TRUS in Evaluation of Male Infertility

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Dr Ho Siew Hong lectured in the Andrology Certification Workshop as part of 3rd Japan-ASEAN Men's Health and Aging Conference on 29 Nov 08

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TRUS in Evaluation of Male Infertility

  1. 1. Role of Transrectal Ultrasound (TRUS) in Male Infertility Dr. Ho Siew Hong Consultant Urologist S H Ho Urology and Laparoscopy Centre Gleneagles Hospital
  2. 2. What is TRUS ? <ul><li>Ultrasound probe placed within rectum </li></ul><ul><li>7 MHz frequency, higher frequency, shorter penetration, better resolution </li></ul><ul><li>Complete picture of prostate, seminal vesicles and ejaculatory duct in real-time, by moving a few millimeters on transverse or longitudinal plane </li></ul>
  3. 3. TRUS
  4. 4. TRUS Sagital Transverse 135 Degrees
  5. 5. Role of TRUS in male infertility <ul><li>Evaluation of abnormalities of ejaculatory duct apparatus </li></ul><ul><li>Able to determine level of obstruction in ejaculatory duct, aids in planning surgery </li></ul><ul><li>Ultrasound guided aspiration – cyst, seminal vesicle fluid </li></ul><ul><li>Almost replaced vasography in evaluation of ejaculatory duct obstruction </li></ul><ul><li>Vasography still necessary if classical characteristics not present on TRUS </li></ul>
  6. 6. Anatomy of ejaculatory duct <ul><li>3 parts of ejaculatory duct: </li></ul><ul><li>Long, extra-prostatic </li></ul><ul><li>Middle, intra-prostatic </li></ul><ul><li>Distal, joining verumontanum in urethra </li></ul><ul><li>Ejaculatory duct obstruction may be present in 5% of subfertile men </li></ul>
  7. 7. Indications for TRUS in infertile males <ul><li>L ow ejaculate volume </li></ul><ul><li>Z ero (azoospermia) or a decreased (oligospermia) number of sperm in the ejaculate </li></ul><ul><li>S ignific a nt sperm motility abnormalities </li></ul><ul><li>H istory of prostate infections, prostatitis </li></ul>
  8. 8. Clinical suspicion of diagnosis of ejaculatory duct obstruction <ul><li>Azoospermia </li></ul><ul><li>Hematospermia </li></ul><ul><li>Painful ejaculation </li></ul><ul><li>Perineal pain </li></ul><ul><li>Urinary tract infections or trauma </li></ul>
  9. 9. Causes of ejaculatory duct obstruction <ul><li>Seminal vesicle stones </li></ul><ul><li>Mullerian duct (utricular) cysts </li></ul><ul><li>Wolffian duct (diverticular) cysts </li></ul><ul><li>Post-surgical scar tissue </li></ul><ul><li>Post-inflammatory scar tissue </li></ul><ul><li>Calcification (stone) near the verumontanum </li></ul><ul><li>Congenital atresia </li></ul><ul><li>Functional obstruction (alpha blocker, anti-psychotic, anti-depressants) </li></ul>
  10. 10. Diagnosis of ejaculatory duct obstruction <ul><li>Azoospermia </li></ul><ul><li>E jaculate volume <2.0 ml and a pH<7.2 that contains no sperm or fructose. </li></ul><ul><li>Normal serum FSH and testosterone. </li></ul><ul><li>Testicular of normal size (20cc) and consistency. </li></ul>
  11. 11. TRUS diagnosis of ejaculatory duct obstruction <ul><li>D ilated seminal vesicles (>1.5 cm width) </li></ul><ul><li>D ilated ejaculatory ducts (>2.3 mm) </li></ul><ul><li>C yst, calcification or stones along the duct </li></ul><ul><li>TRUS and seminal vesicle aspiration showing the presence of sperm in the seminal vesicle fluid within 2 days of ejaculation </li></ul>
  12. 12. Technique <ul><li>Left lateral position </li></ul><ul><li>DRE </li></ul><ul><li>Introduction of rectal ultrasound probe </li></ul><ul><li>No anaesthesia required </li></ul><ul><li>Mild sedation for drainage or aspiration </li></ul>
  13. 13. Transverse plane <ul><li>Prostate evaluation </li></ul><ul><li>Base to apex </li></ul><ul><li>Emphasis on base and mid prostate </li></ul><ul><li>Seminal vesicle </li></ul><ul><li>Small amount of urine in bladder is helpful </li></ul>
  14. 14. Prostate Bladder
  15. 18. Ejaculatory duct
  16. 19. Prostatic cyst, infartion
  17. 20. Sagittal Plane <ul><li>Bladder neck </li></ul><ul><li>Urethra </li></ul><ul><li>Verumontanum </li></ul><ul><li>Ejaculatory duct </li></ul><ul><li>Seminal vesicles, one at a time </li></ul>
  18. 22. Urethra
  19. 23. Ejaculatory duct
  20. 24. D ilated ejaculatory ducts (>2.3 mm)
  21. 25. D ilated seminal vesicles (>1.5 cm width)
  22. 26. Aspiration from seminal vesicles or cysts <ul><li>Negative urine culture </li></ul><ul><li>Mild sedation - midazolam </li></ul><ul><li>Prophylactic antibiotics - 6 to 24 hours prior to aspiration e.g. ciprofloxacillin 500 mg - i/v gentamicin 160 mg before aspiration </li></ul><ul><li>Continue oral antibiotics for another 3-5 days </li></ul>
  23. 27. TRUS aspiration of utricular cyst
  24. 28. TRUS – ejaculatory duct obstruction
  25. 29. Conclusions <ul><li>TRUS is the ideal instrument for evaluation of ejaculatory duct disorders </li></ul><ul><li>Fast replacing vasography </li></ul><ul><li>Excellent planning for surgery </li></ul><ul><li>Option of aspiration from seminal vesicle (diagnostic) or urticle cyst (therapeutic) </li></ul>
  26. 30. Thank you

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