Ultrasound of the male genital tract in relation to male reproductive health

28 Pages·2014·1.3 MB·English

HumanReproductionUpdate,Vol.21,No.1pp.56–83,2015
AdvancedAccesspublicationonJuly19,2014 doi:10.1093/humupd/dmu042
Ultrasound of the male genital tract
in relation to male reproductive health
FrancescoLottiand Mario Maggi*
SexualMedicineandAndrologyUnit,DepartmentofExperimentalandClinicalBiomedicalSciences,UniversityofFlorence,Florence,Italy
*Correspondenceaddress.SexualMedicineandAndrologyUnit,DepartmentofExperimentalandClinicalBiomedicalSciences,University
ofFlorence,VialePieraccini6,50139,Florence,Italy.Tel.[phone];Fax:[phone];E-mail:[email protected]fi.it
SubmittedonNovember13,2013;resubmittedonMay27,2014;acceptedonJune18,2014
D
tableofcontents ow
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lo
a
† Introduction de
d
† Methods fro
m
† Sonographicanatomyofthemalegenitaltractandcolor-Dopplerultrasoundnormalpatterns h
Scrotalregion ttp
Prostate-vesicularregion ://h
u
m
† Color-Dopplerultrasoundinpathologicalconditions u
p
Testis d.o
x
Varicocele fo
Epididymisandvasdeferens rdjo
u
Prostate rn
a
Seminalvesicles ls
.o
† Diagnosticvalueofscrotalandtransrectalultrasoundandspecificapplications rg
a/
SensitivityandspecificityofUSinpredictingazoospermiaoutcomes t H
TestiscolorDopplerultrasoundandsurgicalspermretrievalinazoospermicsubjects arv
a
MalegenitaltractUSandhormonaltreatments rd
L
ColorDopplerultrasoundclinicalutilityandimpactonmalereproductivehealthmanagement ib
† Conclusions rary
o
n
J
a
n
u
a
background:Infertilityaffects(cid:2)7%ofallmen.Despitemuchprogress,mainlyingenetics,itsetiologyremainsobscurein(cid:2)50%ofcases. ry 1
1
Tofillthisgap,imagingofthemalegenitaltract(MGT)hasprogressivelyexpanded,providingusefulinformationintheassessmentofMGTab- , 2
0
normalities. 1
5
methods:
Acritical,systematicreviewoftheavailableliteraturewasperformedusingMedline,withnorestrictionsregardingdateofpubli-
cation(i.e.frominceptiondateuntilMarch2014),alongwithanalysisofpreviousreportsincolorDopplerultrasound(CDUS)atlastextbooks.
NormalanatomyandsonographiccharacteristicsoftheMGThavealsobeensummarized.
results:
Testicularvolume(TV)istightlyassociatedwithbothspermandhormonalparameters.Ultrasound(US)offersagreateraccuracyin
TVmeasurementthanPraderorchidometer(PO).HoweverUS-andPO-derivedTVarecloselyrelated,makingPO-derivedTVinformative
enoughinthework-upoftheinfertilemanineverydayclinicalpractice.US-derivedTVmightplayanindependentroleinspecificclinicalconditions
(i.e.largehydrocele,inguinaltestis,enlargedepididymis).ScrotalUSmaydetectsignsoftesticulardysgenesis,oftenrelatedtoanimpairedsperm-
atogenesisandtoahigherriskofmalignancy,ortesticularlesionssuggestiveofmalignancy.Adecreasedtestisvascularizationischaracteristicof
testiculartorsion,whereashyperemiaisoftenobservedinepididymo-orchitisorinsomemalignantconditions(i.e.lymphoma,leukemia).The
impactofvaricoceledetectionandsurgicalcorrectiononspermparameters/fatherhoodisdebated.Atpresent,theclinicalmanagementof
varicoceleismainlybasedonphysicalexamination.However,CDUSisusefulinassessingvenousreflux,whenpalpationisunreliableand/or
indetectingrecurrence/persistenceaftersurgery.Epididymisheadand/ortaildilationissuggestiveofMGTobstructionorinflammationand
botharerelated,alongwithecho-textureabnormalities,toimpairedspermparameters.ScrotalandtransrectalUS(TRUS)areusefulindetecting
&TheAuthor2014.PublishedbyOxfordUniversityPressonbehalfoftheEuropeanSocietyofHumanReproductionandEmbryology.Allrightsreserved.
ForPermissions,pleaseemail:[email protected]
Malegenitaltractultrasoundandreproductivehealth 57
congenitaluni-orbilateralabsenceofvasdeferens(CBAVD),whichmaybeassociatedwithepididymis,seminalvesicles(SV)orkidneyabnor-
malities/agenesis.TRUSplaysakeyroleinassessingobstructiveazoospermiaanddetectingdistalCBAVDoranomaliesrelatedtoejaculatory
ductsobstruction,suchasejaculatoryductabnormalities,prostatemediancystsorSVenlargement/emptyingimpairment.TRUSfindingslead
to operational decision-making, such as testicular sperm extraction in the case of CBAVD, cyst aspiration in the case of a large prostatic
mediancyst,andsurgicaltreatmentifejaculatoryductabnormalitiesareobserved.TRUSmayrevealprostatevolumereduction(suggestiveof
hypogonadism) orenlargement, whichcan be relatedto agingorevenmetabolicabnormalities. Finally, TRUSmayreveal prostateand SV
echo-textureabnormalitiessuggestiveofinflammationorSVstasis.
conclusions:
MGT-CDUSisausefultoolindetectingabnormalitiesrelatedtoimpairedmalereproductivehealth.However,itsuffersfrom
alackofstandardizationandoftenproducessubjective/vaguediagnoses.Tofillthisgap,theEuropeanAcademyofAndrologyhaspromotedan
ongoingmulticenterstudyaimedatdefiningtheMGT-CDUScharacteristicsofhealthy,fertilemen.
Keywords:scrotalandtransrectalultrasound/color-Dopplerultrasound/malegenitaltract/subfertile/infertilemen/azoospermia
Introduction ‘ultrasonics’[MeSH Terms] OR ‘ultrasonics’[All Fields]) AND (‘infertility,
male’[MeSHTerms]OR(‘infertility’[AllFields]AND‘male’[AllFields])OR D
o
Ithasbeenestimatedthatalmost7%ofmen,intheirreproductiveage, ‘male infertility’[All Fields] OR (‘male’[All Fields] AND ‘infertility’[All wn
are subfertile or infertile, due to testicular, pre-testicular or post- Fields])).TheidentificationofrelevantstudiesintheEnglishlanguagewas loa
d
ftoersti(cid:2)cu1la5r%proofbalellmcsau(sKersauosfz,m2a0le11in).feGrteilniteyt.icDaebspniotermmalaitnieysteaccchonuicnatl psterraftoergmyewdasinedmeppleonydeedn,twlyhebryebbyo,tahfteaurtohbotrasin.iInngathdediftuiollnte,xata‘prteicalrelsg,rtohwerinegf-’ ed from
advancesthat haveimproved diagnostic skills, the etiological factors ethraetncceoulisldtsboefaullseindcluindethdisstruedviieesww.eArnearleyvsiisewoefdprfoerviaodudsitrioepnoalrtpsubinlicCatDioUnSs http
formaleinfertilityarestillobscure,and(cid:2)50%ofmenremainundiag- atlastextbookswasalsoperformed. ://h
nosed (Tuttelmann and Nieschlag, 2010; Krausz, 2011). To fill this um
u
gap, in infertility clinics, the use of imaging of the male genital tract p
(MGT) has been progressivelyexpanded. With the neweradvances Sonographic anatomy of the male d.ox
in technology, in terms of image quality and resolution, ultrasound genital tract and color-Doppler ford
(US),whichemployshigh-frequencysoundwavestoproduceimages, ultrasound normal patterns journ
isnowwidelyusedintheassessmentofmalereproductiveproblems a
ls
(Ammaretal.,2012;RazaandJhaveri,2012).Gray-scaleandcolor- Scrotalregion .org
DopplerUS(CDUS)canprovideusefulinformationintheassessment a/
ofMGTabnormalitiesnotnecessarilyrelatedtoonlyinfertility.Infact, Testiclesarenormallylocatedinthescrotalsac(Figs1and2).Thispecu- t H
a
testicularmalignancyandmaleaccessoryglandinfection(MAGI)canbe liarpositionrequirestheuseofahigh-spatialresolutiontransducerdedi- rva
detected (Woodward et al., 2002; La Vignera et al., 2012). Hence, catedtothestudyof softparts(7–15MHz).Usuallythepatient lays rd L
CDUSimagingoftheMGThasarelevantimpactnotonlyonreproduct- supinewiththepenisrestingonthesuprapubicregionandgelapplied ibra
ivehealthbutalsoonmalehealthingeneral.WhereasscrotalCDUS tothescrotum,supportedbyatowelplacedbetweenthethighs.The ry o
hasbeencommonlyusedinreproductivemedicineforseveralyears, testesareexaminedintransverse,obliqueandlongitudinalplanes,and n J
a
onlyrecentlytransrectalUS(TRUS)hasassumedagrowingimportance images are acquired in both gray-scale and color-Doppler modes, to nu
a
intheimagingofmaleinfertility,extendingtheexaminationtothepros- assess testicular blood flow (Ammar et al., 2012; Appelbaum et al., ry 1
tate, seminal vesicles and deferential ampullas (Ammar et al., 2012; 2013). 1, 2
0
Lotti et al., 2012a; Raza and Jhaveri, 2012). Here we systematically 1
5
review the diagnostic impact of CDUS on the MGT in relation to Testis
subfertility/infertility,givingspecialattentiontoobstructiveandnon- Volume.Inclinicalpractice,testisvolume(TV)isassessedbyPrader’sorch-
obstructiveazoospermia.Conceptsofnormalanatomyandcharacter- idometer(PO)(NieschlagandBehre,2010).However,orchidometryover-
isticUSfindingsoftheMGTwillbecriticallyanalyzed,withtheaimof estimatesTVwhencomparedwithUS(Behreetal.,1989;Lenzetal.,1993;
identifying abnormalities related to the male infertile state. In line Diamondetal.,2000;Goedeetal.,2011;Rastrellietal.,2013).Clinicallythe
with the dataobtained fromourreview,the clinicalutilityof CDUS assessedTVvariesasafactorofage.PrepuberalboysshowaTV≤3ml,
anditsimpactonmalereproductivehealthmanagementishighlighted, with a size .3ml representing the first sign of an ongoing puberty
pointbypoint,andfinallydiscussed(TableI). (Palmert and Dunkel, 2012). During puberty, the TV increases rapidly
(Goedeetal.,2011),upto10-foldbetween10and15years(Beresetal.,
1989).ReferencegrowthcurvesforTVmeasuredbyPOinboysareavail-
Methods
able(Goedeetal.,2011).Inalargecohortofmalesaged0–28years,the
maximumTVwasattainedat17–18and21–22yearsamongnon-gypsies
AnextensiveMedlinesearchwasperformedwithnorestrictionsregarding
andgypsies,respectively(Beresetal.,1989).FindingsofTVdecliningsasa
dateofpublication(i.e.frominceptiondateuntilMarch2014)includingthe
followingwords:(‘male’[MeSHTerms]OR‘male’[AllFields])AND(‘ultraso- function of aging are not universal, as some studies report a decrease
nography’[Subheading]OR‘ultrasonography’[AllFields]OR‘ultrasound’[All (Stearns et al., 1974; Bakeret al., 1976) and some report a stable size
Fields]OR‘ultrasonography’[MeSHTerms]OR‘ultrasound’[AllFields]OR (Harman and Tsitsouras, 1980; Sparrow et al., 1980; Nieschlag et al.,
5
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TableI Malegenitaltract(MGT)color-Dopplerultrasound(CDUS)clinicalutilityandimpactonmalereproductivehealthmanagement.
CDUSparameter Clinicalutility Comments Impactonmalereproductivehealth
.........................................................................................................................
management
Pros Cons
..........................................................................................................................................................................................................................................................
ScrotalCDUS
Testislocalization F:Low – Usefulinlocalizinginguinaltestis – Physicalexaminationofteninformativeenough – Debatedutilitypriororchipexyplanning
GH:Moderate – Uselessinlocalizingintra-abdominaltestis – Noimpactonmanagementofnonpalpable
testes
– Usefulinfollow-upofcryptorchidtestis-related
malignancyriskandcontralateraltestis
Testisvolume(TV) FandGH:Low – USusefulwhenPraderorchidometeris – Praderorchidometer-derivedTVisstrictly – Positivecorrelationwithspermandhormonal
unreliable(largehydrocele,inguinaltestis, relatedtoUS-TV;USshowsgreateraccuracy, parameters
enlargedepididymis) butPraderorchidometerisinformativeenough – PoorutilityinTESEdecision-making
inclinicalsetting – Poorutilityinspermatogenicarrest
Testisecho-textureand F:Moderate – Inhomogeneitysuggeststesticularfunction – Inhomogeneitymaybefoundinseveraldiseases – USusefulinfollow-upformalignancywhen
calcifications GH:Moderate impairmentandabnormalspermmorphology orexposuretoharmfulcauses,soitisnot severeinhomogeneityormicrocalcificationsare
– Severeinhomogeneitywarnsofmalignancy specific found,especiallywhenotherriskfactorsare
– Microcalcificationswarnofmalignancy, – Associationsbetweenmicrocalcificationsand present
suggestingUSfollow-upandeventuallybiopsy malignancyisrecentlydebated – Biopsydebatedinpresenceof
– PoorutilityinTESEdecision-making microcalcifications
– poorutilityininfertilitymanagement
Testicularlesions F:Low – Detectionofsmallandlargelesionsandtheir – Physicalexaminationinformativeenoughto – Usefulinfollow-upofcryptorchidtestis-related
GH:Moderate/ characteristics(extension,vascularization, detectlarge/hardlesions malignancyriskorsmalllesions
High echo-texture) – Poorinformationonthebiologicalbehaviorof – Moderateutilityinlarge/hardlesions
– Usefulinfollow-upofcryptorchidtestis-related thelesion;histologyrequired decision-making
malignancyriskorsmalllesions
Testicularvascularization F:Low – Usefulfortorsion,infarction(reduced), – Notstandardizedforfertilityassessment – Usefulfortorsion,infarction(reduced),orchitis
GH:High orchi-epididymitisorsometumors(enhanced) orsometumors(enhanced)
– Afewreportsonpositivecorrelationwith – Notstandardizedforfertilityassessment
spermparametersandretrievalinTESE – poorutilityforTESEdecision-making
Varicocele F:Moderate US: – Physicalexaminationissufficientfortreatment – Poorutilitywhenvaricoceleispalpableorvisible
GH:Low – Confirmsclinicaldiagnosis decision – Usefulwhenphysicalexaminationisunreliable
– Usefulwhenphysicalexaminationis – Treatmentofsubclinicalvaricoceledisputable – Usefulindetectingrecurrence/persistence
inconclusive – Riskofcomplications aftersurgery
– Detectsthetypeofvenousreflux
– detectssubclinicalvaricocelewithpersistent
reflux L
o
– avoids‘false’varicocele(dilationwithoutreflux) tti
– Detectsrecurrence/persistenceaftersurgery a
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Epididymaldiameters F:Moderate – USshowsgreateraccuracycomparedwith – Difficulttoevaluateafterscrotalsurgeryorin – Epididymalenlargementmayindicatedistal ge
n
GH:Low physicalexamination thepresenceoflargevaricocele obstructioninsubjectswitholigo/ ita
– Enlargedepididymissuggestiveofpastor – Primaryobstructionmayonlybesuggested,but azoospermia,eventuallyleadingtoextentUS ltr
presentinflammationorpost-testicular notproven,byUS investigationtotheprostate-vesicularregion ac
t
obstruction u
ltr
a
s
Epididymalecho-texture FandGH:Low – Echo-textureabnormalitiesmayassociatewith – Notstandardized – Mayassociatewithreducedspermcountand o
u
pastorpresentinflammation motility nd
a
n
Epididymalvascularization F:Low – Hyperaemiaindicatesinflammation – Notstandardized – Hyperemiaindicatesmedicaltreatment d
r
GH:Moderate – Follow-upaftermedicaltreatment (associatedwithmedicalhistoryandclinical ep
symptoms/signs) ro
d
u
c
Epididymalabnormalities F:Moderate – USdetectsabnormalitiesorabsenceofthe – epididymalcystshavelowutilityininfertility – usefulinsuggestingabsenceordownstream tiv
e
GH:Low epididymis assessment obstruction h
e
a
Vasdeferens(VD) F:High – USdetectsabnormalitiesorabsenceofthe – TheintermediateportionoftheVDisnot – UsefulindefiningOAcause lth
GH:Moderate proximalordistalVD detectablebyUS – PositivespermretrievalbyTESE
– VDdilationmayindicatedistalobstruction – VDabsencesuggestsCFTRgeneandkidneysUS
– (see‘epididymaldiameters’) evaluation
TransrectalCDUS
Prostatevolume F:Low – USshowsgreateraccuracythanphysical – Physicalexaminationmayrevealnormal, – Notveryusefulininfertilemalemanagement
GH:Moderate examination reducedorenlargedprostate – Reducedvolumemaysuggesthypogonadism
– Usefultoassessupwardgrowth(bladder) – TRUSisuncomfortable – Usefulinbenignprostatichyperplasia
management
Prostateecho-texture FandGH:Low – Abnormalitiessuggestiveofpastorpresent – Abnormalecho-texture:frequent,poorly – Impactonfertilitynotdemonstrated
inflammation(seeTableII) specific
Prostatevascular F:Low – Mayindicatepresentinflammation(seeTableII) – Fewavailablestudies – Impactonfertilitynotdemonstrated
parameters GH:Moderate – CorrelationwithCPPSandPLS(seeTableII) – Notstandardized
Prostatemediancyst F:Moderate/ – Largecystsmaycauseejaculatoryduct – Nosizecutoffassociatedwithdistalobstruction – UsefulindefiningOAcause
highGH:Low obstruction – AspirationinOAsubjectmayleadtosemen
– USusedinfollow-upaftercystaspiration parametersimprovement
Ejaculatoryducts(ED) F:Moderate/high – TRUSdetectsabnormalities – UsefulindefiningOAcause
GH:Low – EDcystmayindicateCFTRgeneevaluation
Seminalvesicles(SV) F:Moderate/high – TRUSdetectsuni-orbilateralabsence – SVabsencesuggestsCFTRgeneandkidneysUS
agenesis GH:Low evaluation
Seminalvesiclesvolume F:Moderate – DilationafterejaculationmayindicatepartialED – Dilationorhypoplasiaarenotstandardized – DilationsuggestiveofpartialEDobstruction,
GH:Low obstruction butnostandardization
Continued
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5102 ,11 yraunaJ no yrarbiL dravraH ta /gro.slanruojdrofxo.dpumuh//:ptth morf dedaolnwoD
60 LottiandMaggi
1982).Ithasalsobeenreportedthatage,malnutritionandillnessexertin-
ContinuedTableI CDUSparameterClinicalutilityCommentsImpactonmalereproductivehealth.........................................................................................................................managementProsCons..........................................................................................................................................................................................................................................................SeminalvesiclesF:Low/moderate–Abnormalitiesmayindicatepastorpresent–Shouldbeevaluatedafterejaculation–Giantcystmayindicategenitourinaryanomaliesecho-textureGH:Lowinflammationorstasis(seeTableII)investigation–Giantcystmayindicategenitourinaryanomalies–Abnormalitiesmayindicateinflammationorinvestigationstasis TheclinicalutilityoftheparametersinvestigatedbyCDUShasbeenarbitrarilyclassifiedaslow,moderateandhigh,inrelationtofertility(F)orgeneralhealth(GH).Thestatementsmadeareextensivelydiscussedinthetext.MGT,malegenitaltract;US,ultrasound;CDUS,color-Dopplerultrasound;TRUS,transrectalultrasound;TV,testisvolume;TESE,TesticularSpermExtraction(includingmicroTESE);OA,obstructiveazoospermia;ED,ejaculatoryduct;SV,seminalvesicles;CFTR,cysticfibrosistransmembraneconductanceregulator. iUh1wd(wdadIPUlHnmt0dmes5reg1ca2dKnre51LaPpfeFiomctenantohhFeetrltlaotnntnet.09eeoeeO9.09iieeofaroorusSo0dliaa5ieearpphyicsaadddcaplna8gaoUrlgbfic919AUNtrp–iadmns-mrpsiiyr2eldanoon,tehel.aumenltlkminze6dema423ue.uol.etihnzm6StnSh).gi3i6oe,,srnireaeosrtounh;vteusce),;sbnll.ii-0itteatUl2dayezasaAnced2grc,onadlyidSmsefmtTa)Tttttal(ms2,si(nmtge0dtaeeladHs0.enhsohaalefrSadN)uFirbagaarV0fuamae1oGln0enieTc.a0rakdesed,naeogseomorakory(poasoteg0HTleiit9(cid:2)ad7lnnl2algnltat.LVnruegtsiaeon.areeuapglwrd,hiane0snas,ae9isad;m.eaVen,;teeisltoaavrtennvdpu,nc1ptayitsdtlr1rlB;er2lc8fhumeJfa3spy.eclSeThsbwnhsfddrohterio(srUfg3pl,ihu9dee0ts)slvtieetpStaietPaopTeleoyeganeeiyVcalf,at.c2olTrieeac9neh1(c–eSatutrnaec0sidlrotrd(alsVdumnl(Lhryte0tvepEgeear3rkoia-Vagte3edlRgweeaP1tH,sanrhrei+;itoe,aeaeT1luntselcuian;ona,aiPtinocljnOaa8(oiezefdsts,.nrethvnraacP3mclts)VtdPagDnaOu,1thnssghcasa1aT,cnoae,zcaemkleaooh)O5nttpieyi.nael,de2o2tmnTfhfal9olhi.arp,luritbVitlm-.toefaimnteedi.udaepsne.sol0to,eemwoesw8doth0VAtr-eed,aB1umateosseafrmteaeaeoderasr0iglaZ5neeze-p22ac,ime9l,lt(elenurhresmltsm.ddeati.adlese9lr;rbBnrci,o0a0.siid8ihivtesennnce,rseosaiatefetnleSou(urefur;,arTvye.20a1elean7rxzieuoncstgotgn1ci(t,eiarrecialc2lerlureGvhcl(hr0ms7er3VedGat;eluelsTc-rrdsteas4atstiS1aatd,0ei,,tuoaaUrp0ps,oca)iettshonoiBehoocolnorVaoaln9adeby2o1pd–evemlr.on,.4soTifne.myayram,ttSksetm.,nnmelnCFae9e,t03eolaorpbl1)ehmdTrilnphisV2e-aetdicon,liiz,csttT31ad2taibvyu(eea)itnpo25sTeoeiakantomVhitd0ihentlne,B;e.pbwl0sa;ett0esillrahaet0sunnsnV.iiyegTc12tiaHTgm(r(prftiaaben)nsr,mo1cBRvoseas0adc.ehdorHeBoofhi.i3l0eeawtnhVroeVeugotteeon.32eiaagottate7sylorR,eidentiasnm)1moaknoasrlpon,sadsaerhlsashr0mhrwa,aoamlryradtas1(0in(,toamfvuyleutg)tdrokog0peeur,e.etablNTPrenedgh1bo,e9ad.,e)dalaalelesrheueratlnr.0t,uosattoedluia2Uialee09npme,vi8ecstoiy2nhlenDgisltialnshztf;laae2asaallltkt0ecdge9Pflii9ai0eiav–r2esiecSTsidTodoyehtebolsnanl0RTlanioetr0.sna5uiOe.;tzm1amoh0aecpr,6dirlnTlf,gVc,Vnb1usnadteVar8i(slrr;coaht0aaetS1ni.no(2cehPs2alidane1bseVaesnh,o,hy)yeisArll)lnainofs1umtbs.ae0atdo.Otn0os.tfItim;.rjamehodhbeo,2tniknmererstri)hfgl(p.yaod(1u0mcf2e.aPsTouaaaeoHifs0acgpgrG1gc2,,-3eedalpem0l(amePi7naei0rstl.inlotmeU1t2p1tmhygoe90leLrl1alnl,ioe2ls–rtehro)dnOaas.iluhrnes4t0seah0teaep08ne1e,b0et2tSn0uorlt)teeiee5otn(tfriSb(cid:2)1etayl×;nu(d9dnza.(3iaace0otlcah1+Klm–lsltmthpdtyGiitBsa0iailhilllruPiz;fon)ceeert.1aas3raaaretUe1.atudoe1faeav,u))tiaeblmtewmiyar,arbnoitLsr3)ttN..hml0rniaseel15hrtmn4ai,heaS.ycajgia.nsew1oleHeeahpeiameiait,cdeu.sjotntot-enrrldmtoe,–lham0oP9An)mndlasnetaoezledae,el2io1rma.nttaavaUlaaaswbzO8fs5dte,rrysnPeuoslresmphiml0w9Llleruetsogllsbce.sl7se..u.ete2SOgnhtrohneee,18t(eeme(,,rmta)rtilgp×eiali;tiA(tcsnLeia0oLhnoutttt,igdvet5rn3ln2f(r1ahL2ct(voa-hholetit1ogehduDeafapnFs)aihJbza)ieab0nflhe9e,0h/lescsøreh.,rlon.u.p(3gadiitlodlfeaolila,rarg1t2en,t,9.u0im.owdf.fir.Caltrethzasr1r,arha,H,ese,es,nimrsord2i1hgzT3r6fbv–mrmiimrel)t8iteyftad2222sogbre11(titme0)eoeer)eee;.imr(heeVandbs4aH.herhod.0000esunrout99otog01rcnrgt,tTTdaNledeaanomtfsa1100aesattealite89gaacns3TcUaaateac+ponnubehehVeehtnggfo×3188rientnnmi93deialllrataslsVjiddldnnnnneeeee..e.eeSayyss-))----)-)ttt.,,,;,,;;,ll at Harvard Library on January 11, 2015http://humupd.oxfordjournals.org/Downloaded from
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Figure1 Schematicrepresentationofthenormalandpathologicfeaturesofthemalegenitaltract(MGT)inrelationtomalereproductivehealth.Right als
.o
side:normalanatomyoftheMGT.Leftside:pathologicfeaturesoftheMGTsuggestingobstructiveornon-obstructiveoligo-astheno-teratozoospermia rg
(OAT)/azoospermia.Warningsformalignancyareextensivelydiscussedinthetext. a/
t H
a
rv
(Fig.3A).Itissurroundedbyanechogenicfibrouscapsule,thetunica the upper testicular pole (Horstman et al., 1991a) (Figs 2 and 3B). ard
albuginea, which projects into the interior of the testis with fibrous Each TA lies in the spermatic cord with the ipsilateral cremasteric L
ib
septa,dividingitinto200–400lobules(Fig.2).Eachlobulecontainsinter- artery (a branch of the inferior epigastric artery) and the deferential ra
ry
stitialLeydigcellsandseminiferoustubules(ST)(Fig.2),withdifferentiat- artery (a branch of the vesicular artery) (Horstman et al., 1991a) o
n
inggerminalcellsandsomaticSertolicells.ItisestimatedthatSTaccount (Fig. 2). Although there are anastomoses between these vessels, the Ja
n
for(cid:2)85%oftheentireTV(Takiharaetal.,1987;FortiandKrausz,1998; TAprimarilysuppliesthetestis,thedeferentialarteryperfusestheepi- ua
ry
Kollinetal.,2006).Septaradiatingfromthetunicaalbuginea(Fig.2)may didymisandvasdeferens,andthecremastericarterysuppliestheperi- 1
1
beseenasdelicatelinearhypoechoicstriae,convergingtoformthemedi- testicular tissues and the scrotal wall (Horstman et al., 1991a; Isidori , 2
0
astinumtestis(Fig.2),whichappearsinalongitudinalscanasahypere- and Lenzi, 2008) (Fig. 2). After entering the scrotum, the TA runs 15
choicline,eccentricallylocated.Whereastheconceptofecho-texture alongtheposterioraspectofthetestisandpenetratesthetunicaalbu-
homogeneity is a relatively objective finding, the construct of normal ginea,supplyingtwosetsofarteries,thecapsularandthetransmediast-
echogenicityismoreoperator-dependent.Homogeneityhasbeenclas- inal arteries (Fig. 2). The capsular arteries have a superficial course
sifiedona5-pointscalebyLenzetal.(1993)andWestlanderetal.(2001) beneath the tunica albuginea, in a layer called the tunica vasculosa,
(TableII).EchogenicitydependsontheSTmaturationandgermcellre- overthesurfaceofseminiferoustubules(SchlegelandLi-Ming,1997)
presentation.Prepubertaltestis,comparedwiththeadultone,isslightly (Fig.2).Theybranchcentripetalarteriesthatenterthetesticularpar-
more hypoechoic, since ST have not developed a lumen yet. During enchyma and flowtoward themediastinum (Horstman et al., 1991a)
puberty,asafunctionoflumendevelopment,testisechogenicitypro- penetrating between the septa separating the seminiferous tubules
gressively increases, up to average adult level. A reductionin and/or (SchlegelandLi-Ming,1997).Astheyapproachthemediastinum,the
anincreaseininterstitiumleadstoahypoechoicand/orinhomogeneous centripetal arteries arborize into recurrent rami that branch back in
echo-texture(Beresetal.,1989;Loberantetal.,2010)(Fig.4AandB,re- theoppositedirection,carryingbloodfromthemediastinumintothe
spectively). testis (Middleton et al., 1989; Migaleddu et al., 2012) (Fig. 2). In
some men, a large branch of the TA, the centrifugal transmediastinal
Vascularization.Thetestesaremainlyperfusedbythetesticulararteries artery,entersatthemediastinumandrunacrossthetesticularparen-
(TA)(Figs1and2),whicharisefromtheaorta,distaltotherenalar- chymawithastraightcourse,toformcapsularbranchesontheoppos-
teries, enter the spermatic cord at the deep inguinal ring and reach iteside(Horstmanetal.,1991a;Paisetal.,2004)(Fig.2).
62 LottiandMaggi
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Figure2 Schematicrepresentationofthescrotalorgansandrelatedarterialsupply.Themainstructuresofthetestis,aswellasepididymisandvasdef- ls
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erensareshowninblackandwhite.Onetesticularlobuleishighlightedinblue.Thearterialsupplyofthescrotalorgansisshowninred.Thestructureofthe rg
testisandthenormalanatomyofthescrotalarterialsupplyareextensivelydiscussedinthetext. a/
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Pampiniformplexus with echogenicity comparable tothatof thetestisand usuallyslightly ib
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Normalpampiniformplexus(Fig.1)isscarcelyappreciablebyphysical moreechogenicthanthebodyandtail(Dograetal.,2003;Leeetal., ry
o
examination. It is also poorly detected by gray-scale US, because of 2008)(Fig.3C).Itisusuallymeasuredinalongitudinalscanfromthe n J
a
thedifficultyindifferentiatingitfromtheotherstructuresinthespermatic toptothebaseofthetriangle(Pezzellaetal.,2013;Pilatzetal.,2013a) nu
a
cord(Fig.3B).Hence,colororpowerDopplershouldbeappliedand (Fig. 3C). The body and tail are measured considering the anterior- ry
1
theyshouldnotshowanyvenousreflux.Innormalconditions,thepam- posterior diameters (Vicari, 1999; Pezzella et al., 2013) (Fig. 3D). A 1, 2
piniformplexusappearsasacomplexnetworkofsmallvessels,2mmin headof5–12mm(Behreetal.,1995;Vicari,1999;Dograetal.,2003; 01
5
diameter (Dogra et al., 2003; Cina et al., 2006) converging into the Leeetal.,2008;Pezzellaetal,2013;Pilatzetal.,2013a),abodyof2–
spermaticveins.Therightspermaticveinentersobliquelyintotheinfer- 4mm(Behreetal.,1995;Dograetal.,2003;Leeetal.,2008)andatail
iorvenacava,whereastheleftoneentersperpendicularintotheleftrenal of 2–6mm (Vicari, 1999; Dogra et al., 2003; Lee et al., 2008) have
vein,andisthereforeburdenedbyhigherbloodhydrostaticpressure. beenproposedasnormal.BloodflowisdetectablebyCDUSindiscrete
When the pressure becomes excessive and/or the venous valvular vascularspotsinalltractsoftheepididymis(Keeneretal.,1997).
mechanismisimpaired,venousrefluxanddilationmayoccur,leading Thevasdeferens(VD)isastraighttensecordwhichextendsalongthe
tovaricocele(Gatetal.,2008)(seebelow). spermaticcord(Figs1and2).VDabsence,withorwithoutepididymal
agenesis,isoftenadifficultpalpatorydiagnosis,tobeconfirmedbyUS.
AtscrotalUS,theproximalVDappearsasastraightduct,slightlyhypoe-
Epididymisandproximalvasdeferens
choiccomparedwiththeepididymis,originatingfromtheepididymaltail
Thenormalepididymisisasoftorganthatliesalongthesuperiormargin
(Fig.3D)andextending,alongthespermaticcord,towardtheinguinal
ofthetestisandisclassicallydividedintothreesegments:thehead,body
channel(IsidoriandLenzi,2008).
andtail(Figs1and2).Theheadcontains10–15efferentductulesorigin-
atingfromtheretetestis,whichconvergeinasingle,convolutedtubein
Prostate-vesicularregion
the distal portion (Fig. 2). At US, the epididymis is usually detected
posterior-laterallytothetestis,withtheheadandtailattheupperand The prostate-vesicular region is usually assessed at transrectal US
lower pole of the testis, respectively. The normal head is triangular, (TRUS),usingatransrectalbiplanarprobe(linearandconvextransducer,
Malegenitaltractultrasoundandreproductivehealth 63
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64 LottiandMaggi
6.5–7.5MHz)oran‘endfire’probe(6.5MHz,fieldofview50–2008), Seminalvesicles,deferentialampullasandejaculatoryducts
through transverse, longitudinal and oblique scans, with patients The seminal vesicles (SV) are paired, saccular and coiled structures,
placed in the left lateral decubitus (Behre et al., 1995; Older and located superior and posterior to the prostate (Fig. 1), between the
Watson,1996;Vicari,1999,Lottietal.,2011a,b,2012a,c). bladderandtherectum(Ramchandanietal.,1993;KimandLipshultz,
1996; Kim et al., 2009). They produce an alkaline fluid contributing
50–80%oftheejaculatevolume(Ramchandanietal.,1993;Kimetal.,
Prostate 2009).
Theprostateisatubuloalveolar,exocrineglandsurroundingthemale SVappearatTRUSassymmetricorganswhichliecephalictothepros-
urethra(Fig.1)justbelowtheneckofthebladder,whichproducespros- tateandposteriortothebladder(Ramchandanietal.,1993;KimandLip-
taticfluid,anacidicsecretionwhichmakesup(cid:2)30%ofthetotalejaculate shultz,1996;Kimetal.,2009;Lottietal.,2012a).Theyhaveatypical
(Cooper,2010). ‘bow-tie’appearanceintransversalscans,andaclubortennis-racket
ThenormalprostateatTRUSappearsinyoungadultsassymmetric, shapeinlongitudinalscans(Fig.3GandH,respectively).SVecho-texture
triangular or ellipsoid and, in older men, pear- or orange-shaped ischaracterizedbyhomogenousfineechoesanditisslightlylessecho-
(OlderandWatson,1996;RazaandJhaveri,2012).Itsbaseliesatthe genicthantheprostate(Ramchandanietal.,1993;KimandLipshultz,
bladderneck,atthebeginningoftheurethra,detectableinalongitudinal 1996).
scanasahypoechoicductcurvingtowardtheprostaticapex.TRUSiden- SVvolumeispositivelyaffectedbycirculatingtestosterone(Sasagawa
D
tifiesaperipheralzone(PZ),whichextendslaterallyandposteriorlyfrom etal.,1989,1990)andprolactin(Lottietal.,2013a),andincreasesduring ow
n
theapextothebase,andatransitionalzone(TZ),centrallylocatedand aprolongedsexualabstinence(Lottietal.,2012a).Inrelativelyyoung lo
a
slightlyhypoechoic(Fig.3E).ThePZandTZshowa3:1ratioinyoung subjects, SV volume is negatively associated with age (Lotti et al., de
d
men (Doble and Carter, 1989; Jin et al., 2001). Some authors also 2012a)andtendstoshrinkafterthefifthdecade,showingasignificantre- fro
report a central zone (Berger et al., 2006; Jin et al., 2001). Prostate ductionintheeighthcomparedwiththefourthdecade(Terasakietal., hm
volume (PV) is often measured using a planimetric method (Behre 1993). ttp
etal.,1995;Vicari,1999;Lottietal.,2011a,b).Itiscalculatedbymeas- WhilemostoftheavailablestudieshaveassessedSVdiameters,we ://h
u
m
uringthreediameters(anterior-posteriorandtransverseinthetransver- recently proposedcalculating SV volume by measuring themaximum u
p
sal scan, longitudinal in the sagittal one; Fig. 3E and F) using the longitudinal and anterior-posterior diameters, using the ‘ellipsoid/ d.o
x
mathematical formula of the ellipsoid (Collins et al., 1995; St Sauver prolatespheroid’mathematicalformula(Lottietal.,2012a)(Fig.3H). fo
etal.,2006;Lottietal.,2011a,2014a).‘TZvolume’issimilarlycalculated SVvolumevarieswithejaculationandispositivelyrelatedtotheejaculate rdjo
u
(StSauveretal.,2006;Lottietal.,2014a).APVof20–25mlhasbeen volume,butnotwithspermparameters(Lottietal.,2012a). rn
a
proposed as normal in young men (Raza and Jhaveri, 2012). The Thedeferentialampullas(DA)(Fig.1)appearatTRUSasovalstruc- ls
.o
normaladultprostateshowsthin,denselypackedandhomogeneously turesmedialtotheSVintransversalscans,justcephalictotheprostate, rg
a/
deployedechoes.Theperiprostaticvenousplexus(PVP)isdetectable orasdistalVDenlargementsinlongitudinalscans(Fig.3GandI,respect- t H
asaslightlyhypoechoicsystemofvessels(Fig.3EandF).Intraprostatic ively).Theyhaveanecho-texturesimilartothatoftheSV. arv
a
arteriesaregroupedincentral/periuretralandperipheral/capsularar- Theejaculatoryducts(Fig.1)appearatTRUSassubtleandhypoe- rd
teries,supplyingtheTZandPZ,respectively(OlderandWatson,1996). choic,withanormalcaliber,2mm(Fig.3J).Theyaredetectablein Lib
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Figure3 Normalcolor-Dopplerultrasound(CDUS)featuresoftheorgansofthemalegenitaltract.(A)Testisofnormalvolume,homogeneityand ua
echogenicitywithellipsoidshape.Longitudinal(rightfigure)andtransversal(leftfigure)scansofthetestis,withlength(D1),width(D2)andheight(D3) ry 1
measurementsarereported.(B)Leftfigure:B-modeappearanceofthespermaticcord(SC)andtheupperpoleofthetestis(T)inalongitudinalscan. 1, 2
Small,non-dilatedvenousvesselsofthepampiniformplexusaredifficulttodifferentiatefromtheotherstructuresoftheSC.Rightfigure:CDUSdetection 01
5
ofthetesticularartery(arrow)intheSCandrecurrentramus(^)ofanintratesticularcentripetalartery.Venousrefluxatrestinthevenousvesselsisnot
detectable.(C)Normalepididymalheadwithtriangularshapeinalongitudinalscan,homogeneous,withechogenicitycomparabletothatofthetestis(T).Its
lengthismeasuredfromthetoptothebaseofthetriangle.(D)Homogeneousepididymalbodyandtailandproximalvasdeferens(pVD)inalongitudinal
scan.Theirechogenicityisslightlyhypoechoiccomparedwiththetestisandtheepididymalheadin(C).Theirdiametersarereportedasdashedlines.The
reddashedlineindicatestheendoftheepididymaltailandthebeginningofthepVD.Thecurvearrowindicatestheepididymal-deferentialhandle.(E)
Prostateofnormalvolume,homogeneityandechogenicityinatransversalscan.Peripheralandtransitionalzones(PZandTZ)showa3:1ratioin
youngmen.Rightandleftlobes(RLandLL,respectively)andperiprostaticvenousplexus(PVP)areindicated.Anterior-posteriorandtransversediameters
(‘apd’and‘td’,respectively)arereported.(F)Prostateofnormalvolume,homogeneityandechogenicityinasagittalscan.Peripheralandtransitionalzones
(PZandTZ,respectively)andtheapex(A)areindicated,aswellasthebladder(B),urethra(U),prostaticutricle(*)andperiprostaticvenousplexus(PVP).
Thelongitudinaldiameter(‘ld’)isreported.(G)Rightandleftseminalvesicles(rSVandlSV,respectively)withtypical‘bow-tie’appearanceand,medialto
them,rightandleftdeferentialampullas(sDAandlDA,respectively)inatransversalscan.(H)Seminalvesicle(SV)assessedby‘endfire’probeinsagittal
scan.Thefundusandbodyarereported,aswellasthelongitudinalandanterior-posteriordiameters(‘ld’and‘apd’dashedlines,respectively).Aschematic
modelofSVvolumecalculationisreported,usingthe‘ellipsoid/prolatespheroid(d1.d2¼d3)’(redellipse)mathematicalformula(d1×d2×d3×4/
3×p),withd1¼ldandd2¼apd,andd3assumed¼d2(reddashedline)(accordingtoLottietal.(2012a)).(I)Distalvasdeferens(dVD)anddeferential
ampulla(DA)besideasectionoftheseminalvesicle(SV)assessedby‘endfire’probeinasagittalscan.(J)Ejaculatoryduct(arrows)andprostaticutricle
assessedby‘endfire’probeinasagittalscan.Thedeferentialampulla(DA),asectionoftheseminalvesicle(SV),theurethral(U)course(dashedline),
bladder(B)andprostate(Pr)arereported.
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TableII Color-Dopplerultrasound(CDUS)abnormalitiesoftheorgansofthemalegenitaltract,clinicalassociationsandavailablecutoffdiscriminatingnormaland n
pathologicfeatures. ital
tr
a
c
t
CDUSecho-patternabnormalities Associations Cutoff u
.......................................................................................................................................................................................................................................................... ltr
a
Testis so
u
n
Inhomogeneity – Carcinomainsituincryptorchidmen(Lenzetal.,1987) Abnormalpattern:grade2–5 d
a
Lenzetal.(1993) – Testistumor(Lenz,1991;Woodwardetal.,2002;IsidoriandLenzi,2008) nd
– Severalpathologicalconditions,includinghypogonadism,ischemia,orchitis,trauma, r
(1) Veryuniformpattern e
(2) Slightlyirregularpattern torsion,exposuretophysicalorchemicalagents,chemo-andradio-therapyoralcohol pro
abuse(Loberantetal.,2010;Migaledduetal.,2012;Lottietal.,2013b) d
(3) Moderatelyirregularpatternorsmallechogenic u
pointsthroughoutanysectionalview – Klinefelter’ssyndrome:inhomogeneoustesticleswithspreadhyper-andhypoechoicfoci ctiv
(EkerhovdandWestlander,2002) e
(4) Veryirregularpatternorbrightechogenicspots(at h
– M540bodies,roundanucleatedelements,detectedbyfluocytometryinthesemen, e
leastthroughoutthetestis) a
(5) Tumorsuspectedduetodemarcatedarea markersofapoptosis-relatedspermatogenesisderangement(Lottietal.,2012d) lth
– Metabolicsyndrome,aclusterofmedicalconditionswhichincreasestheriskoftype2 Abnormalpattern:grade3–5
Westlanderetal.(2001) diabetesmellitusandcardiovasculardiseases,recentlyrecognizedasanewriskfactoralso
forfertility(Albertietal.,2009;Kasturietal.,2008;Lottietal.,2013b)
(1) Homogeneous
(2) Homogeneouswithsomehyperechogenicfoci
(3) Heterogeneouswithspreadhyperechogenicity
(4) Heterogeneouswithbothhyperechogenicand
cystic(hypoechogenic)parenchima
(5) Post-operativeintratesticularlesion
– Calcifications/Microcalcifications, – TMandtesticularcancer(debated)(RichenbergandBrejt,2012;Appelbaumetal.,2013) – Microcalcifications:1–3mm
– Testicularmicrolithiasis(TM) – TMandmaleinfertility(Yeeetal.,2011) – TM,≥5/USscan
(RichenbergandBrejt,2012)
Epididymis
Hypoechogenicity – Acute/subacuteinflammation(Woodwardetal.,2003;IsidoriandLenzi,2008) Notreported
– MAGI,elevatedsIL8(Vicari,1999;Lottietal.,2011a;LottiandMaggi,2013)
Hyperaemia
Hyperechogenicity – Chronicinflammation(Woodwardetal.,2003;IsidoriandLenzi,2008)
– MAGI,elevatedsIL8(Vicari,1999;Lottietal.,2011a;LottiandMaggi,2013)
Coarsecalcifications
Prostate
Glandularasymmetry – MAGI(ChristiansenandPurvis,1991;Vicari,1999), Notreported;proposed5mm
– Fibro-scleroticMAGI(LaVigneraetal.,2011e)
Nonhomogeneity – MAGI,CP/CPPS(DiTrapanietal.,1988;ChristiansenandPurvis,1991; Abnormalpattern:grade1–3:1,mild;2,moderate;3,
Behreetal.,1995;Vicari,1999) severeinhomogeneity
– ElevatedsIL8(Lottietal.,2011a;LottiandMaggi,2013) (Lottietal.,2011b,2014b)
– Overweight/obesity(Lottietal.,2011b)andMetS(Lottietal.,2014a)
– PLS(Lottietal.,2014b)
Continued
6
5
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