Role of Transrectal Ultrasound (TRUS) in Male Infertility Dr. Ho Siew Hong Consultant Urologist S H Ho Urology and Laparoscopy Centre Gleneagles Hospital

What is TRUS ? Ultrasound probe placed within rectum 7 MHz frequency, higher frequency, shorter penetration, better resolution Complete picture of prostate, seminal vesicles and ejaculatory duct in real-time, by moving a few millimeters on transverse or longitudinal plane

Ultrasound probe placed within rectum

7 MHz frequency, higher frequency, shorter penetration, better resolution

Complete picture of prostate, seminal vesicles and ejaculatory duct in real-time, by moving a few millimeters on transverse or longitudinal plane

TRUS

TRUS Sagital Transverse 135 Degrees

Role of TRUS in male infertility Evaluation of abnormalities of ejaculatory duct apparatus Able to determine level of obstruction in ejaculatory duct, aids in planning surgery Ultrasound guided aspiration – cyst, seminal vesicle fluid Almost replaced vasography in evaluation of ejaculatory duct obstruction Vasography still necessary if classical characteristics not present on TRUS

Evaluation of abnormalities of ejaculatory duct apparatus

Able to determine level of obstruction in ejaculatory duct, aids in planning surgery

Ultrasound guided aspiration – cyst, seminal vesicle fluid

Almost replaced vasography in evaluation of ejaculatory duct obstruction

Vasography still necessary if classical characteristics not present on TRUS

Anatomy of ejaculatory duct 3 parts of ejaculatory duct: Long, extra-prostatic Middle, intra-prostatic Distal, joining verumontanum in urethra Ejaculatory duct obstruction may be present in 5% of subfertile men

3 parts of ejaculatory duct:

Long, extra-prostatic

Middle, intra-prostatic

Distal, joining verumontanum in urethra

Ejaculatory duct obstruction may be present in 5% of subfertile men

Indications for TRUS in infertile males L ow ejaculate volume Z ero (azoospermia) or a decreased (oligospermia) number of sperm in the ejaculate S ignific a nt sperm motility abnormalities H istory of prostate infections, prostatitis

L ow ejaculate volume

Z ero (azoospermia) or a decreased (oligospermia) number of sperm in the ejaculate

S ignific a nt sperm motility abnormalities

H istory of prostate infections, prostatitis

Clinical suspicion of diagnosis of ejaculatory duct obstruction Azoospermia Hematospermia Painful ejaculation Perineal pain Urinary tract infections or trauma

Azoospermia

Hematospermia

Painful ejaculation

Perineal pain

Urinary tract infections or trauma

Causes of ejaculatory duct obstruction Seminal vesicle stones Mullerian duct (utricular) cysts Wolffian duct (diverticular) cysts Post-surgical scar tissue Post-inflammatory scar tissue Calcification (stone) near the verumontanum Congenital atresia Functional obstruction (alpha blocker, anti-psychotic, anti-depressants)

Seminal vesicle stones

Mullerian duct (utricular) cysts

Wolffian duct (diverticular) cysts

Post-surgical scar tissue

Post-inflammatory scar tissue

Calcification (stone) near the verumontanum

Congenital atresia

Functional obstruction (alpha blocker, anti-psychotic, anti-depressants)

Diagnosis of ejaculatory duct obstruction Azoospermia E jaculate volume <2.0 ml and a pH<7.2 that contains no sperm or fructose. Normal serum FSH and testosterone. Testicular of normal size (20cc) and consistency.

Azoospermia

E jaculate volume <2.0 ml and a pH<7.2 that contains no sperm or fructose.

Normal serum FSH and testosterone.

Testicular of normal size (20cc) and consistency.

TRUS diagnosis of ejaculatory duct obstruction D ilated seminal vesicles (>1.5 cm width) D ilated ejaculatory ducts (>2.3 mm) C yst, calcification or stones along the duct TRUS and seminal vesicle aspiration showing the presence of sperm in the seminal vesicle fluid within 2 days of ejaculation

D ilated seminal vesicles (>1.5 cm width)

D ilated ejaculatory ducts (>2.3 mm)

C yst, calcification or stones along the duct

TRUS and seminal vesicle aspiration showing the presence of sperm in the seminal vesicle fluid within 2 days of ejaculation

Technique Left lateral position DRE Introduction of rectal ultrasound probe No anaesthesia required Mild sedation for drainage or aspiration

Left lateral position

DRE

Introduction of rectal ultrasound probe

No anaesthesia required

Mild sedation for drainage or aspiration

Transverse plane Prostate evaluation Base to apex Emphasis on base and mid prostate Seminal vesicle Small amount of urine in bladder is helpful

Prostate evaluation

Base to apex

Emphasis on base and mid prostate

Seminal vesicle

Small amount of urine in bladder is helpful

Prostate Bladder

Ejaculatory duct

Prostatic cyst, infartion

Sagittal Plane Bladder neck Urethra Verumontanum Ejaculatory duct Seminal vesicles, one at a time

Bladder neck

Urethra

Verumontanum

Ejaculatory duct

Seminal vesicles, one at a time

Urethra

Ejaculatory duct

D ilated ejaculatory ducts (>2.3 mm)

D ilated seminal vesicles (>1.5 cm width)

Aspiration from seminal vesicles or cysts Negative urine culture Mild sedation - midazolam Prophylactic antibiotics - 6 to 24 hours prior to aspiration e.g. ciprofloxacillin 500 mg - i/v gentamicin 160 mg before aspiration Continue oral antibiotics for another 3-5 days

Negative urine culture

Mild sedation - midazolam

Prophylactic antibiotics - 6 to 24 hours prior to aspiration e.g. ciprofloxacillin 500 mg - i/v gentamicin 160 mg before aspiration

Continue oral antibiotics for another 3-5 days

TRUS aspiration of utricular cyst

TRUS – ejaculatory duct obstruction

Conclusions TRUS is the ideal instrument for evaluation of ejaculatory duct disorders Fast replacing vasography Excellent planning for surgery Option of aspiration from seminal vesicle (diagnostic) or urticle cyst (therapeutic)

TRUS is the ideal instrument for evaluation of ejaculatory duct disorders

Fast replacing vasography

Excellent planning for surgery

Option of aspiration from seminal vesicle (diagnostic) or urticle cyst (therapeutic)

Thank you