MALE INFERTILITY IS ONE OF THE MOST OVERLOOKED AND IGNORED TOPIC.I TRY TO ASSIMILATE ALL PROBABLE IMAGING FEATURE TO CORRECTLY DIAGNOSE IT SO THAT UROSERGEONS CAN PROCEED EASILY.
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Role of imaging of diagnosis and management of male infertility
1. ROLE OF IMAGING OF DIAGNOSIS AND
MANAGEMENT OF MALE INFERTILITY
BY DR. PRASUN DAS
2ND YEAR PGT ,NRSMCH
2. INTRODUCTION
• Infertility- Inability to conceive after frequent engagement in unprotected sexual
intercourse for 1 yr.
• 15-20% couples within reproductive period
• Out of them, 30% cases are purely of significant male infertility factor, 20% cases
having both male and female components
• Aim:
Identify treatable, reversible, and/or health-threatening conditions
select patients who are suitable for assisted reproduction techniques
determine appropriate genetic counseling and prevention measures such as preimplantation and
prenatal diagnosis to safeguard the health of future offspring
to identify etiologic conditions that may be reversed with resultant improvement in the male’s fertility
status
3.
4.
5.
6.
7. EVALUATION OF MALE INFERTILITY
The American Urological Association and the American Society for Reproductive Medicine have jointly
produced guidelines covering several aspects of the evaluation and management of male infertility.
• HISTORY TAKING : 1ST EVALUATE REPRODUCTIVE HISTORY
Past fertility
past investigations and treatments for infertility
presence of associated systemic diseases and/or treatments for the same
current and past medication history
past and recent history of surgeries with particular emphasis to surgeries performed in the inguinal/pelvic/testicular region
chemotherapies and/or radiotherapy
the occupational exposure to potential toxins/chemicals
personal lifestyle factors like smoking and alcohol consumption and/or drug abuse
family history of infertility and other congenital defects
sexual history
Childhood and developmental history
ages of the patient and his partner, any gynecologic cofactors involving the female partner
• PHYSICAL EXAMINATION:
BMI
BP
ASSESSING DEGREE OF ANDROGENIZATION
ASSESSING RESPIRATORY AND CARDIOVASCULAR SYSTEM
ASSESSMENT OF ABDOMEN AND PELVIC REGION WITH SPECIAL EMPHASHIS ON INGUINAL AND GENITAL REGION
DIGITAL RECTAL EXAMINATION
UROLOGICAL REFERRAL IS MUST AFTER CLINICAL
SUSPICION FOLLOWED BY SEMEN
ANALYSIS,ENDOCRINOLOGICAL WORKUP
9. 36%
24%
11%
10%
8%
6%
5%
varicocele idiopathic
semen disorder testicular failure
obstruction other
cryptorchidism
Parameter Normal
Volume >2 mL
pH 7.2–7.8
Sperm
concentration
>20 million/mL
Total sperm count >40 million
Motility >50% with normal
motility
Morphology >30% normal
forms
Semen analysis
10. INDICATIONS OF IMAGING IN MALE INFERTLITY
ABSOLUTE INDICATIONS
• Low volume azoospermia
without testicular atrophy
• Low volume severe
oligospermia(concentration 5
million/ml)
• Abnormal digital rectal
examination
RELATIVE INDICATIONS
• Painful ejaculation
• Hematospermia
• Unexplained retrograde ejaculation
• Anejaculation
• Unilaterally non functioning/absent kidney
• H/O severe hypospadius
11. ROLE OF DIFFERENT MODALITIES OF IMAGING
The main role of imaging
identification of the causes of infertility, such as congenital anomalies and
disorders that obstruct sperm transportand may be correctable.
to guide methods for impregnating the female partner, such as sperm aspiration from the epididymis or
seminiferous tubules followed by in vitro fertilization or intracytoplasmic
sperm injection .
ULTRASONOGRAPHY :
Scrotal USG : The first-line imaging test
a high-frequency duplex echo transducer (7.5 MHz and higher).
to evaluate testicular size, anatomical variants, and abnormalities of
the testes, epididymii, and proximal genital tract. Colour flow is used
to assess the spermatic vein
Images of both testes transverse and sagittal planes with comparing to the
contralateral
Color and pulsed Doppler parameters
the Lambert's formula for testicular volume
volume (mL) = length × width × anteroposterior depth (cm) × 0.71
12. USG ANATOMY:
1. Pre pubertal testis– low to medium echogenic
2. Post pubertal– homogenous and medium echogenic
3. Mediastinum testis –an echogenic band in c-c direction
4. Hypoechoic thin rim of fluid
5. Epididymal head slightly hyperechoic than testis,but body less echogenic
DOPPLER FINDING
• Intratesticular artery low impedance waveform with large amount of end diastolic low.
• Extratesticular scrotal arterial supply (cremasteric and deferential arteries) has high impedance waveform
with reversed low in diastole.
PENILE USG WITH DOPPLER:
the penis scanned from its ventral surface using longitudinal and transverse views
Evaluation should be carried out while the penis is flaccid and after intracavernosal injection of
vasoactive drugs (PGE1/PAPAVERINE/PHENTOLAMINE)
informed consent prior to intracavernosal injection of
prostaglandin regarding the small risk of priapism
evaluating physical causes of erectile dysfunction
Greyscale ultrasound to exclude structural abnormalities
To check peak systolic velocity and end diastolic velocity
13. • GREYSCALE USG FINDING : In the flaccid state, the corporal bodies as cylindrical structures
with intermediate echogenicity and homogeneous echotexture. The corpus spongiosum and the glans are more echogenic
than the corpora cavernosa. When collapsed, the urethra appears as a transverse line. The echogenicity of the corpora
cavernosa progressively decreases during tumescence starting from the region surrounding the cavernosal arteries because
of sinusoids dilatation.
During maximal penile rigidity, a fine echogenic
network is appreciable in the corpora cavernosa due to sinusoidal interfaces. Sinusoidal spaces at the base of
the penis are normally larger that in t he remaining portions of the shaft. Blood entrapped within the
sinusoids often appears slightly corpusculated
COLOUR DOPPLER FINDINGS : Normal flow pattern and anatomical variations in cavernosal artery,penile
artery and vein,Dorsal,bulbar & urethral artery,helicine artery, Arterial and caverno-spongiosal communication
& visualisation of penile tip
Ultrasonography of the
penis (transverse section
from dorsal): corpora
cavernosa (1+2), corpus
spongiosum (3), penile skin
(4) and dorsal penile vessels
(5)
Penile Doppler
ultrasonography (longitudinal
section) 15 min after
intracavernous injection of
alprostadil: tunica albuginea (1),
corpus cavernosum with
cavernous artery (2), corpus
spongiosum (3)
14. TRANS-RECTAL USG : evaluation of patients with azoospermia to exclude
obstruction and to determine the absence or hypoplasia of the seminal
vesicles and ejaculatory ducts.
A 6.5–7.5 MHz probe is used, with the bladder partially filled (to provide an acoustic window) and with the
patient lying in a lateral decubitus position.
The normal prostate gland symmetric, triangular, and ellipsoid structure
surrounded by a thin echogenic capsule
The seminal vesicles are paired elongated
structures, which lie cephalad to the prostate and posterior to the
urinary bladder, with a bow-tie configuration. These structures are
hypoechoic, with a few fine internal echoes and a network of tubules
with septations
The vasa deferentia are seen axially as a pair of oval, convoluted, tubular structures
located medial to the seminal vesicles and just cephalad to the prostate and with an echotexture similar
to the seminal vesicles. The ejaculatory duct is formed by the confluence of the seminal vesicle and the
terminal portion of the vas deferens. It appears as a small, hypoechoic (paired) structure, with a calibre of 2 mm
and crosses the prostate gland obliquely to terminate in the prostatic urethra, lateral and proximal to the
verumontanum. The entire course, from the seminal vesicle to the urethra, can be visualized only on the sagittal
image.
15. MRI
• the modality of choice for imaging the accessory sex glands and their ducts and can help guide diagnostic or
corrective interventional procedures.
• useful for both detection and characterisation of prostatic cysts detected on a
TRUS and evaluation of the vas deferens, seminal vesicles and ejaculatory
ducts
• also used to evaluate the brain and sella turcica in cases in which an abnormality of these areas is suspected on the basis
of hormonal assays.
• PROTOCOL : Three-dimensional T2-weighted fast spin-echo MR imaging
• T2-weighted MR imaging with fat saturation is the best sequence
for assessing inflammation. Dynamic contrast-enhanced MR imaging yields
additional information regarding tissue perfusion that is particularly helpful for
diagnosing malignant conditions.
16. MRI ANATOMY
• The normal testis -homogeneous signal on T1 and
T2,intermediate in T1 signal and hyperintense in T2 signal
relative to skeletal muscle. The epididymis -heterogeneous but isointense to the
testis on T1 images and hypointense to the testis on T2 images.
Postcontrast T1 -homogeneous enhancement of the testis,
with relative hyperintensity of the epididymis.
The scrotal wall - hypointense on T1 and T2
• SEMINAL VESICLE :T2-weighted sequences homogeneously
hyperintense, The T1 signal isointense to slightly hyperintense relative to skeletal muscle
• PENIS the corpora demonstrate intermediate signal on T1-weighted images and high signal on T2-weighted
images
Both the corpora cavernosa and the corpus
spongiosum enhance with gadolinium administration.
• Prostate: Peripheral zone- T2 hyper intense, Central zone less hyperintense
AFMS- LOW IN T2
17. CT :is most useful for evaluating calcifications and stones
along the reproductive tract that are causing obstruction.
evaluation of metastases from prostate carcinoma, Seminal vesicle pathology more
often encountered on CT imaging performed for nonspecific pelvic pain or for another
unrelated indication.
reserved for staging of testicular cancer and screening for retroperitoneal adenopathy
Additional imaging to rule out any pathology in upper urinary tract and brain
Invasive imaging techniques :
Testicular Venography is regarded as the
gold standard for diagnosis of a varicocoele by demonstrating
reflux of contrast into the testicular vein.It is an invasive
technique it is reserved for when embolisation of the testicular vein is to be undertaken following clinical and
ultrasound diagnosis.
Vasography: This is an invasive procedure requiring either blind
or ultrasound-guided puncture of the vas deferens and retrograde contrast
injection with filling of the ducts and spill into the bladder confirming
patency.
18. Imaging evaluation of pre-testicular causes
1. Primary Hypogonadism (Hypergonadotropic Hypogonadism) : Klinefelter
syndrome(KS), a sex chromosome disorder that results from the presence of a supranumerary X
chromosome (karyotype 47,XXY), is the most common cause of primary
hypogonadism in males
patients present with firm testes, increased height, female hair distribution, and obesity;
have diabetes mellitus; and have an increased incidence of leukemia,
nonseminomatous extragonadal germ cell tumors,infertility,
and gynecomastia
ON USG : Small testes, with a coarse or nodular
echotexture, hypervascularization, and microlithiasis are
associated with KS. The KS nodules ARE MOSTLY
benign Leydig cell tumors/hyperplasias.
Radiography is performed to assess for bone density, radioulnar synostosis,
and dental concerns (taurodontism).
Echocardiography is performed to assess for mitral valve prolapse.
19. 2. Secondary Hypogonadism (Hypogonadotropic Hypogonadism)
Kallman syndrome : deficiency of gonadotropin-releasing hormone secreted from the
hypothalamus
ON MRI : The olfactory nerves, bulbs, and sulci are absent
(arhinencephaly).Importantly the hypothalamus and pituitary are normal
in appearance.
TRANSTHORACIC ECHO TO BE DONE TO CHECK ASD,EBSTEIN ANOMALY, DEXA SCAN TO SEE BONE DENSITY,USG KUB TO LOOK FOR
AGENESIS
Prader-Willi syndrome : secondary hypogonadism and is characterized by cryptorchidism, obesity, mental retardation, and infantile
hypotonia.( SEVERE SCOLIOSIS NOTED IN ABD. RADIOGRAPH)
MRI of the head (to evaluate for hypopituitarism
Chest radiography (if cor pulmonale is suspected)
extremity film for limp evaluation, hip films to screen for hip dysplasia
3. Pituitary tumours : Prolactinoma is the most common cause of infertility
due to hyperprolactinemia. Prolactin-producing tumors in males tend
to be macroadenomas.
On MRI: T1 : isointense
T1 C+ (Gd) : moderate to bright enhancement T2: typically isointense to grey matter
GRE/SWI: DETECT any hemorrhagic components, which appear as areas of signal loss
CT : Solid adenomas without hemorrhage, typically have attenuation similar to the brain (30-40 HU) and demonstrate moderate
contrast enhancement
T1-weighted contrast-enhanced MR images show adenoma on the right side of the
pituitary gland that has a central area of fluid or necrosis.
20. IMAGING EVALUATION OF TESTICULAR CAUSES
• 1. VARICOCELE : the most common correctable cause of
male infertility
abnormal dilatation of the pampiniform
plexus lead to symptoms that include scrotal pain and discomfort and failed
testicular growth and development. clinical diagnosis with the patient in the
standing position and performing the Valsalva maneuver.
Upper image: Longitudinal sonogram
through the pampiniform plexus of the
left testis. The image shows several
anechoic tubes. Lower image: The
application of color Doppler imaging in
the same patient shows bidirectional
flow within the anechoic tubes.
• Right sided varicocele
prompts for an
abdominal USG/CT to
rule out any
retroperitoneal mass
• Intra testicular variant a rare one showing
dilated intratesticular veins seen in relation to
the mediastinum testis and extending
peripherally
21. Methods Diagnostic criteria
Sonography Tortuous, tubular, anechoic structures adjacent to
the testis corresponding to dilated veins of the
pampiniform plexus with calibers of 2–3 mm
during the Valsalva maneuver
Color Doppler
sonography
Reflux into the spermatic vein that increases
during the Valsalva maneuver.
Phelobography Increase in the caliber of the internal spermatic
vein with reflux into the abdominal, inguinal,
scrotal, or pelvic portions of the spermatic vein,
and the presence of collateral circulation
Magnetic
Resonance
Imaging
Dilatation of the vessels of the pampiniform
plexus with signal intensity that varies depending
on the flow rate and enhancement after injection
of contrast medium
Scintigraphy Intrascrotal accumulation of technetium-99-
labeled red cells with reflux observed during
dynamic maneuvers
Grade Features
1 Reflux in vessels in the inguinal channel is detected only during the
Valsalva maneuver, while scrotal varicosity is not evident in the standard
US study
2 Small posterior varicosities that extend to the superior pole of the
testis. Their diameters increase and venous reflux is seen in the
supratesticular region only during the Valsalva maneuver.
3 Vessels appear enlarged at the inferior pole of the testis when the
patient is evaluated in a standing position; no enlargement is detected if
the patient is examined in a supine position. Reflux observed only under
during the Valsalva maneuver.
4 Vessels appear enlarged even when the patient is studied in a supine
position; the dilatation is more marked in the upright position and
during the Valsalva maneuver. Testicular hypotrophy is common at this
stage.
5 Venous ectasia is evident even in the prone decubitus and supine
positions. Reflux is observed at rest and does not increase during the
Valsalva maneuver.
Sarteschi
classification
22. • 2. TESTICULAR ATROPHY : volume of the affected testis
reduced to 50% of the volume of the unaffected testis
ON USG, global reduction in the volume of the
testis ,decrease in both testicular reflectivity and
vascularity, The epididymis usually appears
normal
3.TORSION: Twisting of spermatic cord --- venous drainage impaired —progressive loss of
arterial supply
• twisting of the spermatic cord: whirlpool sign( twisting or whirling may also be appreciated on
Doppler)
• altered blood flow : incomplete torsion: elevated resistive index (RI >0.75) & to and fro
flow
• complete torsion : an absence of blood flow in both the testis and epididymis
• increase in the size of the testis and epididymis
• homogeneous echotexture: early finding, before necrosis
• heterogeneous echotexture: a late finding (after 24 hours), implies necrosis
• reactive hydrocele
• reactive thickening of the scrotal skin with hyperemia and
increased flow on color Doppler examination
• peripheral testicular neovascularization
USG
FINDINGS
23. MRI: PREFERRED SEQUENCE : FAST FIELD ECHO AND DYNAMIC
CONTRAST ENHANCED
1.decreased or lack of perfusion on dynamic contrast-enhanced
MRI.
2.low or very low signal intensities with spotty or streaky
patterns on fat-suppressed T2-weighted, heavily T2-weighted, or T2*-
weighted images
NUCLEAR IMAGING: 1. NUBBIN SIGN
2. BULL’S EYE SIGN Axial T1-weighted MRI image
following administration of IV
gadolinium showing decreased
enhancement of the left testis
(arrow) compared to the right
(arrowhead)
24. • 4.EPIDIDYMO-ORCHITIS : Inflammatory conditions of the testes and epididymis affect
spermatogenesis and alter both the number and the quality of sperm because sperm storage, motility, and
development, and the maturation of the sperm membrane
• ON USG : The epididymal tail most affected, and
reactive hydrocele and scrotal wall thickening
• Increased size and, depending on the time of evolution, decreased, increased, or heterogeneous
echogenicity
• epididymal peak systolic velocity (PSV) greater than 15 cm/sec is highly
suggestive of epididymitis, especially when the PSV on the affected side is
significantly higher than the unaffected (with a ratio > 1.7) . a resistive index
(RI) < 0.5 is frequently present
5. TESTICULAR MICRO-LITHIASIS : Calcium deposits develop within the
seminiferous tubules or arise from the basement component of tubules.
The rate of concomitant testicular malignancy is higher in
individuals with microlithiasis than in those without microlithiasis.
USG : five or more echogenic foci without posterior acoustic
shadowing that are smaller than 3 mm per field of view
25. • 6. Cryptorchidism : most frequent congenital
abnormality of the male genitalia.
• The infertility in these individuals is due to the abnormal location of the testis outside of the scrotum,
which results in impaired spermatogenesis. Most common location is in the inguinal canal. The
undescended testis has smaller seminiferous tubules, decreased spermatogenesis function, and a
thickened basement membrane by the time the boy reaches 1½ years of age. Increased
incidence of germ cell tumour of testis.
• Ultrasound
lack of a testis in the scrotal sac(instead pars infravaginalis
gubernaculi noted)
the undescended testis is a homogeneously hypoechoic
ovoid structure, SMALLER AND LESS ECHOGENIC THAN the
contralateral testis, with an echogenic mediastinum testis
• MRI
• Coronal T1W(AND ALSO T2[IMAGE]) images can show the
gubernaculum testes and spermatic cord, which can be followed to
locate the undescended testes. Also, an ectopic pelvic or
retroperitoneal location of testes can be identified. Diffusion-weighted
MRI shows the normal testes as markedly hyperintense structures,
differentiating them from surrounding structures .
26. • 7. TESTICULAR CANCER: the most common cancer in
males aged 15–35 years and is one of the most curable cancers worldwide,
with a cure success rate of 95%.reduced semen quality and fertility, as the
function of both the affected testis and the unaffected testis is impaired at the
time of diagnosis. disruption in the hypothalamic-pituitary-gonadal axis,
immunologic or cytologic injury to the germinal epithelium, systemic
cancer–related processes (eg, fever and malnutrition), and psychological
conditions such as anxiety and depression. Spermatogenesis is highly sensitive
to the cytotoxic effects of radiation therapy and chemotherapy
owing to the associated rapid cell division. Retroperitoneal lymph node dissection
can affect ejaculation by causing sympathetic nerve plexus damage and resultant
retrograde ejaculation or anejaculation . An increased incidence of
cancer in the contralateral testis also has been reported
•1st decade: yolk sac tumor and testicular
teratoma
•2nd decade: choriocarcinoma
•3rd decade: embryonal cell carcinoma
•4th decade: seminoma
•≥7th decade: lymphoma (usually non-Hodgkin
lymphoma) and spermatocytic seminoma
the US features of testicular
malignancy are variable,
most of these tumors are
heterogeneous and
hypoechogenic compared
with the surrounding
testicular parenchyma.
Increased vascularity within
the lesion also may be present
Seminoma-well defined,homogenously
hypoechoic
Embryonal type-intra-cystic component
Teratoma-heterogenous with calcification
Chorio-Hemorrhagic,focal necrosis
Sertoli-large variant has dense calcification
Lymphoma-Ill defined,diffuse,invoving
spermatic cord
27. Diagnosis Primary modality: testicular
ultrasound
Problem solving: testicular MRI
Staging Nodal or visceral metastases: CT chest,
abdomen, pelvis
Brain metastases in high-risk or
symptomatic patients: CT brain
Brain or bone metastases: MRI
Post-treatment evaluation Pulmonary recurrence: chest
radiograph
Abdominal recurrence in first 3 years:
CT or MRI
Assessment for tumor in residual mass,
or for evaluating patients with normal
CT/MRI but elevated serum tumor
markers: FDG-PET
A 20-year-old patient presented with a
palpable testicular mass. Grayscale (a)
and color Doppler ultrasound (b) images
of the right testis show a hypoechoic
mass (arrow in a) in the right testis with
peripheral vascularity. Orchiectomy
revealed a 1.4 cm embryonal cell
carcinoma with vascular invasion
MRI: SEMINOMA-T1
ISO,T2 HYPO
NON-SEMINOMATOUS-T1-
ISO/HYPER,T2
HYPO(MORE
HETEROGENOUS)
LYMPHOMA-HYPO IN
T1,T2
28. Flank pain as presentation of stage II seminoma. A 35-year-old patient
presented with flank pain and CT was performed to evaluate for renal stone.
(a) Scans of the abdomen and pelvis showed no urinary tract calculi or
hydronephrosis. However, retroperitoneal adenopathy is noted in the
retrocaval (arrow) and left paraaortic regions (arrowhead). As the adenopathy
is in the nodal drainage pathway of the testis, ultrasound was performed to
evaluate for a possible testicular lesion as the primary source. (b) Grayscale
ultrasound image of the right testis demonstrates a hypoechoic mass (arrow)
replacing most of the parenchyma suspicious for malignancy. Biopsy of a
retroperitoneal node revealed seminoma and the patient was treated with
chemotherapy. (c) Grayscale ultrasound image of the right testis 3 months
after chemotherapy shows decreased size of the testicular mass (arrow). The
residual hypoechoic parenchyma demonstrated fibrosis at orchiectomy
without viable tumor. Post-treatment fibrosis without viable tumor is a
common pathologic finding in treated seminoma
29. POST TESTICULAR CAUSES- IMAGING EVALUATION
When physical examination and semen analysis results are normal, obstruction of the
ductal system, which accounts for up to 40% of azoospermia cases, should be suspected
• 1. Epididymal obstruction : Infection is the most common
cause. Gonococcal and chlamydial infections can lead to scarring and
ultimately obstruction.
Ultrasound may be normal in a large number of patients. When
abnormal, findings of epididymitis, epididymal cyst, or epididymal mass may
be present
2. Vas Deferens Obstruction.: most commonly caused by
vasectomy, but it can result from inguinal hernia repair, improperly performed
vasography, or contrast medium–induced irritation. Prior vasal obstruction can lead to
increased intraluminal pressure that results in microrupture and obstruction of fragile
epididymal tubules.
USG: characteristic appearance of the postvasectomy epididymis: dilated
tubular ectasia
Scrotal ultrasound demonstrating thickening and
enlargement of the epididymal body (arrow) in a
case of infective epididymitis. The testis is spared
from the infective process.
Epididymal tubular ectasia in a 40-year-old man who underwent a vasectomy
15 years ago and was interested in vasectomy reversal. Longitudinal gray-scale
US images through the head and tail of the right epididymis show tubular
structures with obstruction-induced dilatation (arrow) involving the right
epididymis, consistent with tubular ectasia of the epididymis.
30. 3. Seminal vesiculitis: Associated with epididymitis,urethritis and chronic prostatitis.
Urinalysis-Hematuria,pneumaturia,leucocytes,Semen analysis- Hemato/oligospermia,seminal
hypervascularity,reduced ejaculatory volume
TRUS: enlargement of seminal vesicles (>14 mm thick) and thickened
septa(collection of heterogeneous but predominantly low echogenicity-IF
ABSCESS)
CT: ACUTE-ENLARGED,CHORNIC-WALL THICKENED WITH FOCAL CALCIFIC
CHANGE
MRI: LOW ON T1,HIGH ON T2(WALL ENHANCE)
4.SEMINAL VESICLE AGENESIS: If bilateral-a/w agenesis of vastus with normal urinary tract(i.e CF)
If unilateral:embryological insult before 7 weeks’ gestation when the ureteral bud separates from the mesonephric
duct, associated with renal malformation.
If the insult occurs after 7 weeks’ gestation, the seminal vesicle agenesis will not be associated with renal
agenesis
Right seminal vesicle is
absent (agenesis), while left
seminal vesicle is hypo
plastic.
31. 5. Congenital Bilateral Absence of the Vas Deferens : the
most common cause of extratesticular ductal system
obstruction. When CBAVD is the only manifestation in a patient who
harbors at least one mutation in the Cystic Fibrosis Transmembrane Conductance
Regulator (CFTR) gene, this condition is known as the genital form of
Cystic Fibrosis (CF).
scrotal ultrasound: demonstrates dilatation of the
efferent ducts with the epididymis stopping
abruptly at the junction of the body and tail
beyond which no vas deferens is seen.
TRUS of the caudal junction of the vas deferens and the seminal vesicles
shows absence of the ampulla of the vas deferens .
CBAVD associated with abnormalities of the seminal vesicle and ejaculatory duct ,renal anomalies,
including agenesis, cross-fussed ectopia and ectopic pelvic location. In view of this, renal
ultrasound is advised when agenesis of the vas
deferens is diagnosed.
32. 6. Ejaculatory duct obstruction:. Whenever ejaculatory duct
obstruction is being considered in a patient with low ejaculate volume, retrograde
ejaculation should be ruled out by performing postejaculatory urinalysis to assess for
the presence of sperm
TRUS-The presence of midline cysts, dilated seminal vesicles
(anterior-posterior diameter >1.5 cm), or dilated ejaculatory
ducts (>2.3 mm) on TRUS is suggestive
If dilated seminal vesicles -TRUS-guided seminal vesicle aspiration
may be performed to confirm the diagnosis (with
simultaneous cryopreservation of any sperm found)
MRI : Dilation of ejaculatory duct (the diameter > 2 mm)
the wall of ejaculate duct being thick and enhanced
33.
34. 7. CYSTIC LESIONS
• Ejaculatory Duct Cysts: develop in the wolffian duct system are
unilocular, paramedian thin-walled cysts that occur as a result of partial distal obstruction of
the ejaculatory duct
On MR images, the cysts appear as thin-walled unilocular
cystic lesions in a paramedian location along the course of the
ejaculatory duct within the prostate gland, and they have low
signal intensity on T1-weighted images and high signal intensity
on T2-weighted images, similar to fluid.
• Cysts and Syringoceles of the Cowper Gland
Duct:Cowper glands are paired accessory sex organs that secrete mucoid material,
providing an alkaline milieu and lubrication for the spermatozoa just before ejaculation
On MR images, a Cowper gland duct cyst is seen as a
unilocular T2-hyperintense cyst posterior or posterolateral to the
bulbomembranous portion of the posterior urethra
Cowper gland cyst in a 24-year-old
man with infertility. Sagittal T2-
weighted MR image shows a
hyperintense lobulated ovoid cyst
(arrow) in the posterolateral
portion of the membranous
urethra, consistent with a Cowper
gland cyst.
35. • Prostatic utricle cyst
Origin: endoderm of Mullerian duct remnant
Incidence: 1st to 2nd decade
At the level of veromontaneum
Midline,<10 mm
Within the prostate
A/W hypospadias,cryptorchidism, unilateral renal agenesis
Communicate with urethra
• Mullerian duct cyst
• Origin: mesoderm of Mullerian duct remnant
• Incidence: 3rd to 4 th decade
• Anywhere within the path of duct regression
• Extends laterally ,>10 mm
• Beyond the prostate
• No association
• Not communicate with urethra
Sagittal T2-weighted MR images through the pelvis
show a hyperintense midline subcentimeter cystic
structure (arrow) confined to the prostate,
consistent with a prostatic utricle cyst
sagittal T1-weighted MR
image shows high-signal-
intensity fluid (arrow), due
to hemorrhage, that
extends beyond the base of
the prostate, consistent
with a müllerian duct cyst.
36. • Seminal Vesicle Cysts : unilocular thin-walled cysts adjacent
to the posterolateral aspect of the urinary bladder. associated with upper
urinary tract abnormalities such as ipsilateral renal agenesis and
dysplasia(ADPKD)(IF EDO + ---ZINNER SYNDROME)
ON TRUS: ECHO FREE /HEMORRHAGIC
UNILOCULAR
(a) Axial T2-weighted MR image through the pelvis shows
seminal megavesicles with a fluid-fluid level. The high-signal-
intensity area (dashed arrow) is simple fluid, and the low-signal-
intensity fluid (arrows) is due to hemorrhage. (b) Coronal T2-
weighted MR image shows that both kidneys are completely
replaced by cysts, consistent with autosomal dominant
polycystic kidney disease.
Seminal vesicle obstruction is defined as a seminal
vesicle with an anteroposterior diameter of more than
15 mm, length longer than 50 mm, and large anechoic
areas containing sperm on aspiration
37. TRUS midline image of markedly
cystic seminal vesicles (R, right; L,
left).
Sagittal US of one of this patient’s
kidneys shows innumerable anechoic
cysts, the largest labeled (C), and
allows for a diagnosis of bilateral
polycystic kidney disease.
USG SHOWING
ANECHOIC CYSTIC SOL
IN RT SEMINAL
VESICLE
38. 8. PROSTATIC CAUSES
• Male fertility is controlled by a Zn2+-dependent short circuit of the Krebs cycle within prostate epithelial
cells . Homeostasis of the prostate epithelium is reliant on the intracellular androgendependent
accumulation of Zn2+ and citrate . Sperm motility requires the coordinated action of the components of the
two main fluids in the human seminal plasma: the prostatic fluid, which is enriched with Zn2+, citrate and
kallikreins, and the semenogelin-enriched seminal vesicle secretion .The prostate is the direct target for a
number of benign and malignant diseases that are potentially linked to impaired fertility status . Prostatitis
might be directly linked with changes in fertility
• Apart from previously described congenital cysts, MAINLY CHRONIC PROSTATITIS IS A SIGNIFICANT MALE
INFERTILITY COMPONENT.
• The National Institutes of Health (NIH) have classified prostatitis into four distinct syndromes :
• I: acute bacterial prostatitis
• II: chronic bacterial prostatitis
• III: chronic prostatitis and chronic pelvic pain syndrome (CPPS)
• further subclassified as inflammatory or non-inflammatory
• IV: asymptomatic inflammatory prostatitis
39. Ultrasound
Focal hypoechoic region in the peripheral zone
of the gland. Discrete fluid collection suggests
abscess formation. Color Doppler ultrasound
demonstrates increased flow in the periphery of
the abscess.
CT
. Contrast-enhanced CT is the best imaging tool if abscess suspected
and will demonstrate a diffusely enlarged, edematous gland with
predilection for peripheral zone involvement
When an abscess is present it is seen as a rim-enhancing,
unilocular or multilocular, hypodensity in the
peripheral zone. Central zone involvement is encountered in
status post-transurethral resection of the prostate (TURP) patients. The
infection can extend through the capsule into the periprostatic
tissues, seminal vesicles, and peritoneum.
MRI
The prostate will be diffusely enlarged, often with associated
inflammatory changes of periprostatic fat and of the seminal vesicles .
Acute prostatitis
•T1: peripheral zone iso- or hypointense to transition zone
•T2: hyperintense
•T1 C+ (Gd) diffusely enhancing
MRI IN CHRONIC PROSTATITIS
•ADC: can give low ADC values due to destruction of the
prostate gland leading to a decrease in the water diffusion
capability
•DWI: degree of diffusion restriction in chronic
prostatitis tends to be less than in prostate carcinoma
41. 9. PENILE CAUSES OF INFERTILITY
• 1. Erectile Dysfunction : the persistent inability to achieve
and/or maintain a penile erection sufficient to engage in satisfactory sexual activity.
Penile Doppler US is reserved for those
patients in whom arterial or venous insufficiency
is suspected and there is little or no functional
response to phosphodiesterase-5 inhibitor agents
A peak systolic velocity of less
than 25 cm
Dampened waveform and high
velocity jets
An end-diastolic velocity greater
than 7 cm/sec.
GREY SCALE FINDING: PRESENCE OF CALCIFICATIONS,KINKING OF
CAVERNOSAL ARTERIES, DIAMETRE CHANGE AFTER INJECTION AND
TEXTURAL CHANGE OF ERECTILE TISSUE
42. 2. PEYRONIE’S DISEASE : Formation of fibrous tissue plaques causing
deformity .
GREY SCALE FINDING : grossly thickened tunica albuginea
echogenic plaques with calcifications
Colour doppler : high velocity,low resistance
MRI: thickened and irregular low intensity areas on T1,T2
Invasive : Dynamic infusion cavernosometry and
cavernosography
Magnetic resonance imaging appearance of Peyronie’s
disease. Parasagittal T2-weighted image of the penis
obtained after intracavernosal prostaglandin injection
shows penile deformation and diffuse, irregular thickening
of the tunica albuginea
Calcified dorsal plaques. Longitudinal scans on the
ventral aspect of the penis. Isoechoic plaque showing
small calcifications (arrowheads).
43. 3. PRIAPISM : Prolonged erection in absence of sexual stimulation unrelieved by ejaculation
Ischemic veno-occlusive type( low flow)
• Sickle cell disease ,Drugs,Solid malignancy
• USG: THROMBOSIS OF CORPORA, DECREASED/ABSENT
CAVERNOSAL FLOW(PSV <25,RI inc.)
T 1 : INCREASED SIGNAL
Non-ischemic high flow type
• Traumatic,Neurogenic, Post shunting
• USG: ARTERIO-VENOUS FISTULA
MILD inc. of penile artery PSV
T2: FLOW VOID
Cocaine
induced;blood
settled with fluid-
fluid level,
consistent with
stasis
Post traumatic :
color blush from
lacerated
cavernosal artery
44. USE OF IMAGING IN TREATMENT GUIDANCE
• In obstructive azoospermia : TRUS can be used to guide
median cyst puncture and seminal vesicle aspiration in cases of suspected
ejaculatory duct obstruction (EDO) .
TRUS-guided echo-enhanced seminal vesiculography in
combination with Transurethral resection of ejaculatory
duct is considered the best imaging method when treating
EDO
Direct vesiculography and image-guided
balloon placement and ejaculatory duct for partial
obstruction or extraprostatic obstruction.
TRUS or endorectal MRI can be used to
assess the distance between the posterior wall of
the prostatic urethra and the wall of the ducts
before undertaking TURED.
Transrectal US image of seminal
vesicle puncture. Transverse
sonogram obtained during
transrectal needle puncture
for seminal vesiculography shows
a dilated seminal vesicle, a finding
suggestive of EDO
45. • Percutaneous angioembolization Of varicocele
: Local anaesthesia------USG guided puncture of right common
femoral vein(IJV in co axial system)----Contrast injected into
testicular vein------occlusion by sclerosing agent----coils distally in
the inguinal ligament and progressing proximally
Antero-posterior radiograph
obtained during left testicular
venogram. Multiple dilated
and refluxing veins, at the
level of the scrotum (black
arrows) and at the lower
pelvic–inguinal level
(white arrows) (B, contrast-
filled bladder).
Antero-posterior radiograph obtained
during left
testicular angio-embolization for
varicocele. Multiple embolization
coils have been deployed within the
venous lumen (solid arrows),
via a transjugular angiographic catheter
(open arrow).
46. Patients in Whom Varicocele
Repair Is Less Likely to Be of
Benefit
Factors that decrease the likelihood of
pregnancy after spermatic vein interruption
include the following:
• Noncorrectable infertility in the female partner
• Significant testicular atrophic or dystrophic
changes on ultrasound
• Advanced age
• Total sperm count of less than 10 million/mL
• Sperm densities greater than 40 million/mL
47. • Image-guided sperm retrieval : helpful to guide testicular sperm aspiration in
azoospermic patients. Fewer complications.
testicular vascularity index distribution obtained by scrotal power Doppler ultrasound can
be used to predict sites with the greatest potential for spermatogenesis for sperm retrieval during
microscopic testicular sperm extraction (micro-TESE). This technique is based on the hypothesis that
spermatogenesis is more likely to occur in regions that are well perfused with oxygenated blood
Infertility with no established indications for imaging
Some conditions associated with male infertility may not benefit from investigative imaging . These include idiopathic
infertility,psychogenic erectile dysfunction, hypogonadotropic hypogonadism,
diagnosed testicular failure, genetic causes of male infertility, or immunological
causes, unless an underlying scrotal or upper urinary tract infection, urinary tract anomaly, stones, or tumors are
suspected.
