seminal vesicle.
2. Traumatic Factor Absence of an external ejaculate on ejaculation is a phenomena that is sometimes observed as a sequela of prostatic surgery and vesical neck resection. The loss or marked diminution of external semen on ejaculation occurs in practically all prostatectomized patients in whom the vas has been sectioned. Since most of these patients are aged there is no fertility problem. However, median bar, vesical neck contracture, and mid-lobe hypertrophy occur in many adults under fifty years of age, and they are usually treated by transurethral resection. About 20 per cent of these patients have ejacula-
392
BROONY
[Fertility & Sterility
tory dysfunction as a sequela to their surgery. This occurrence may have serious implications as far as fertility is concerned. A typical case was a male who, following a transurethral resection for a median bar, no longer had a seminal discharge with his orgasms. His relative infertility had become absolute. The urethrogram showed a funneled vesical neck due to scar tissue secondary to the transurethral revision. The patient was regurgitating his ejaculate into the bladder through the dilated internal sphincter. The recognition and surgical treatment of obstructions at the bladder neck in male children has increased and the possibility of an ejaculatory dysfunction occurring later in life must be remembered. 3. Endocrine Factors Ejaculatory dysfunctions are observed in many patients suffering from metabolic and hormonal disturbances. If the condition occurred before puberty, the prostate often remains infantile. The mechanism producing the symptoms is sometimes obscure. D.G., age 24, single, wished to know if he was fertile. His libido was poor and he infrequently attempted masturbation. On the few times that he was able to have an orgasm it occurred without an external ejaculate. He developed severe testicular discomfort following an attempt to have intercourse. On physical examination, his genital organs were normal to inspection and palpation. The prostate on rectal palpation felt small, flat, and indefinite. A drop of prostatic secretion was obtained after massage of the gland and it contained a few white blood cells and epithelial cells. His basal metabolic rate and the F.S.H. urinary excretion were normal, but the 17-ketosteroid urinary excretion was subnormal. After many attempts he finally produced by masturbation a semen specimen of 1.5 cc. It contained 56,000,000 spermatozoa per cubic centimeter with 50 per cent motile. He had to milk the specimen out of the urethra. The urethrogram (Fig. 3) revealed a small undeveloped prostate. This was verified by urethroscopy. The finding of a short supracollicular urethra is consistent with that usually observed on the urethrogram of the male before puberty.
It is not possible to discuss here all the endocrine dysfunctions which affect the size and the secretory ability of the accessory reproductive glands. Urethrography has been found of value in their study. 4. Neuromuscular Factors Ejaculation is produced by a muscular contraction under nerve control. Many neuromuscular disturbances produce ejaculatory dysfunctions. This
Vol. 4, No. 5, 1953]
URETHROGRAPHY
393
can be demonstrated experimentally. Ejaculation can be abolished or its force diminished by sympathectomy in the lumbar region. This loss was noted by a young man on whom the operation had been performed for hypertension. He still retained his erectile power but no secretion was produced even though he went through an orgasm. Urethrography showed funneling of the vesical neck. His ejaculate was regurgitating into the bladder.
Fig. 3. D.C. Note the close relationship of the verumontanum to the bladder base. The prostate has failed to develop and the supracollicular urethra has not elongated to the adult length.
Many ejaculatory dysfunctions are due to progressive atonicity. We have no means of measuring the ejaculatory force. There are males whose ejaculation never had any power; others who have noted that gradually their semen no longer shoots out but drips out. Urethrographic studies have disclosed that many of these patients have a large atonic anterior urethra. The normal capacity of the anterior urethra is 7-10 cc. These males have a capacity in their anterior urethra of over 30 cc. and it is all out of proportion
BRODNY
394
[Fertility & Sterility
to the external size of the penis. The etiology of this atonicity is difficult to determine. L.F., age 26, was seen because of sexual difficulties. He had trouble producing an erection and sometimes ejaculated when semi-erect. There never was force to his ejaculate. On rectal examination, he had a firm fibrous-feeling prostate. He had no F.S.H. activity in his urine and a diminished 17-ketosteroid urinary output. His seminal specimen was obtained with much difficulty. It had a low count with a poor motility and the volume was 4.8 cc. It was necessary to use 45 cc. of medium to obtain his urethrogram (Fig. 4).
Fig. 4. L.F. Note the generalized urethral atonicity and the large capacity of the anterior urethra. It can also be observed from the shadows of the soft tissue that the penis was short and small.
Males with atonic vesical necks may have ejaculatory dysfunctions. The atonicity may be congenital and may be unsuspected. The following patient was carefully investigated by a physician who limits his practice to the diagnosis and treatment of fertility problems. The patient had testicular biopsies, hormonal and metabolic studies. The only abnormal and unique finding was in the studies of the semen. The amount fluctuated from 1 to 3 cc. and the count from 3,000,000 per cc. to 50,000,000 per cc. Urethragraphic examination (Fig. 5) disclosed a dilated vesical neck. Seminal
Vol. 4, No. 5, 1953]
URETHROGRAPHY
395
studies were then repeated. The patient obtained the specimen in a glass jar by coitus interruptus and then voided into two glass containers. Both urine specimens were loaded with sperms. The discrepancy in the specimens was due to reflux ejaculation. Among the acquired lesions of the central nervous system that may cause disturbances in ejaculation, the most important are tabes, spina bifida occulta, myelitis, and traumas to the cord. 13 In these conditions, a funneling of the vesical neck is usually found on the urethrogram.
Fig. 5.
E.F. This patient had an atonic vesical neck and refluxed some of his semen into the bladder on ejaculation.
PROSTATIC AND SEMINAL VESICULAR FACTORS AFFECTING FERTILITY The prostate provides propulsive force, fluid dilution, and a host of biochemical substances to the ejaculate and it is necessary to determine the status of the gland if changes in semen quality are to be properly interpreted. The classical technics of studying the gland and its secretions are rectal palpation, microscopic examination, and chemical analysis of the
BRODNY
396
[Fertility & Sterility
expressed prostatic secretion. These procedures contribute valuable data as to the condition of the organ but they fail to reveal many basic anatomicopathologic changes which may influence the character of the glandular secretion. There are two methods available for this examination. They are urethroscopy and urethrography. In the study of the infertile male, I have found the latter most valuable and acceptable as a routine procedure. I use the former method as a complementary one in selected cases. Urethrography yields valuable information as to the gross anatomic status of the prostate gland, the character of its tissues, and the diseases involving it. The following pathologies of the prostate often can be deduced indirectly by urethrographic study. They are ( 1) infection, ( 2) congestion, ( 3) fibrosis, ( 4) hypertrophy, and ( 5) calcification. 1 . Infection
The relationship of infection of the accessory glands to male infertility is still unsettled. Huggins emphatically denied any such relationship, "In our Clinic we have obtained no correlation between the extent of infection in the prostate and infertility and on this evidence we believe that such infection processes do not contribute to infertility." There is clinical evidence that prostatovesicular infections do have a deliterious effect on fertility. Abeshouse stated, "It has been my experience that the relative infertile patient, whose spermatozoa count is between 25 and 50 million or lower, is unable to impregnate his wife until these foci of infection are eradicated." It is very difficult to prove or disapprove the role of prostatic infe6tion as a factor in infertility. The effects of prostatitis on the seminal quality is in all probability produced by the liberation of toxic products or by the modification of the secretions and secretory output. However, it is important if we are to progress in our knowledge of a possible relationship to know if infection is or is not present and if possible the extent of involvement. The following case is typical of the problem produced by longstanding chronic infection. M.P., age 46 (Fig. 6), 25 years ago contracted a urethral infection which was inadequately treated. He was married for 21 years and his wife never became pregnant. Liquification of his semen was slow and it remained more viscous than is usual. His spermatozoa count ranged from 6,000,000 to 13,000,000 active
Vol. 4, No. 5, 1953]
URETHROGRAPHY
397
spenn~tozoa per cc. Their morphology was not remarkable. There were 20-30 white blood cells per high power field in the prostatic secretion. Examination of his wife did not show any significant pathology which should interfere with impregnation. The postcoital tests showed no spermatozoa in the cervical secretion. The urethrogram helped visualize the gross pathologic changes produced
Fig. 6. M.P. Urethrogram of a patient with long-standing neglected urethral infection. The small and numerous filling defects produced in the urethra above the verumontanum are better visualized on the original roentgenograms.
by the infection. Their significance in relation to infertility demands correlative studies of a large group of infertile patients with infections of the accessory reproductive organs. The following inflammatory lesions involving the prostate and the prostatic urethra can be visualized on the urethrogram (Fig. 7). Lymphocytic Urethral Bodies (Pelouze Bodies). Pelouze first noted the
398
BRODNY
[Fertility & Sterility
presence of certain lymphocytic bodies occurring in the posterior urethra and stressed their relationship to chronic infection. These bodies interfere with drainage of the prostatic fluid during massage and prolong the infection. Bulbourethral Adenitis (Cowperitis). This has been adequately discussed in a previous report. 4 Prostatitis. Prostatitis produces distortion of the posterior urethra (Fig.
Fig. 7. Topographical changes which may be produced by infections of the urethra or of the accessory organs of reproduction. These lesions give rise to characteristic alterations of the urethrogram.
6). The changes observed on the urethrogram are narrowing and elongation of the supracollicular portion of the urethra, elevation of the base of the bladder, patency of the prostatic ducts, and enlargement of the verumontanum (verumontanitis). The verumontanum is elongated and widened and appears as a fusiform filling defect proximal to the external sphincter. Prostatic Abscesses and Caverns. Infections in the prostate may progress to abscess formation. The chronic type of abscess is sometimes missed
Vol. 4, No. 5, 1953)
URETHROGRAPH¥
399
clinically. The urethrogram is valuable in ascertaining the presence of these lesions and their size, location, and extent. Abscesses are usually found in the posterior and lateral portions of the prostate and may be single or multiple. Generally these abscesses rupture and drain into the urethra. If the lesions drain adequately, they will heal; but if the opening into the urethra is too narrow, a chronic abscess cavity results (Fig. 8). This lesion
Fig. 8. B.R. Note the three irregularly filled pockets outlined by the opaque medium and extending into the prostatic tissue. The verumontanum is compressed and elongated in appearance. The supracollicular urethra is distended by the medium due to obstruction at the vesical neck produced by fibrosis.
is a common cause of persistent prostatitis and has been named "prostatic caverns." The urethrogram localizes the caverns and shows their position, size, depth, if they are multiple or solitary, diverticular, tortuous, or aborescent. In this respect, this method of investigation is more valuable than endoscopy since the size of the opening of the urethra is no criterion of the extent or ramifications of the cavern. These cavity formations act as foci of infection and re-infection and undoubtedly contribute their toxic secretions to the ejaculate.
400
BRODNY
[Fertility & Sterility
These cavities are sometimes tuberculous in origin and clinically may be relatively silent if they have not produced an epididymitis. The rectal examination seldom reveals significant data. O'Brant, in a semen analysis of 20 patients with proven genital tuberculosis, found a significant diminution in the amount of semen and the percentage of motile sperms. The number of leukocytes and lymphocytes were highly increased in the specimen in advanced tuberculosis.
Fig. 9. C.B. The prostatic caverns may be acid fast or nonspecific in origin. They cannot be differentiated except by bacteriologic investigation. The absence ·of the shadow of the verumontanum is significant.
C.B. (Fig. 9), male, age 56, had a left nephrectomy 20 years ago. Guinea pig tests have remained negative. Mild frequency and nocturia once to twice are the only symptoms now present. No seminal studies were done. His wife had been examined in the past and no gynecologic pathology was noted. No pregnancies have occurred during twenty years of married life.
Vol. 4, No. 5, 1953]
URETHROGRAPHY
401
Seminal vesiculitis frequently exists with prostatitis (Fig. 2) and presents an indefinite clinical picture varying from that of an acutely ill patient to one who is asymptomatic. The relationship of seminal vesiculitis to infertility is completely undermined. It is very difficult to study the pathology of the vesicles by catheterization of the opening of the ejaculatory ducts on the colliculus. Those investigators who have done injections of the vas
Fig. 10. E.B., age 47. Note the displacement of the prostatic urethra and the elevation of the trigone. The verumontanum is also compressed and elongated.
have demonstrated the high incidence of unsuspected pathology in this area. 12 • 23 The urethrogram will often visualize a distended seminal vesicle (Fig. 10). E.B., age 47, was seen primarily for low back pain. He had been previously examined elsewhere for infertility and the significant finding reported was a 9 cc. volume of ejaculate. On rectal examination, both vesicles were palpable and bulging, and the secretion after stripping contained many large vesicular slugs.
402
BRODNY
[Fertility & Sterility
2. Congestion Many sexual practices, such as coitus interruptus over a long period of time (Fig. 11 ) , prolonged ungratified sexual excitement, too frequent masturbation (Fig. 12), and abnormal sexual indulgence, can lead to chronic congestion of the prostate. The condition is also sometimes produced in the celibate by chronic secretory stasis and in the libertine by an abnormal strain on the gland.
Fig. 11. H.E.L., age 42. Patient has practiced coitus interruptus for the past 11 years since the birth of his second child. One year ago he developed premature ejaculation and poor erections. On rectal examination, the prostate was boggy and enlarged. Note that the veru is widened and that the base of the bladder is bilaterally elevated by each prostatic lobe without compression of the prostatic urethra.
Prostatic congestion is not an important cause of sterility but it can indirectly lower the fertility index. Many patients with chronic congestion suffer from erectile difficulties and ejaculatory dysfunctions which result in improper penetration and deposition. Enlargement and congestion of the
Vol. 4, No.5, 1953]
URETHROGRAPHY
403
verumontanum occurs concomitantly with that in the prostate and by compressing the openings of the ejaculatory ducts produces some degree of seminal stasis. The effect that congestion may have on the pH, the chemical composition, and the enzymes of the semen is not well understood. The seminal volume is apt to go to extremes, being often under 2 cc. in some patients and over 5 cc. in many others.
Fig. 12. J.S., age 23. Patient has masturbated once to three times daily for many years. He developed progressive frequency and nocturia. Note the spasticity of the prostatic urethra, the atonicity of the bulbous urethra, and the three concavities at the bladder base and trigone produced by the congested lateral lobes and the distended seminal vesicle.
Congestion of the prostate produces urethrographic changes which are somewhat different than those seen with prostatitis. There is a bilateral semicircular elevation of the base of the bladder produced by edema of the lateral lobes, the verumontanum is enlarged and ovoid in type, and the prostatic ducts are seldom visualized. On rectal examination, an enlarged, tender, and swollen prostate is palpable and a distended vesicle may be felt. The prostatic secretion usually contains more formed elements such as white blood cells and red blood cells and epithelial cells than is usually observed.
404
BRODNY
[Fertility & Sterility
3. Fibrosis The fibrotic prostate is a definite entity and is not infrequently observed during the decades of men's greatest fertility between 20 and 50 years of age. The glandular elements of the prostate may fail to develop at puberty, as is observed in eunichoidal males (Fig. 3), may be replaced by connective tissue in chronic infectious processes of long standing, or may atrophy due to the premature onset of presenile changes. The histologic changes consist of replacement of the secretory acini by muscular or fibrous tissue with the eventual contraction and shrinkage of the entire prostate. On rectal examination, the prostate is very firm, regular in contour, but subnormal in size. On massage of the gland, little if any prostatic secretion is obtainable. The urethrographic findings are shortening and narrowing of the supracollicular portion of the prostatic urethra, flattening of the base of the bladder, and sometimes absence of the filling defect usually produced by the verumontanum. Urethrography should be of value in studying the status of the prostate in males with a high F.S.H., with gynecomastia, or with liver disease. The possibility of a concomitant atrophy of the prostate should be investigated. Matthews et al. 20 have shown that estrogenic substances injected in large doses will produce atrophy of the prostate in rats. The relationships of prostatic fibrosis to chemical and physical changes in the semen quality have not been determined. Undoubtedly the amount of prostatic secretion is diminished according to the extent of destruction of the secretory elements. This factor alone could lower the fertilizing potentialities of the male since one of the recognized functions of the prostatic secretion is to augment the volume of the semen. 4. Hyperplasia Overgrowth of the glandular elements of the prostate is a change that occurs with advancing years. However, varying degrees of prostatic hyperplasia are not infrequently observed during the fourth and fifth decades of life and certainly is present in those males who marry women some years younger than themselves. The relationship of the degree of glandular hyperplasia in a given prostate to the volume and quality of the ejaculate has not been determined. Attempts have been made to correlate changes in seminal quality with the age of the donor but no evidence has been
Vol. 4, No. 5, 1953]
URETHROGRAPHY
405
produced that advancing years per se is a factor. The correlation should, however, be made with the degree of hyperplasia of the prostate. A classification of the types and the urethrographic findings in prostatic hypertrophy has been previously reported. 5 5. Calcification
Prostatic calcifications are usually asymptomatic and are considered of little clinical importance. Their relationship to seminal qualities and infertility has been neglected. They are often an incidental finding, but unless a special effort is made their presence will not be detected by routine examinations. Prostatic calculi are sometimes palpable on rectal examination as hard irregular crepitant areas in the gland, but most often their presence escapes detection. Calcifications can be easily recognized on the plain roentgenogram and appear as mottled or massive areas of calcium deposits limited to the prostatic region. Urethrography will demonstrate associated pathology. Dilated prostatic ducts are often found. There is a marked difference in the reported incidence of prostatic calculi. Thompson reviewed 13,000 autopsies at Guy's Hospital in England and reported only 29 cases. Herbst found prostatic calculi in approximately one-half of a group of prostatic glands removed at routine autopsy. Prostatic calculi are reported as commonly occurring in the fifth and sixth decades of life, but they will be more frequently observed in the third and fourth decades, if roentgenographic studies of the prostatic area are routinely done. Kretchmer reported a series in which 30 per cent were under 40 years of age. Thomas and Robert, in a review of 305 cases, noted that two thirds of the patients were between 40 and 60 years of age and that there were four 10-year-old boys who had prostatic stones. The human prostatic secretion contains a high calcium content and it is this factor that is believed by some to be responsible for the deposition. The prostatic fluid is rich in citric acid and the citrates probably bind the calcium salts as they do in other fluids rich in calcium. A close relationship between the citric acid contents of the prostatic fluid and the level of testosterone has been observed. The presence of prostatic calcification could indicate a local disturbance in the citrate or calcium metabolism. Prostatitis is frequently associated with prostatic calculi and the infection is believed by many to be responsible for initiating the formation. Calcification affects the character of the prostatic secretion by destroying
406
BRODNY
[Fertility & Sterility
secretory tissue or by obstructing the prostatic ducts with calcareous deposits. Herbst and Merricks have noted that groups of prostatic stones are often located near the terminal portions of the ejaculatory ducts, producing extreme ductal distortion by pressure and interfering with drainage. The citric acid content of the prostatic secretion may also be affected. There is some evidence that it influences sperm motility. A study of the citric acid and calcium content of the semen and a correlation of the urethrographic finding with the fertility status is indicated in patients with prostatic calculi. COLLICULAR FACTORS AFFECTING FERTILITY The exact functions of the verumontanum are obscure but clinically it is closely related to many types of sexual dysfunctions. There is also some evi-
Fig. 13. J.F., age 32. Anomalous prostatic urethra. Note the elongation of the supracollicular portion of the urethra and the unusual relationship of the verumontanum to the external sphincter.
dence that its glandular portion produces an alkaline secretion which mixes with that of the prostate. From a fertility standpoint, the verumontanum is important because of its anatomic association with the ejaculatory ducts. Obstruction of the ejaculatory ducts can occur secondary to many diseases
Vol. 4, No. 5, 1953]
URETHROGRAPHY
407
involving the posterior urethra, especially of the verumontanum. Their openings are situated on the colliculus, and anomalies and pathologies of this organ influence the quantity and quality of the ejaculate. Atrophy or scarification of the verumontanum sometimes results in stenosis of the meati of the ejaculatory ducts. The still prevalent practice of indiscriminate fulguration of the verumontanum and the instillation of strong caustics into the posterior urethra often produces distortion of the normal anatomy of this area. The urethrogram visualizes the anatomic pathologic status of the entire prostatic urethra and the colliculus region is usually especially well delineated.
Fig. 14.
A.C. Note the atonicity of the bladder and vesical neck and the tremendous size of the verumontanum.
J.F., male, aged 32, was married for 10 years and his wife never became pregnant. Unfortunately a semen specimen could not be obtained. The roentgenogram (Fig. 13) shows an anomaly of the prostatic urethra and the verumontanum. The relatively high incidence of congenital anomalies in this area in children has been noted by Campbell and undoubtedly they remain unrecognized in the adult because of minimal clinical symptoms. Their importance in male infertility is a subject for investigation.
408
BRODNY
[Fertility & Sterility
Verumontanitis with the accompanying edema produces some obstruction to the orifices of the ejaculatory ducts. With infection the shadow produced by the verumontanum on the urethrogram is enlarged, prominent, and tends to be ovular (Fig. 14). There is no reflux of dye into the normal ejaculatory ducts during retrograde urethrography. Sometimes infection or other pathology results in relaxations of the meati of the ducts and some of
Fig. 15.
K.K., age 32. Note the enlarged filling defect produced by the colliculus and the media which has refluxed into both ejaculatory ducts.
the media passes into the ejaculatory duct or into the seminal vesical and they are visualized on the roentgenogram. This occurred on the urethrogram of patient K.K. (Fig. 15). The study of a larger series of such reflux is necessary to determine the relationship of this phenomena to male infertility.
Vol. 4, No.5, 1953]
URETHROGRAPHY
409
Atrophy of the verumontanum often accompanys prostatic fibrosis, is sometimes seen with tuberculous prostatitis (Fig. 9), in eunichoidism, and in genital infantalism. Papillomata and "Cysts may grow on the colliculus and produce obstruction. H.R. (Fig. 16) had a cyst of the verumontanum which was carefully and successfully destroyed by transurethral resection.
Fig. 16.
H.R., age 30. The filling defect above that of the colliculus was a cystic structure.
CONCLUSIONS 1. Urethrography is indicated in the evaluation of the normal fertility index of the male. Though the procedure may often show a normal genital tract, it will not infrequently reveal unsuspected and pertinent pathology. 2. Urethrography is advisable for the proper interpretation of the basic etiologic factors producing certain changes in seminal qualities. 3. Urethrography is indispensable for studying the effects of specific
410
BRODNY
[Fertility & Sterility
pathologies involving the urethra and the accessory sexual organs of reproduction on fertility. 4. Urethrography is valuable in the investigation of all patients who have fertility problems and who also have concomitant ejaculatory, sexual, neurologic or endocrine symptoms. REFERENCES 1. ABESHOUSE, B. S. Sterility and infertility in the male: A clinical study of 500 consecutive cases. Urol. & Cutan. Rev. 51:433, 1947. 2. BRODNY, M. L. A new instrument for urethrography in the male. ]. Urol. 46: 350, 1941. 3. BRODNY, M. L., and RoBINS, S. A. The use of a new viscous water-miscible contrast medium (Rayopake) for cystourethrography. ]. Urol. 58:182, 1947. 4. BRODNY, M. L., and RoBINS, S. A. Urethrography in bulbo-urethral adenitis. ]. Urol. 43:844, 1940. 5. BRODNY, M. L., and RoBINS, S. A. Prostatic obstruction: a urethrocystographic classification. Rev. urol. Mexico 8:162, 1950. 6. BRODNY, M. L., and RoBINS, S. A. The value of roentgenography of the male urethra following infection. Am.]. Syph., Gonor. & Ven. Dis. 32:272, 1948. 7. BRODNY, M. L., and RoBINS, S. A. Urethrocystography in the male child. ].A.M.A. 137:1511, 1948. 8. CAMPBELL, M. B. Clinical Pediatric Urology ( ed. 2). Philadelphia, Saunders, 1951. 9. CRABTREE, E. G., and BRODNY, M. L. An estimate of the value of urethrogram and cystogram in the diagnosis of prostatic obstruction. ]. Urol. 29:235, 1933. 10. FARRIS, E. J. Number of motile spermatozoa as index of fertility in man: Study of 406 semen specimens. ]. Urol. 61:1099, 1949. 11. FRUHWALD, R. Urethrography in gonorrhea of male and female. Wchnschr. 90: 133, 1930. 12. HERBST, R. H., and MERRICKS, J. W. Transurethral drainage of seminal vesicles in seminal vesiculitis. Illinois M.]. 86:190, 1944. 13. HORNE, H. W., PAULL, D.P., and MuNRO, D. Fertility studies in the human male with traumatic injuries of the spinal cord and cauda equina. New England ]. Med. 239:959, 1948. 14. HoTCHKISS, R. S., BRUNNER, E. K., and GRENLEY, P. Semen analyses of 200 fertile men. Am.]. M. Sc. 196:362, 1938. 15. HuGGINS, C. "The role of the accessory glands in fertility." In Conference on Diagnosis in Sterility. Springfield, Illinois, Thomas, 1946, pp. 67-75. 16. KRETSCHMER, H. L. True prostatic calculi. Surg., Gynec., Obst. 44:163, 1927. 17. LANGER, E. Diagnosis of malformation of the urethra and urinary bladder. Ztschr. Urol. 23:324, 1929. 18. LANGER, E. The demonstration of deformities of the urethra. Dermat. W chnschr. 87:1362, 1928. 19. MAcLEoD, J. The male factor in fertility and infertility. Fertil. & Steril. 1:347, 1950. 20. MATTHEWS, C. S., EMERY, F. E., and ScHWABE, E. L. Regressive changes in reproductive system of male rats induced by stilbestrol. Endocrinology 28:761, 1941.
Vol. 4, No. 5, 1953]
URETHROGRAPHY
411
21. MuNRO, D., HoRNE, H. W., and PAULL, D. P. The effect of injury to the spinal cord and cauda equina on the sexual potency of men. New England /. Med. 239:903, 1948. 22. O'BRANT, 0. Semen analysis in tuberculosis. Brit. J. Urol. 23:46, 1951. 23. PEREIRA, A. Roentgen interpretation of vesiculograms. Am. J. Roentgenol. 69: 361, 1953. 24. ScHERSTEN, B. Skandinav. Arch. & Physiol. 74, Suppl. 9, 1936. 25. THOMAS, B. A., and RoBERT, J. Prostatic calculi. /. Urol. 18:470, 1927. 26. THOMPSON, A. R. Notes on the formation of stones in the prostate gland. Guys Hosp. Rep. 79:446, 1929.
Appointment of New Editor Dr. M. Edward Davis, of Chicago, was appointed Editor of FERTILITY AND STERILITY by the Board of Directors of the American Society for the Study of Sterility at the annual meeting in May, 1953. Dr. Davis, who is Joseph Bolivar De Lee Professor of Obstetrics and Gynecology at the University of Chicago and Chicago Lying-In Hospital, takes over the editorial chair with the present issue. The vacancy was created by the resignation of Dr. Pendleton Tompkins, founding editor, who asked to be relieved because of pressure of other duties. It was under Dr. Tompkins' editorial guidance that FERTILITY AND STERILITY was launched in January, 1950. The success of the journal and its high standing throughout the world are due in no small measure to Dr. Tompkins' devotion and leadership. Dr. Davis has announced the appointment of two new Associate Editors, Dr. Alan F. Guttmacher, Head of the Department of Obstetrics and Gynecology at Mt. Sinai Hospital, New York, and Dr. Somers H. Sturgis, Assistant Clinical Professor of Gynecology at Harvard University. Original articles submitted for consideration by the editors for publication should be addressed as follows: M. Edward Davis, M.D., Chicago Lying-In Hospital, 5841 Maryland Avenue, Chicago 37, Illinois.
M. Leopold Brodny, M.D.
THE
of genital pathology which may interfere with the proper progress of spermatozoa from the cervix to the tubal ostium is an important step in evaluating female infertility. A roentgenographic method, hysterosalpinography, is used to investigate these factors and is recognized as a valuable procedure for determining tubal patency and for the diagnosis of gynecologic conditions which affect or influence the degree of fertility. Pathologic changes which modify the ejaculate and interfere with the free passage of spermatozoa may also occur in the urethra and the accessory organs of reproduction, but it is not so well known that a roentgenographic method, urethrography, is available for a comparative purpose in the male. The male urethra and its appendages serve to furnish an adequate channel for the passage of semen, to provide propulsive power for the proper deposition of the ejaculate, and to secrete media for the protection and nutrition of spermatozoa. Alterations in these mechanisms can lower fertility or produce infertility. It is the purpose of this paper to present urethrography as a simple and safe procedure for the diagnosis of urethral factors which interfere with ejaculation, and for the visualization of adenexal factors which modify the ejaculate. I propose to describe the topographic changes observed on the urethrograms of patients with fertility problems and to correlate these findings with the qualities of their semen. Urethroscopy can be employed for studying the urethral anatomy but it is inadequate in many respects. The lens limits the examination to transitory DETECTION
From the Fertility Clinic of the Beth Israel Hospital, Boston, Massachusetts. Presented at the First World Congress on Fertility and Sterility, May 26, 1953. 386
Vol. 4, No.5, 1953]
URETHROGRAPHY
387
views of many small anatomic areas and the data are recorded by verbal descriptions which vary in perspective and completeness. The urethrogram permits the systematic study of groups of patients with similar lesions and provides a permanent topographic record from which disturbed sexual functions and seminal changes can be interpreted on an anatomic physiologic basis. The added psychologic advantages of this procedure lies in its freedom from pain and discomfort, its ease of performance, and the absence of complications. The technic of urethrography employing a specially designed urethragraphic instrument has been described in an earlier paper. 2 Various opaque media such as Lipiodol, Iodochloral, sodium iodide, Skiodan, acacia, and Rayopaque have been used. We now employ a new substance, Medopaque U, * which is superior to the iodized oils for urethrocystographic use. This medium mixes with water and urine, :flows easily, is well tolerated by the mucous membranes, and produces a homogeneous shadow with sharply defined outlines. The opacity of Medopaque U can be controlled by dilution with water. The medium does not break up into globules when mixed with urine in the bladder. Instruments and catheters are easily cleaned. A report on Medopaque U will shortly be in print. ROENTGENOGRAPHIC ANATOMY OF THE MALE URETHRA
The male urethra begins at the internal sphincter of the bladder, perforates the prostate in a slightly concave curve from the base to the apex, passes through the triangular ligament and continues along the ventral surface of the penis to the tip of the glans (Fig. 1). The urethra is arbitt·arily divided by the triangular ligament into an anterior cavernous portion and a posterior muscular portion. The roentgenologic interpretation of the urethrogram requires a thorough knowledge of the appearance of the normal urethra. In the relaxed state the base of the bladder is slightly convex and lies at the level of the upper border of the pubic bones. There are three normal areas of narrowing in the urethral canal: the vesical neck; the external sphincter; and the urethral meatus. There are also three normal areas of dilatation: the collicular portion of the prostatic urethra; the bulbous part of the anterior urethra; and the fossa navicularis. The prostatic portion of the urethra is, in the midline, about 3 em. in length. It is a fusiform structure beginning at the bladder as a narrow area *Furnished by the Bell-Craig Company, New York.
BRODNY
388
[Fertility & Sterility
produced by the so-called internal sphincter and terminating as a narrow constriction which represents the external sphincter. In the widest portion of the prostatic urethra is an ovoid area of increased radiance produced by the elevation of the verumontanum. The membranous portion of the urethra is wedge-shaped with the apex at the external sphincter and the distal portion terminating at the bulb. In the anteroposterior view there appears at the bulbous portion of the urethra a denser shadow than the rest of the
Fig. 1.
Normal urethrogram; anteroposterior and oblique views.
urethra. This is due to the penile-scrotal curve of the urethra producing overlapping of shadows. The anterior urethra is best visualized in its entirety in the oblique view. Its outline is regular, and the canal narrows as it terminates at the meatus. Urethrography is indicated in the study of all males with infertility problems and especially when the following conditions are present: ( 1) congenital urogenital anomalies; 7 • 17 • 18 ( 2) ejaculatory dysfunctions; ( 3) sexual disturbances; ( 4) endocrine diseases; ( 5) systemic diseases with neurogenic manifestations; 13 ( 6) persistent or recurrent prostatitis or urethritis; 6 (7) abnormal findings on rectal examination of the prostate and vesicles; ( 8) modified seminal qualities. This report has been divided into four sections for the sake of clarity and efficient presentation. The problems discussed in these arbitrary divisions are not distinct entities but often occur concomitantly.
Vol. 4, No. 5, 1953]
URETHROGRAPH¥
389
ANATOMIC FACTORS PRODUCING VARIATIONS OF NORMAL SEMEN U rethrography is valuable as a routine procedure for the evaluation of standards of male fertility. Many of the intensive studies on male fertility reported in the past two decades have been concerned primarily with determining what constitutes a normal semen and which factors in the seminal quality are most important in determining the degree of fertility. Marked discrepancies have been found in similar studies of normal semen conducted by different investigators. It was invariably taken for granted that the genital status of the donors in these groups was normal and this was especially considered so if the donor had a previous child or his wife was pregnant at the time of examination. It must be remembered that the index of fertility should be based not solely on the eventual production of a pregnancy in a fertile woman but on the number of properly inseminated ovulations which failed to take and on the number of pregnancies which did not go to term. Usually the normality of the male was determined by the clinical history, and if a urologic survey was conducted, it consisted of a local external examination of the genitalia, rectal palpation of the prostate and seminal vesicles, and microscopic examination of the expressed secretion and the urinary sediment. Urethroscopy was seldom routinely employed because of the objection of the patient. A wide variety of urologic and sexual disorders are silent and primarily or secondarily affect ejaculation and the ejaculate. Many of these disturbances are difficult to detect by routine history and local examination. As a result much of the theorizing which attempted to account for these variations has been derived from the study of males in whom the status of the urethra and its adenexal glands was inadequately determined. The influence of hidden urethral factors in determining the normal volume of semen is a case in point. Studies of the normal semen volume conducted by Hotchkiss, by Farris, and by MacLeod have not produced comparative results. MacLeod observed in referring to this factor, "There must be basic reasons for the different values reported by various authors." The answer often lies in unrecognized changes in the accessory sexual organs which influence their secretory output and in genital lesions which by distorting, constricting or disrupting the urethral lumen diminish the amount or the force of the ejaculate or cause seminal reflux into the bladder.
390
BRODNY
[Fertility & Sterility
A correlation of the urethral topography as visualized in the urethrogram with the ejaculatory findings in a large group of supposedly normal males would disclose many anatomico-pathologic reasons for some of the significant variables in seminal standards.
EJACULATORY FACTORS AFFECTING FERTILITY There is observed in many couples an inconsistency between the number of spermatozoa present in a semen specimen produced by masturbation and the number that should be found in the postcoital cervical secretion. The absence or small numbers of spermatozoa in the cervical secretion is usually attributed to secretory hostility or to local genital pathology of the female but often it is due to faulty deposition. Improper coital technic is well recognized as a cause of faulty deposition but disturbances in ejaculation as an etiologic factor is frequently overlooked. The following factors producing ejaculatory dysfunctions can be visualized on the urethrogram.
1. Obstructive Factors There is clinical evidence that in certain patients some of the semen is prevented from reaching the external environment by obstructions in the urethral canal. It is not possible to visualize the mechanisms of ejaculation but since the peristaltic action of ejaculation is of such short duration and the ejaculate is so thick and viscous, a urethral narrowing must cause some degree of ejaculatory stasis. If the strictured urethra is energetically milked into a glass jar ~hortly after intercourse, the amount of retained fluid can be noted. This maneuver was done in the case of M.R. who among some minor urinary symptoms also complained of "satisfactory relations but very little discharge." He had a history of a periurethral abscess and chronic prostatic infection many years ago. He obtained only 1.5 cc of ejaculate by coitus interruptus into a glass container and was able to milk 1.8 cc into a second jar a few minutes later. The urethrogram (Fig. 2) visualized the anatomicopathologic factors which mechanically produced retention of the ejaculate and thereby lowered the external seminal volume. There is a wide variety of disorders which constrict, distort, or disrupt the urethral lumen in the male. It is not feasible to present a complete urologic and roentgenographic discussion of all the lesions which produce
Vol. 4, No. 5, 1953]
URETHROGRAPHY
391
these anatomic alterations in a report primarily concerned with fertility. However, the incidence of such conditions in the general male population is not negligible and the incidence in males with poor fertility may be higher than suspected.
Fig. 2. M.R., age 49. Note the constricted area in the bulbous urethra and the small sinus tract about 2 em. long. The verumontanum is elongated and compressed. The trigone is displaced anteriorly by a distended seminal vesicle.
2. Traumatic Factor Absence of an external ejaculate on ejaculation is a phenomena that is sometimes observed as a sequela of prostatic surgery and vesical neck resection. The loss or marked diminution of external semen on ejaculation occurs in practically all prostatectomized patients in whom the vas has been sectioned. Since most of these patients are aged there is no fertility problem. However, median bar, vesical neck contracture, and mid-lobe hypertrophy occur in many adults under fifty years of age, and they are usually treated by transurethral resection. About 20 per cent of these patients have ejacula-
392
BROONY
[Fertility & Sterility
tory dysfunction as a sequela to their surgery. This occurrence may have serious implications as far as fertility is concerned. A typical case was a male who, following a transurethral resection for a median bar, no longer had a seminal discharge with his orgasms. His relative infertility had become absolute. The urethrogram showed a funneled vesical neck due to scar tissue secondary to the transurethral revision. The patient was regurgitating his ejaculate into the bladder through the dilated internal sphincter. The recognition and surgical treatment of obstructions at the bladder neck in male children has increased and the possibility of an ejaculatory dysfunction occurring later in life must be remembered. 3. Endocrine Factors Ejaculatory dysfunctions are observed in many patients suffering from metabolic and hormonal disturbances. If the condition occurred before puberty, the prostate often remains infantile. The mechanism producing the symptoms is sometimes obscure. D.G., age 24, single, wished to know if he was fertile. His libido was poor and he infrequently attempted masturbation. On the few times that he was able to have an orgasm it occurred without an external ejaculate. He developed severe testicular discomfort following an attempt to have intercourse. On physical examination, his genital organs were normal to inspection and palpation. The prostate on rectal palpation felt small, flat, and indefinite. A drop of prostatic secretion was obtained after massage of the gland and it contained a few white blood cells and epithelial cells. His basal metabolic rate and the F.S.H. urinary excretion were normal, but the 17-ketosteroid urinary excretion was subnormal. After many attempts he finally produced by masturbation a semen specimen of 1.5 cc. It contained 56,000,000 spermatozoa per cubic centimeter with 50 per cent motile. He had to milk the specimen out of the urethra. The urethrogram (Fig. 3) revealed a small undeveloped prostate. This was verified by urethroscopy. The finding of a short supracollicular urethra is consistent with that usually observed on the urethrogram of the male before puberty.
It is not possible to discuss here all the endocrine dysfunctions which affect the size and the secretory ability of the accessory reproductive glands. Urethrography has been found of value in their study. 4. Neuromuscular Factors Ejaculation is produced by a muscular contraction under nerve control. Many neuromuscular disturbances produce ejaculatory dysfunctions. This
Vol. 4, No. 5, 1953]
URETHROGRAPHY
393
can be demonstrated experimentally. Ejaculation can be abolished or its force diminished by sympathectomy in the lumbar region. This loss was noted by a young man on whom the operation had been performed for hypertension. He still retained his erectile power but no secretion was produced even though he went through an orgasm. Urethrography showed funneling of the vesical neck. His ejaculate was regurgitating into the bladder.
Fig. 3. D.C. Note the close relationship of the verumontanum to the bladder base. The prostate has failed to develop and the supracollicular urethra has not elongated to the adult length.
Many ejaculatory dysfunctions are due to progressive atonicity. We have no means of measuring the ejaculatory force. There are males whose ejaculation never had any power; others who have noted that gradually their semen no longer shoots out but drips out. Urethrographic studies have disclosed that many of these patients have a large atonic anterior urethra. The normal capacity of the anterior urethra is 7-10 cc. These males have a capacity in their anterior urethra of over 30 cc. and it is all out of proportion
BRODNY
394
[Fertility & Sterility
to the external size of the penis. The etiology of this atonicity is difficult to determine. L.F., age 26, was seen because of sexual difficulties. He had trouble producing an erection and sometimes ejaculated when semi-erect. There never was force to his ejaculate. On rectal examination, he had a firm fibrous-feeling prostate. He had no F.S.H. activity in his urine and a diminished 17-ketosteroid urinary output. His seminal specimen was obtained with much difficulty. It had a low count with a poor motility and the volume was 4.8 cc. It was necessary to use 45 cc. of medium to obtain his urethrogram (Fig. 4).
Fig. 4. L.F. Note the generalized urethral atonicity and the large capacity of the anterior urethra. It can also be observed from the shadows of the soft tissue that the penis was short and small.
Males with atonic vesical necks may have ejaculatory dysfunctions. The atonicity may be congenital and may be unsuspected. The following patient was carefully investigated by a physician who limits his practice to the diagnosis and treatment of fertility problems. The patient had testicular biopsies, hormonal and metabolic studies. The only abnormal and unique finding was in the studies of the semen. The amount fluctuated from 1 to 3 cc. and the count from 3,000,000 per cc. to 50,000,000 per cc. Urethragraphic examination (Fig. 5) disclosed a dilated vesical neck. Seminal
Vol. 4, No. 5, 1953]
URETHROGRAPHY
395
studies were then repeated. The patient obtained the specimen in a glass jar by coitus interruptus and then voided into two glass containers. Both urine specimens were loaded with sperms. The discrepancy in the specimens was due to reflux ejaculation. Among the acquired lesions of the central nervous system that may cause disturbances in ejaculation, the most important are tabes, spina bifida occulta, myelitis, and traumas to the cord. 13 In these conditions, a funneling of the vesical neck is usually found on the urethrogram.
Fig. 5.
E.F. This patient had an atonic vesical neck and refluxed some of his semen into the bladder on ejaculation.
PROSTATIC AND SEMINAL VESICULAR FACTORS AFFECTING FERTILITY The prostate provides propulsive force, fluid dilution, and a host of biochemical substances to the ejaculate and it is necessary to determine the status of the gland if changes in semen quality are to be properly interpreted. The classical technics of studying the gland and its secretions are rectal palpation, microscopic examination, and chemical analysis of the
BRODNY
396
[Fertility & Sterility
expressed prostatic secretion. These procedures contribute valuable data as to the condition of the organ but they fail to reveal many basic anatomicopathologic changes which may influence the character of the glandular secretion. There are two methods available for this examination. They are urethroscopy and urethrography. In the study of the infertile male, I have found the latter most valuable and acceptable as a routine procedure. I use the former method as a complementary one in selected cases. Urethrography yields valuable information as to the gross anatomic status of the prostate gland, the character of its tissues, and the diseases involving it. The following pathologies of the prostate often can be deduced indirectly by urethrographic study. They are ( 1) infection, ( 2) congestion, ( 3) fibrosis, ( 4) hypertrophy, and ( 5) calcification. 1 . Infection
The relationship of infection of the accessory glands to male infertility is still unsettled. Huggins emphatically denied any such relationship, "In our Clinic we have obtained no correlation between the extent of infection in the prostate and infertility and on this evidence we believe that such infection processes do not contribute to infertility." There is clinical evidence that prostatovesicular infections do have a deliterious effect on fertility. Abeshouse stated, "It has been my experience that the relative infertile patient, whose spermatozoa count is between 25 and 50 million or lower, is unable to impregnate his wife until these foci of infection are eradicated." It is very difficult to prove or disapprove the role of prostatic infe6tion as a factor in infertility. The effects of prostatitis on the seminal quality is in all probability produced by the liberation of toxic products or by the modification of the secretions and secretory output. However, it is important if we are to progress in our knowledge of a possible relationship to know if infection is or is not present and if possible the extent of involvement. The following case is typical of the problem produced by longstanding chronic infection. M.P., age 46 (Fig. 6), 25 years ago contracted a urethral infection which was inadequately treated. He was married for 21 years and his wife never became pregnant. Liquification of his semen was slow and it remained more viscous than is usual. His spermatozoa count ranged from 6,000,000 to 13,000,000 active
Vol. 4, No. 5, 1953]
URETHROGRAPHY
397
spenn~tozoa per cc. Their morphology was not remarkable. There were 20-30 white blood cells per high power field in the prostatic secretion. Examination of his wife did not show any significant pathology which should interfere with impregnation. The postcoital tests showed no spermatozoa in the cervical secretion. The urethrogram helped visualize the gross pathologic changes produced
Fig. 6. M.P. Urethrogram of a patient with long-standing neglected urethral infection. The small and numerous filling defects produced in the urethra above the verumontanum are better visualized on the original roentgenograms.
by the infection. Their significance in relation to infertility demands correlative studies of a large group of infertile patients with infections of the accessory reproductive organs. The following inflammatory lesions involving the prostate and the prostatic urethra can be visualized on the urethrogram (Fig. 7). Lymphocytic Urethral Bodies (Pelouze Bodies). Pelouze first noted the
398
BRODNY
[Fertility & Sterility
presence of certain lymphocytic bodies occurring in the posterior urethra and stressed their relationship to chronic infection. These bodies interfere with drainage of the prostatic fluid during massage and prolong the infection. Bulbourethral Adenitis (Cowperitis). This has been adequately discussed in a previous report. 4 Prostatitis. Prostatitis produces distortion of the posterior urethra (Fig.
Fig. 7. Topographical changes which may be produced by infections of the urethra or of the accessory organs of reproduction. These lesions give rise to characteristic alterations of the urethrogram.
6). The changes observed on the urethrogram are narrowing and elongation of the supracollicular portion of the urethra, elevation of the base of the bladder, patency of the prostatic ducts, and enlargement of the verumontanum (verumontanitis). The verumontanum is elongated and widened and appears as a fusiform filling defect proximal to the external sphincter. Prostatic Abscesses and Caverns. Infections in the prostate may progress to abscess formation. The chronic type of abscess is sometimes missed
Vol. 4, No. 5, 1953)
URETHROGRAPH¥
399
clinically. The urethrogram is valuable in ascertaining the presence of these lesions and their size, location, and extent. Abscesses are usually found in the posterior and lateral portions of the prostate and may be single or multiple. Generally these abscesses rupture and drain into the urethra. If the lesions drain adequately, they will heal; but if the opening into the urethra is too narrow, a chronic abscess cavity results (Fig. 8). This lesion
Fig. 8. B.R. Note the three irregularly filled pockets outlined by the opaque medium and extending into the prostatic tissue. The verumontanum is compressed and elongated in appearance. The supracollicular urethra is distended by the medium due to obstruction at the vesical neck produced by fibrosis.
is a common cause of persistent prostatitis and has been named "prostatic caverns." The urethrogram localizes the caverns and shows their position, size, depth, if they are multiple or solitary, diverticular, tortuous, or aborescent. In this respect, this method of investigation is more valuable than endoscopy since the size of the opening of the urethra is no criterion of the extent or ramifications of the cavern. These cavity formations act as foci of infection and re-infection and undoubtedly contribute their toxic secretions to the ejaculate.
400
BRODNY
[Fertility & Sterility
These cavities are sometimes tuberculous in origin and clinically may be relatively silent if they have not produced an epididymitis. The rectal examination seldom reveals significant data. O'Brant, in a semen analysis of 20 patients with proven genital tuberculosis, found a significant diminution in the amount of semen and the percentage of motile sperms. The number of leukocytes and lymphocytes were highly increased in the specimen in advanced tuberculosis.
Fig. 9. C.B. The prostatic caverns may be acid fast or nonspecific in origin. They cannot be differentiated except by bacteriologic investigation. The absence ·of the shadow of the verumontanum is significant.
C.B. (Fig. 9), male, age 56, had a left nephrectomy 20 years ago. Guinea pig tests have remained negative. Mild frequency and nocturia once to twice are the only symptoms now present. No seminal studies were done. His wife had been examined in the past and no gynecologic pathology was noted. No pregnancies have occurred during twenty years of married life.
Vol. 4, No. 5, 1953]
URETHROGRAPHY
401
Seminal vesiculitis frequently exists with prostatitis (Fig. 2) and presents an indefinite clinical picture varying from that of an acutely ill patient to one who is asymptomatic. The relationship of seminal vesiculitis to infertility is completely undermined. It is very difficult to study the pathology of the vesicles by catheterization of the opening of the ejaculatory ducts on the colliculus. Those investigators who have done injections of the vas
Fig. 10. E.B., age 47. Note the displacement of the prostatic urethra and the elevation of the trigone. The verumontanum is also compressed and elongated.
have demonstrated the high incidence of unsuspected pathology in this area. 12 • 23 The urethrogram will often visualize a distended seminal vesicle (Fig. 10). E.B., age 47, was seen primarily for low back pain. He had been previously examined elsewhere for infertility and the significant finding reported was a 9 cc. volume of ejaculate. On rectal examination, both vesicles were palpable and bulging, and the secretion after stripping contained many large vesicular slugs.
402
BRODNY
[Fertility & Sterility
2. Congestion Many sexual practices, such as coitus interruptus over a long period of time (Fig. 11 ) , prolonged ungratified sexual excitement, too frequent masturbation (Fig. 12), and abnormal sexual indulgence, can lead to chronic congestion of the prostate. The condition is also sometimes produced in the celibate by chronic secretory stasis and in the libertine by an abnormal strain on the gland.
Fig. 11. H.E.L., age 42. Patient has practiced coitus interruptus for the past 11 years since the birth of his second child. One year ago he developed premature ejaculation and poor erections. On rectal examination, the prostate was boggy and enlarged. Note that the veru is widened and that the base of the bladder is bilaterally elevated by each prostatic lobe without compression of the prostatic urethra.
Prostatic congestion is not an important cause of sterility but it can indirectly lower the fertility index. Many patients with chronic congestion suffer from erectile difficulties and ejaculatory dysfunctions which result in improper penetration and deposition. Enlargement and congestion of the
Vol. 4, No.5, 1953]
URETHROGRAPHY
403
verumontanum occurs concomitantly with that in the prostate and by compressing the openings of the ejaculatory ducts produces some degree of seminal stasis. The effect that congestion may have on the pH, the chemical composition, and the enzymes of the semen is not well understood. The seminal volume is apt to go to extremes, being often under 2 cc. in some patients and over 5 cc. in many others.
Fig. 12. J.S., age 23. Patient has masturbated once to three times daily for many years. He developed progressive frequency and nocturia. Note the spasticity of the prostatic urethra, the atonicity of the bulbous urethra, and the three concavities at the bladder base and trigone produced by the congested lateral lobes and the distended seminal vesicle.
Congestion of the prostate produces urethrographic changes which are somewhat different than those seen with prostatitis. There is a bilateral semicircular elevation of the base of the bladder produced by edema of the lateral lobes, the verumontanum is enlarged and ovoid in type, and the prostatic ducts are seldom visualized. On rectal examination, an enlarged, tender, and swollen prostate is palpable and a distended vesicle may be felt. The prostatic secretion usually contains more formed elements such as white blood cells and red blood cells and epithelial cells than is usually observed.
404
BRODNY
[Fertility & Sterility
3. Fibrosis The fibrotic prostate is a definite entity and is not infrequently observed during the decades of men's greatest fertility between 20 and 50 years of age. The glandular elements of the prostate may fail to develop at puberty, as is observed in eunichoidal males (Fig. 3), may be replaced by connective tissue in chronic infectious processes of long standing, or may atrophy due to the premature onset of presenile changes. The histologic changes consist of replacement of the secretory acini by muscular or fibrous tissue with the eventual contraction and shrinkage of the entire prostate. On rectal examination, the prostate is very firm, regular in contour, but subnormal in size. On massage of the gland, little if any prostatic secretion is obtainable. The urethrographic findings are shortening and narrowing of the supracollicular portion of the prostatic urethra, flattening of the base of the bladder, and sometimes absence of the filling defect usually produced by the verumontanum. Urethrography should be of value in studying the status of the prostate in males with a high F.S.H., with gynecomastia, or with liver disease. The possibility of a concomitant atrophy of the prostate should be investigated. Matthews et al. 20 have shown that estrogenic substances injected in large doses will produce atrophy of the prostate in rats. The relationships of prostatic fibrosis to chemical and physical changes in the semen quality have not been determined. Undoubtedly the amount of prostatic secretion is diminished according to the extent of destruction of the secretory elements. This factor alone could lower the fertilizing potentialities of the male since one of the recognized functions of the prostatic secretion is to augment the volume of the semen. 4. Hyperplasia Overgrowth of the glandular elements of the prostate is a change that occurs with advancing years. However, varying degrees of prostatic hyperplasia are not infrequently observed during the fourth and fifth decades of life and certainly is present in those males who marry women some years younger than themselves. The relationship of the degree of glandular hyperplasia in a given prostate to the volume and quality of the ejaculate has not been determined. Attempts have been made to correlate changes in seminal quality with the age of the donor but no evidence has been
Vol. 4, No. 5, 1953]
URETHROGRAPHY
405
produced that advancing years per se is a factor. The correlation should, however, be made with the degree of hyperplasia of the prostate. A classification of the types and the urethrographic findings in prostatic hypertrophy has been previously reported. 5 5. Calcification
Prostatic calcifications are usually asymptomatic and are considered of little clinical importance. Their relationship to seminal qualities and infertility has been neglected. They are often an incidental finding, but unless a special effort is made their presence will not be detected by routine examinations. Prostatic calculi are sometimes palpable on rectal examination as hard irregular crepitant areas in the gland, but most often their presence escapes detection. Calcifications can be easily recognized on the plain roentgenogram and appear as mottled or massive areas of calcium deposits limited to the prostatic region. Urethrography will demonstrate associated pathology. Dilated prostatic ducts are often found. There is a marked difference in the reported incidence of prostatic calculi. Thompson reviewed 13,000 autopsies at Guy's Hospital in England and reported only 29 cases. Herbst found prostatic calculi in approximately one-half of a group of prostatic glands removed at routine autopsy. Prostatic calculi are reported as commonly occurring in the fifth and sixth decades of life, but they will be more frequently observed in the third and fourth decades, if roentgenographic studies of the prostatic area are routinely done. Kretchmer reported a series in which 30 per cent were under 40 years of age. Thomas and Robert, in a review of 305 cases, noted that two thirds of the patients were between 40 and 60 years of age and that there were four 10-year-old boys who had prostatic stones. The human prostatic secretion contains a high calcium content and it is this factor that is believed by some to be responsible for the deposition. The prostatic fluid is rich in citric acid and the citrates probably bind the calcium salts as they do in other fluids rich in calcium. A close relationship between the citric acid contents of the prostatic fluid and the level of testosterone has been observed. The presence of prostatic calcification could indicate a local disturbance in the citrate or calcium metabolism. Prostatitis is frequently associated with prostatic calculi and the infection is believed by many to be responsible for initiating the formation. Calcification affects the character of the prostatic secretion by destroying
406
BRODNY
[Fertility & Sterility
secretory tissue or by obstructing the prostatic ducts with calcareous deposits. Herbst and Merricks have noted that groups of prostatic stones are often located near the terminal portions of the ejaculatory ducts, producing extreme ductal distortion by pressure and interfering with drainage. The citric acid content of the prostatic secretion may also be affected. There is some evidence that it influences sperm motility. A study of the citric acid and calcium content of the semen and a correlation of the urethrographic finding with the fertility status is indicated in patients with prostatic calculi. COLLICULAR FACTORS AFFECTING FERTILITY The exact functions of the verumontanum are obscure but clinically it is closely related to many types of sexual dysfunctions. There is also some evi-
Fig. 13. J.F., age 32. Anomalous prostatic urethra. Note the elongation of the supracollicular portion of the urethra and the unusual relationship of the verumontanum to the external sphincter.
dence that its glandular portion produces an alkaline secretion which mixes with that of the prostate. From a fertility standpoint, the verumontanum is important because of its anatomic association with the ejaculatory ducts. Obstruction of the ejaculatory ducts can occur secondary to many diseases
Vol. 4, No. 5, 1953]
URETHROGRAPHY
407
involving the posterior urethra, especially of the verumontanum. Their openings are situated on the colliculus, and anomalies and pathologies of this organ influence the quantity and quality of the ejaculate. Atrophy or scarification of the verumontanum sometimes results in stenosis of the meati of the ejaculatory ducts. The still prevalent practice of indiscriminate fulguration of the verumontanum and the instillation of strong caustics into the posterior urethra often produces distortion of the normal anatomy of this area. The urethrogram visualizes the anatomic pathologic status of the entire prostatic urethra and the colliculus region is usually especially well delineated.
Fig. 14.
A.C. Note the atonicity of the bladder and vesical neck and the tremendous size of the verumontanum.
J.F., male, aged 32, was married for 10 years and his wife never became pregnant. Unfortunately a semen specimen could not be obtained. The roentgenogram (Fig. 13) shows an anomaly of the prostatic urethra and the verumontanum. The relatively high incidence of congenital anomalies in this area in children has been noted by Campbell and undoubtedly they remain unrecognized in the adult because of minimal clinical symptoms. Their importance in male infertility is a subject for investigation.
408
BRODNY
[Fertility & Sterility
Verumontanitis with the accompanying edema produces some obstruction to the orifices of the ejaculatory ducts. With infection the shadow produced by the verumontanum on the urethrogram is enlarged, prominent, and tends to be ovular (Fig. 14). There is no reflux of dye into the normal ejaculatory ducts during retrograde urethrography. Sometimes infection or other pathology results in relaxations of the meati of the ducts and some of
Fig. 15.
K.K., age 32. Note the enlarged filling defect produced by the colliculus and the media which has refluxed into both ejaculatory ducts.
the media passes into the ejaculatory duct or into the seminal vesical and they are visualized on the roentgenogram. This occurred on the urethrogram of patient K.K. (Fig. 15). The study of a larger series of such reflux is necessary to determine the relationship of this phenomena to male infertility.
Vol. 4, No.5, 1953]
URETHROGRAPHY
409
Atrophy of the verumontanum often accompanys prostatic fibrosis, is sometimes seen with tuberculous prostatitis (Fig. 9), in eunichoidism, and in genital infantalism. Papillomata and "Cysts may grow on the colliculus and produce obstruction. H.R. (Fig. 16) had a cyst of the verumontanum which was carefully and successfully destroyed by transurethral resection.
Fig. 16.
H.R., age 30. The filling defect above that of the colliculus was a cystic structure.
CONCLUSIONS 1. Urethrography is indicated in the evaluation of the normal fertility index of the male. Though the procedure may often show a normal genital tract, it will not infrequently reveal unsuspected and pertinent pathology. 2. Urethrography is advisable for the proper interpretation of the basic etiologic factors producing certain changes in seminal qualities. 3. Urethrography is indispensable for studying the effects of specific
410
BRODNY
[Fertility & Sterility
pathologies involving the urethra and the accessory sexual organs of reproduction on fertility. 4. Urethrography is valuable in the investigation of all patients who have fertility problems and who also have concomitant ejaculatory, sexual, neurologic or endocrine symptoms. REFERENCES 1. ABESHOUSE, B. S. Sterility and infertility in the male: A clinical study of 500 consecutive cases. Urol. & Cutan. Rev. 51:433, 1947. 2. BRODNY, M. L. A new instrument for urethrography in the male. ]. Urol. 46: 350, 1941. 3. BRODNY, M. L., and RoBINS, S. A. The use of a new viscous water-miscible contrast medium (Rayopake) for cystourethrography. ]. Urol. 58:182, 1947. 4. BRODNY, M. L., and RoBINS, S. A. Urethrography in bulbo-urethral adenitis. ]. Urol. 43:844, 1940. 5. BRODNY, M. L., and RoBINS, S. A. Prostatic obstruction: a urethrocystographic classification. Rev. urol. Mexico 8:162, 1950. 6. BRODNY, M. L., and RoBINS, S. A. The value of roentgenography of the male urethra following infection. Am.]. Syph., Gonor. & Ven. Dis. 32:272, 1948. 7. BRODNY, M. L., and RoBINS, S. A. Urethrocystography in the male child. ].A.M.A. 137:1511, 1948. 8. CAMPBELL, M. B. Clinical Pediatric Urology ( ed. 2). Philadelphia, Saunders, 1951. 9. CRABTREE, E. G., and BRODNY, M. L. An estimate of the value of urethrogram and cystogram in the diagnosis of prostatic obstruction. ]. Urol. 29:235, 1933. 10. FARRIS, E. J. Number of motile spermatozoa as index of fertility in man: Study of 406 semen specimens. ]. Urol. 61:1099, 1949. 11. FRUHWALD, R. Urethrography in gonorrhea of male and female. Wchnschr. 90: 133, 1930. 12. HERBST, R. H., and MERRICKS, J. W. Transurethral drainage of seminal vesicles in seminal vesiculitis. Illinois M.]. 86:190, 1944. 13. HORNE, H. W., PAULL, D.P., and MuNRO, D. Fertility studies in the human male with traumatic injuries of the spinal cord and cauda equina. New England ]. Med. 239:959, 1948. 14. HoTCHKISS, R. S., BRUNNER, E. K., and GRENLEY, P. Semen analyses of 200 fertile men. Am.]. M. Sc. 196:362, 1938. 15. HuGGINS, C. "The role of the accessory glands in fertility." In Conference on Diagnosis in Sterility. Springfield, Illinois, Thomas, 1946, pp. 67-75. 16. KRETSCHMER, H. L. True prostatic calculi. Surg., Gynec., Obst. 44:163, 1927. 17. LANGER, E. Diagnosis of malformation of the urethra and urinary bladder. Ztschr. Urol. 23:324, 1929. 18. LANGER, E. The demonstration of deformities of the urethra. Dermat. W chnschr. 87:1362, 1928. 19. MAcLEoD, J. The male factor in fertility and infertility. Fertil. & Steril. 1:347, 1950. 20. MATTHEWS, C. S., EMERY, F. E., and ScHWABE, E. L. Regressive changes in reproductive system of male rats induced by stilbestrol. Endocrinology 28:761, 1941.
Vol. 4, No. 5, 1953]
URETHROGRAPHY
411
21. MuNRO, D., HoRNE, H. W., and PAULL, D. P. The effect of injury to the spinal cord and cauda equina on the sexual potency of men. New England /. Med. 239:903, 1948. 22. O'BRANT, 0. Semen analysis in tuberculosis. Brit. J. Urol. 23:46, 1951. 23. PEREIRA, A. Roentgen interpretation of vesiculograms. Am. J. Roentgenol. 69: 361, 1953. 24. ScHERSTEN, B. Skandinav. Arch. & Physiol. 74, Suppl. 9, 1936. 25. THOMAS, B. A., and RoBERT, J. Prostatic calculi. /. Urol. 18:470, 1927. 26. THOMPSON, A. R. Notes on the formation of stones in the prostate gland. Guys Hosp. Rep. 79:446, 1929.
Appointment of New Editor Dr. M. Edward Davis, of Chicago, was appointed Editor of FERTILITY AND STERILITY by the Board of Directors of the American Society for the Study of Sterility at the annual meeting in May, 1953. Dr. Davis, who is Joseph Bolivar De Lee Professor of Obstetrics and Gynecology at the University of Chicago and Chicago Lying-In Hospital, takes over the editorial chair with the present issue. The vacancy was created by the resignation of Dr. Pendleton Tompkins, founding editor, who asked to be relieved because of pressure of other duties. It was under Dr. Tompkins' editorial guidance that FERTILITY AND STERILITY was launched in January, 1950. The success of the journal and its high standing throughout the world are due in no small measure to Dr. Tompkins' devotion and leadership. Dr. Davis has announced the appointment of two new Associate Editors, Dr. Alan F. Guttmacher, Head of the Department of Obstetrics and Gynecology at Mt. Sinai Hospital, New York, and Dr. Somers H. Sturgis, Assistant Clinical Professor of Gynecology at Harvard University. Original articles submitted for consideration by the editors for publication should be addressed as follows: M. Edward Davis, M.D., Chicago Lying-In Hospital, 5841 Maryland Avenue, Chicago 37, Illinois.