BJU International (1999), 84, 1050–1053

Seminal vesicle sperm aspiration in the diagnosis ofejaculatory duct obstructionI . ORHAN, R. ONUR, S. CAYAN*, I.T. KOKSAL† and A. KADIOGLU†Departments of Urology, Firat University Faculty of Medicine, Elazig, *Mersin University Faculty of Medicine, Mersin and †IstanbulUniversity School of Medicine, Istanbul, Turkey

Objective To determine the eCectiveness of seminal patients with EDO by bilateral seminal vesicle aspir-ation and only one (10%) had no sperm within thevesicle aspiration in the diagnosis and treatment of

patients with ejaculatory duct obstruction. aspirate fluid. Of these 10 patients, two had immotilesperm and the remaining seven (14 samples) hadPatients, subjects and methods Between March 1998

and February 1999, 10 infertile men with ejaculatory a mean motile sperm count of 0.63 (0.45,0.1–1.0)×106 /mL, whereas seven of eight menduct obstruction (EDO, mean age 32.7 years, range

25–47) and 10 fertile volunteers (mean age 33.2 assessed in the control group had no motile sperm(one patient had immotile sperm within the aspirateyears, range 25–42) underwent transrectal ultra-

sonography (TRUS) and TRUS-guided seminal vesicle fluid); this diCerence was significant (P<0.01).Conclusions The aspiration of significant numbers ofaspiration. The volume of and presence of motile

sperm in the aspirate was compared with the TRUS motile sperm from the seminal vesicles suggests thepresence of distal obstructions of the ejaculatory ductfindings for both groups.

Results From TRUS of the patients with EDO, the mean and enables infertile couples to be candidates forassisted reproduction. However, there is a need for(sd, range) transverse diameter of the right and left

seminal vesicles were 1.97 (0.54, 0.8–2.6) cm and further research to determine the use of this techniquein the diagnosis of partial EDO.1.93 (0.53, 0.9–2.6) cm; the corresponding values in

the control group were 1.03 (0.15, 0.8–1.3) cm and Keywords Ejaculatory duct, obstruction, seminal vesicle,aspiration1.0 (0.12, 0.8–1.4) cm, respectively (P<0.001). In

all, 20 aspirate samples were obtained from the

sperm are not normally present within seminal vesiclesIntroduction

immediately after ejaculation [8,9]. There is no anatom-ical sphincter at the junction of vesicles and vas deferens,Ejaculatory duct obstruction (EDO) is an uncommon but

surgically correctable cause of male infertility [1–4]; and in cases of EDO there may be sperm reflux; spermcan then be detected within the seminal vesicles [5,7–9].pathology from EDO occurs in <1% of infertile men,

whereas the frequency of incomplete obstructive patho- We report the diagnostic eBcacy of TRUS-guided seminalvesicle aspiration (SVA) in patients with EDO whenlogies is reportedly 4.4% [1,3–5]. In the absence of an

additional pathology, an infertile azoospermic patient compared with normal fertile patients.with low ejaculate volume and with a negative test forfructose in semen should be evaluated for complete

Patients and methodsobstructive pathologies of the ejaculatory duct [1,3,5,6].However, abnormalities resulting in partial EDO may Between March 1998 and February 1999, 10 patients

with complete EDO (mean age 32.7 years, sd 5.80, rangecause a wide range of semen values, from azoospermiato normozoospermia, and thus it is more diBcult to 25–47) underwent TRUS and TRUS-guided SVA; for

comparison, 10 fertile volunteers (mean age 33.2 years,diagnose [1,3,5].Anatomically, the seminal vesicles join the vas defer- sd 4.07, range 25–42) who were referred for vasectomy

during the same period underwent the same procedureens at the posterior aspect of the prostate to form theejaculatory ducts [7]. During normal ejaculation, sperm (controls). All patients and subjects provided informed

consent for the procedure.from the vas deferens pass through the ejaculatory ductsand drain bilaterally into the posterior urethra. Thus The patients were evaluated by a detailed history,

complete physical examination, at least three spermanalyses, hormone profiles (including serum levels ofAccepted for publication 17 August 1999

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SEMINAL VESICLE SPERM ASPIRATION 1051

FSH, LH and testosterone) and TRUS. They also had a of the vas. The mean (sd, range) volume of ejaculate inthis group was 0.88 (0.16, 0.5–1.0) mL. Semen analysistesticular biopsy taken, underwent a semen pellet test

and urine analyses for retrograde ejaculation. As vaso- showed azoospermia in all patients and the serum pellettest was negative. Urine samples obtained after ejacu-graphy is currently the most appropriate diagnostic test

for complete EDO, bilateral vasography was performed lation were assessed for the presence of sperm andretrograde ejaculation was excluded in all infertileon the infertile patients simultaneously with the testicu-

lar biopsy, carried out through a partial-thickness trans- patients. The histopathology of the testicular biopsyrevealed normal spermatogenesis in eight patientsverse vasotomy. Subsequently the vasotomy sites were

repaired using a microsurgical technique. Patients with whereas two were diagnosed with hypospermatogenesis.The simultaneous vasogram showed dilated but intactobstruction at the level of the ejaculatory ducts on

vasography underwent TRUS. vasa deferentia, with dilated ejaculatory ducts. Therewas no leakage of the contrast medium into the prostaticThe criteria for EDO by TRUS were defined as: (i) a

transverse diameter of the seminal vesicle of >1.5 cm; urethra or bladder. The ejaculatory ducts of these selec-ted infertile patients appeared to be obstructed at its(ii) dilatation of the ejaculatory ducts; (iii) calcifications

or calculi within the ejaculatory duct and/or verumon- orifice just within and beneath the prostate gland.The physical examination of the volunteers showedtanum; (iv) cysts (of the ejaculatory duct or Mullerian

canal) located centrally or eccentrically [8–10]. TRUS no abnormalities; the semen analysis gave a meanejaculate volume of 3.05 (0.64, 2.00–4.50) mL. Thewas performed 2 h after ejaculation; all men received

oral antibiotics (ciprofloxacin 500 mg twice daily) and a mean number and motility were 53.3 (13.71)×106/mL and 72.8 (9.3, 57–78)%, respectively. Theplain enema before the procedure. TRUS was performed

with the patient or subject in the lateral decubitus hormonal evaluation of men in the control group showedno abnormalities.position using a Toshiba 140 A (Toshiba Corp, Tokyo,

Japan) Doppler unit with a 6-MHz intracorporeal probe. Of the 10 patients with EDO, TRUS detected dilatationof the seminal vesicles and midline cysts in six, calcifi-The seminal vesicles were evaluated in the sagittal and

axial planes. The vesicles were aspirated using 20 cm cation at the level of ejaculatory ducts in two andeccentrically located cysts in two. TRUS of the control18–20 G Chiba needles (MD Tech Company, FL), with

each vesicle aspirated after being identified by real-time men revealed no abnormality except calcification at thelevel of verumontanum in one.ultrasonography.

The volume of and the presence of motile sperm in The mean transverse diameters of the seminal vesiclesin the two groups are shown in Table 1; the diCerencethe aspirate samples of both groups were compared. All

patients and subjects were examined for the presence of in diameters between the groups was significant(P<0.001). In all, 18 men underwent bilateral SVAany additional urinary tract abnormality and infertility

pathology, e.g. varicocele, agenesis of the vas, etc. The (two men in the control group did not tolerate theprocedure); 20 aspirate samples were obtained from theresults were assessed using Student’s t-test, with P<0.05

considered to indicate significant diCerences. patients and only one had no sperm within it. Of the10 patients, two had immotile sperm and the remainingseven (14 samples) had motile sperm (Table 1). In the

Resultscontrol group, TRUS-guided SVA showed no motile spermin the eight men sampled, although one men hadThe physical examination of the patients revealed bilat-

eral distension of the epididymis in three and dilated immotile sperm within the aspirated fluid (Table 1). Theincidence of motile sperm within the aspirated fluid wasseminal vesicles in two (on DRE). There was no other

pathology causing infertility, e.g. varicocele or agenesis significantly higher in the patients with EDO (P<0.01).

Table 1 Diameters of the seminal vesicles, the aspirate volume and motile sperm counts in the infertile and control groups

Mean (sd)

Seminal vesicle diameter (cm) Aspirate volume (mL)Motile sperm

Group Right Left Right Left count (106/mL)

Infertile 1.97 (0.54) 1.93 (0.53) 0.85 (0.26) 0.90 (0.23) 0.63 (0.45)Control 1.03 (0.15)‡ 1.01 (0.11)‡ 0.44 (0.25)† 0.45 (0.26)† 0.07*‡

*Only one patient in the control group had immotile sperm. †P<0.01; ‡P<0.001.

© 1999 BJU International 84, 1050–1053

1052 I . ORHAN et al.

There were no significant complications associated series of 150 patients evaluated by TRUS, reported noabnormality in 53%, hyperechoic lesions at the level ofwith SVA but of the 20 men slight fever was detected in

four and they were treated with oral antibiotics. Three the ejaculatory duct in 39%, midline cysts with no spermin 11%, cysts containing sperm in 3% and prostaticmen developed haemospermia after the procedure which

resolved spontaneously. The only painful complication retention cysts in 4%. Similiarly, Jarow [8,9] foundsignificant diCerences between fertile and infertile mennoted after the procedure was a pelvic haematoma in

one man, who received oral analgesics and antibiotics in the diameters of the seminal vesicles, and stated thatseminal vesicle transverse diameters of >15 mm indi-and recovered with no complications.cated EDO.

TRUS is a reliable diagnostic tool in men with completeDiscussion

EDO, especially when combined with seminal analysis.However, both TRUS and vasography are not definitiveObstruction of the epididymis and vas deferens, and the

treatment of these obstructive abnormalities, are well in cases of partial EDO when the semen values may varyfrom azoospermia to normospermia [5,8,9,13]. Thus,defined in male infertility [1–3]. However, more distal

obstructions, either complete or partial, have recently there is no ‘gold standard’ technique in the diagnosis ofobstructive ejaculatory duct anomalies [5,8–10].been recognized and treated [1,4,5]. In a review of

168 azoospermic patients, Hendry et al. [11] reported Anatomically, there is no sphincter between the semi-nal vesicles and ejaculatory ducts, and normal fertiletesticulo-epididymal obstruction in 49%, agenesis of the

vas in 15%, acquired obstruction of the vas in 13% and men do not have significant numbers of motile sperm inthe seminal vesicles immediately after ejaculation [8,9].EDO in 1%. The incidence of partial EDO was reported

as 4.4%, whereas complete obstruction was detected in However, in the presence of an anatomical or functionalobstruction, sperm reflux may occur and sperm can be<1% of infertile men [5,11,12].

With the advent of new imaging modalities, patho- detected within the seminal vesicles [8,9]. Jarow per-formed TRUS-guided SVA in 12 fertile volunteers bothlogies of the distal ejaculatory ducts have been diagnosed

more frequently. As the pathologies producing EDO are 2 h and 5 days after ejaculation to determine the eCectsof abstinence on the volume and number of sperm withinpotentially correctable causes of male infertility, there is

a continuing demand to develop less invasive diagnostic the aspirated samples; abstinence had no eCect on thevolume, whereas the ejaculates obtained at 2 h and 5and therapeutic approaches to manage them [5,8,9,13].

Patients with obstructive pathologies of the ejaculatory days had significantly diCerent motile sperm counts [9].Similarly, Jarow [8,9] reported that the presence of moreduct may have no specific symptoms [5,6]. Although

semen variables, including sperm volume, density and than three motile sperm per high-power field in theseminal vesicle aspirate obtained immediately after ejacu-motility, have usually been found to be decreased in

most such cases, normal semen values with a normal lation indicated obstruction. In the present study, sevenof the 10 patients with EDO had motile sperm in thehormonal profile may also be present [5,6,10]. Bilateral

dilatation of the seminal vesicles and/or dilated ejaculat- aspirated fluid whereas none of the eight control menhad; thus, aspiration of sperm from the seminal vesiclesory ducts, midline or eccentrically located cysts and

ejaculatory duct calcifications are the common findings suggests the presence of more distal obstruction. SVA isan invasive method of evaluating male infertility andof complete EDO on TRUS and vasography [5,6,8–10].

In contrast, partial EDO may have variable clinical should be used only in properly selected patients underaseptic conditions. Pelvic haematoma and haemospermiapresentations and vasography may not reveal the

diagnosis, as the contrast medium used in this method are the commonest complications after the procedure[8,9].would pass into the bladder on partial obstruction,

similar to the flow seen in patients with no obstruction Colpi et al. [13] proposed seminal tract washout (STW)as a reference functional test for diagnosing distal semi-[8–10,13].

Because it is not invasive, TRUS has become popular nal tract sub-obstruction. However, procedures like STWand vasography in patients with partial EDO would showin the initial diagnosis of EDO in male infertility

[1,5,6,8,9,13]; thus, all patients suspected of having spontaneous flow of the injected fluid into the bladderand thus there remain no objective criteria to defineEDO should undergo vasography and TRUS. In many

clinical studies, TRUS was reported to be the first choice partial EDO by either of test.In conclusion, SVA is an accurate diagnostic test inin the assessment of obstruction [5,8–10]. Littrup et al.

[14] evaluated 52 patients with EDO and reported that cases of EDO and may be used to detect EDO pathologyin infertile men. Moreover, sperm harvested by TRUS-22% had seminal vesicle or ejaculatory duct calculi,

whereas 6% had ejaculatory duct cysts and 8% had guided SVA may be used in assisted reproductiontechniques.cystic dilatation of the seminal vesicles. Jarow [15], in a

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SEMINAL VESICLE SPERM ASPIRATION 1053

before and after transurethral surgery for ejaculatory ductReferencesobstruction. J Urol 1996; 155: 1291–41 Meacham RB, Hellerstein DK, Lipshultz LI. Evaluation and

11 Hendry WF, Levison D, Parkinson CM, Parslow JM, Royletreatment of ejaculatory duct obstruction in the infertileMR. Testicular obstruction. Clinico-pathological studies.male. Fertil Steril 1993; 59: 393–7Ann R Coll Surg Engl 1990; 72: 396–4012 Carter SS, Shinohara K, Lipshultz LI. Transrectal ultra-

12 Belker AM, Steinbock GS. Transrectal prostate ultrasono-sonography in disorders of the seminal vesicles andgraphy as a diagnostic and therapeutic aid for ejaculatoryejaculatory ducts. Urol Clin N Am 1989; 16: 773–90duct obstruction. J Urol 1990; 144: 356–93 Hellerstein DK, Meacham RB, Lipshultz LI. Transrectal

13 Colpi GM, Negri L, Nappi RE, Chinea B. Is transrectalultrasound and partial ejaculatory duct obstruction in maleultrasonography a reliable diagnostic approach in ejaculat-infertility. Urology 1992; 39: 449–52ory duct sub-obstruction? Human Reprod 1997; 12:4 Weintraub MP, De Mouy E, Hellstrom WJ. Newer modalities2186–91in the diagnosis and treatment of ejaculatory duct obstruc-

14 Littrup PJ, Lee F, McLeary RD. Transrectal US of seminaltion. J Urol 1993; 150: 1150–4vesicles and ejaculatory ducts: Clinical correlation.5 Schlegel PN. Management of ejaculatory duct obstruction.Radiology 1998; 168: 625–8In: Lipshultz LI, Howards SS.eds. Infertility in the Male 3rd

15 Jarow JP. Transrectal ultrasonography of infertile men.edn. St. Louis, Mosby-Year Book., 1997: 385–94Fertil Steril 1993; 60: 1035–96 GoluboC ET, Stifelman MD, Fisch H. Ejaculatory duct

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Authors7 Nguyen HT, Etzell J, Turek PJ. Normal human ejaculatoryI. Orhan, MD, Assistant Professor of Urology.duct anatomy. J Urol 1996; 155: 1639–42R. Onur, MD, Chief Resident in Urology.8 Jarow JP. Seminal vesicle aspiration in the management ofS. Cayan, MD, Assistant Professor of Urology.patients with ejaculatory duct obstruction. J Urol 1994;I.T. Koksal, MD, Urologist.152: 899–901A. Kadioglu, MD, Associate Professor of Urology.9 Jarow JP. Seminal vesicle aspiration of fertile men. J UrolCorrespondence: Dr I. Orhan, F.U. Firat Tip Merkezi Uroloji1996; 156: 1005–7

10 Turek PJ, Magana JO, Lipshultz LI. Semen parameters Anabilim dali, 23200/Elazig, Turkey.

© 1999 BJU International 84, 1050–1053