UvA-DARE is a service provided by the library of the University of Amsterdam (https://dare.uva.nl)
UvA-DARE (Digital Academic Repository)
Male accessory gland infection and subfertility: a diagnostic challenge
Trum, J.W.
Publication date
1999
Link to publication
Citation for published version (APA):
Trum, J. W. (1999). Male accessory gland infection and subfertility: a diagnostic challenge.
General rights
It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons).
Disclaimer/Complaints regulations
If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible.
RA Schipper, J W Trum, EJ Messelink, F van der Veen, KH Kurth.
Abstract
Objective: To examine whether ultrasound abnormalities of the prostate and seminal
vesi-cles that may be related to male accessory gland infection, are reproducible.
Methods: Forty-seven men attending a infertility clinic were studied. Imaging findings of
transrectal ultrasonography were recorded. Kappa (K)-values to determine the intra-and inter-observer variation were assessed.
Results: Calcifications have a good intra-observer (K=0.77; 9 5 % C.I.: 0.59 to 0.96) and
good inter-observer repro-ducibility (K=0.73; 95% C.I.:0.54 to 0.93) Dilatation of the peri-prostatic venous plexus greater than 150 mm2 has a moderate intra-observer (K=0.57; 95% C.I.:0.33 to 0.80) and good inter-observer reproducibi-lity (K=0.74; 9 5 % C.I.:0.55 to 0.94). Other ultrasound abnormalities of the prostate are not reproducible. None of the ultrasound abnormalities of the seminal vesicles are reproducible.
Conclusions: In our study the prevalence of ultrasound abnormalities that may be related
to male accessory gland infection was as high as 96 %. However, only calcifications and dilatation of the venous plexus had a good reproducibility. Other observed ultrasound abnormalities of the prostate and seminal vesicles were poorly reproducible and are there-fore of no use in the diagnosis of male accessory gland infection.
Introduction
Transrectal ultrasonography (TRUS) has proven its usefulness in the diagnosis of benign
prostatic hyperplasia and prostatic carcinoma [1]. In male infertility TRUS can be used to
detect and evaluate the treatment of ejaculatory duct obstruction and to demonstrate
con-genital hypoplasia of the seminal vesicles [2,3] •
The role of transrectal ultrasound in the diagnosis of inflammation of the prostate and
seminal vesicles is still controversial. Many ultrasonographic abnormalities like capsular
thickening, calcifications, dilatation of the prostatic venous plexus, edema of the
bladder-neck, enlargement and cystic formation in the seminal vesicles are said to be characteristic
findings in male accessory gland infection [4-11]. However, some of these ultrasound
abnormalities are not well defined. Furthermore certain ultrasonographic features that were
said to be typical in patients with prostatitis were also found in prostates of healthy
per-sons [11].
Male accessory gland infection may be associated with poor semen quality and male
infer-tility [12-15].
TRUS may be of value in the diagnosis of accessory gland infection in male infertility
patients. However, before the accuracy of TRUS can be studied in the diagnosis of male
accessory gland infection in an infertility population, the intra- and inter observer
varia-tion of the above menvaria-tioned ultrasonographic abnormalities has to be determined [16].
The objective of this study is therefore, to determine the reproducibility of these
ultraso-nographic features.
Methods
Between November 1995 and April 1996 we asked a cohort of 47 men of subfertile
coup-les, who consecutively presented at the Center for Reproductive Medicine of the
Academic Medical Center in Amsterdam to participate in the study. Inclusion of these
men in the study, was regardless of the presence of accessory gland infection or
oligo-asthe-no-teratozoospermia. This study was carried out as part of a study in the detection of
sexually transmitted disease as cause of male infertility. Approval by the Institutional
Review Board of our hospital was obtained. All patients gave written informed consent.
Prostate specific antigen values in serum were measured (hybritech test), to exclude
prosta-tic carcinoma. All patients had a transrectal ultrasonography. All examinations were
perfor-med with a 7.5 Mhz probe (Briiel & Kjaer, Na;rum, Denmark). The prostate was scanned
in transverse planes and sagittal planes. The periprostatic plexus is always visible, but in
normal subjects the overall surface of the largest detectable section is less than 150mm2.
Dilatation of the periprostatic plexus greater than 150mm2, thickening of the prostatic
capsule, calcifications, and edema of the bladderneck were recorded. The seminal vesicles
were also scanned in transverse planes and sagittal planes. Cysts, presence of honeycomb
structures due to septa inside the seminal vesicles that are not visible in normal seminal
vesicles, calcifications and dilatation of the venous plexus were recorded. All examinations
were done by one observer and recorded on videotape. Intra-observer variation was
asses-sed in all patients using the videotape. For inter-observer variation two observers assesasses-sed
all patients independently. Both observers were blinded for the results of the first scan and
for the presence or absence of genital tract infections of the patient. Both observers were
senior urological residents with experience in transrectal ultrasonography. The data were
analyzed by calculation of the Kappa-coefficient (K). [17].
Results
The mean age of the patients was 34.2 years with a range from 24.8 to 51.7 years. The
median PSA value was 1.4 ng/ml with a range from 0.5 tol 1 ng/ml.
Transrectal ultrasonography was well tolerated by all patients. No signs of benign
hyperpla-sia or prostatic carcinoma were found.
The distribution of ultrasonographic findings of the prostate for both observers was as
fol-lows:Dilatation of the peri-prostatic plexus was seen in 26 (55%) vs. 24 patients (51%).
Thickening of the prostatic capsule was seen in 24 (51%) vs. 6 patients (12%),
calcifica-tions in 19 (40%) vs. 19 patients (40%), edema of the bladdemeck in 14 (30%) vs. 3
patients (6%) and cysts were observed in 2 (4%) vs. 1 patient (2%).
The distribution of ultrasonographic findings in the seminal vesicles was as follows:
Abnormalities of the seminal vesicles were equally distributed on both sides. Cysts were
seen in 14 (30%) vs. 1 patient (2%) on the right side and in 15 (32%) vs. 1 patient (2%)
on the left side. A honeycomb structure was seen in 16 (34%) vs. 12 patients (25%). In
half of the cases this finding was bilateral. Calcifications were seen in 2 (4%) vs. 0 patients.
Dilatation of the venous plexus in the seminal vesicles was seen in 2 (4%) vs. 8 patients
(17%).In only two patients non-of the above mentioned ultrasound abnormalities could
be found.
The data of the reproducibility are shown in table I and table II. In the present study
calci-fications had a good reproducibility. Dilatation of the venous plexus had a moderate
intra-observer and a good inter-intra-observer reproducibi-lity. Edema of the bladderneck and
thicke-ning of the prostatic capsule were not reproducible. None of the ultrasound abnormalities
of the seminal vesicles were reproducible or the prevalence was too low to calculate a
Table I Kappa values of intra- and inter-observer variation of ultrasonographic abnormalities of the prostate
Ultrasound abnormality intra-observer inter-observer
kappa (95%CI) kappa (95%CI)
Calcifications 0.77 (0.59-0.96) 0.73 (0.54-0.93)
Dilatation venous plexus 0.57 (0.33-0.80) 0.74 (0.55-0.94)
Edema bladderneck 0.59 (0.34-0.85) 0.01 (-0.24-0.26)
Thickening capsule 0.28 (0.00-0.55) 0.08 (-0.20-0.36)
Table II Kappa values of intra- and inter-observer variation of ultrasonographic variables of the seminal vesicles.
Ultrasound abnormality
Honeycomb left Honeycomb right Cystic lesion left Cystic lesion right
intra- observer inter-ol jserver
kappa (95%CI) kappa (95%CI)
0.50 (0.08-0.91) 0.33 (-0.09-0.75) 0.19 (-0.36-0.74) 0.33 (-0.09-0.75) 0.47 (0.18-0.76) 0.09 (-0.31-0.49) 0.36 (0.05-0.67) 0.04 (-0.48-0.39)
Discussion
Our results show that calcifications and dilatation of the venous plexus are reproducible in
infertility patients. This applies both for intra- and inter-observer reproducibility.
Ultrasound abnormalities like edema of the bladderneck, thickening of the prostatic
capsu-le and the echogenic pattern of the prostate are not reproducibcapsu-le. Abnormalities of the
seminal vesicles are not reproducible.
To our knowledge, no study has been done to assess the reproducibility of
ultrasonogra-phic features that may be associated with male accessory gland infection. Although we
stu-died a small number of patients, the 9 5 % confidence intervals of the K -values are small
enough to support our conclusions.
Poor agreement for the other ultrasonographic variables may be explained by the
follo-wing. The borders of the prostatic capsule are not clearly defined. There are no data on the
normal size of the prostatic capsule in healthy men or patients. The same applies for the
size of the bladderneck. Strict criteria are lacking for the ultrasonographic image of a
hone-ycomb structure of the seminal vesicles.
Furthermore, measurements of these ultrasound abnormalities are dependent on the
posi-tion of the probe, and may therefore be different at each investigaposi-tion.
Dilatation of the venous plexus and calcifications in the seminal vesicles were seen in low
frequencies. Therefore no kappa-values for these ultrasonographic variables could be
com-puted. However, it is likely that these abnormalities, like calcifications and dilatation of the
venous plexus in the prostate, have a good reproducibility.
Other abnormalities associated with male infertility like a Miillerian duct cyst (prostatic
utricular cyst) or hypoplasia of the seminal vesicles, were not seen in our study group.
We do acknowledge that reviewing recorded ultrasonograms is not an ideal study design
but in terms of patient acceptability it was the best alternative. Video recordings were
stan-dardized to prevent bias by focusing on abnormalities.
Three-dimensional ultrasound examinations and the use of automated analysis of
ultraso-nographic images may lead to a more reproducible assessment of prostate and seminal
vesi-cles in the future.
In conclusion, in our study the prevalence of ultrasonographic abnormalities that may be
related to male accessory gland infection was as high as 96%. However only calcifications
of the prostate gland and dilatation of the venous plexus in infertility patients had a good
intra-and inter-observer reproducibility. Other ultrasonographic abnormalities were poorly
reproducible and are therefore of no value in the diagnosis of male accessory gland
infecti-on with TRUS.
The accuracy of TRUS using reproducible criteria as a diagnostic tool to select men with
References
1 Peeling WB, Griffiths GJ. Imaging of the prostate by ultrasound. J Urol 1984; 132:217-223 2 Meacham RB, Hellerstein DK, Lipschultz LI. Evaluation and treatment of ejaculatory duct
obstruction in the infertile male. Fertil Steril 1993;59: 393-397.
3 Kim ED, Lipschultz LI. Role of ultrasound in the assessment of male infertility. J Clin Ultrasound 1996;24:437-453.
4 Doble A, Carter SS. Ultrasonographic findings in prostatitis. Urol Clin North Am 1989;4:763-772. 5 Griffirhs CJ, Crooks AJR, Roberts EE, Evans KT, Buck AC, Thomas PJ, Peeling WB. Ultrasonic
appearances associated with prostatic inflammation: a preliminary study. Clin Radiol. 1984;35:343. 6 Di Trapani D , Pavone C, Serretta V, Cavallo N , Costa M, Pavone-Maculso M. Chronic Prostatitis
and Prostatodynia: Ultrasonographic Alterations of the Prostate, Bladder Neck, Seminal Vesicles and Periprostatic Plexus. Eur Urol 1988;15:230-234.
7 Littrup PJ, Lee F, McLeary RD, Wu D, Lee A, Kumasaka G H . US of the seminal vesicles and ejacu latory ducrs; Clinical correlation. Radiology 1988;168:625-628.
8 Ludwig M, Weidner W Transrectal prostatic sonography as a useful diagnostic means for patients with chronic prostatitis or prostatodynia. Br J Urol 1994;73:664-668.
9 Wiegand S, Weidner W. Per rectal ultrasonography of the prosrate in the diagnosis of chronic prostatitis and prostatodynia. In: Weidner W, Brunner H, Krause W, Rothaug CF, ed. Therapy of Prostatitis. Munich; Bd. 11 der Reihe Klinische und experimentelle Urologie: Zukschwerdt 1986:3-13 10 Hendrikx AJM, de la Rosette JJMCH,van Helvoort-van Dommelen CA,van Dijk MA,
Semmelink H, Rijntjes NV, Debruyne FM. Histological analysis of ultrasonic images of the prostate: An accurate technique. Ultra-sound Med Biol 1990;7:667-674.
11 de la Rosette JJMCH, Karrhaus HFM, de Bruyne FMJ. Ultrasonographic findings in patients with nonbacterial prostatitis. Urol. Int. 1992;48:323-328.
12 Christiansen E, Tollefsrud A, Purvis K. Sperm quality in men with chronic abacterial prostatovesicu litis verified by rectal ultrasonography. Urology 1991;38:545-549.
13 Wolff H, Politch JA, Marrinez A, Haimovici F, Hill JA, Anderson DJ. Leukocytospermia is associa ted with poor semen quality. Fertil Steril 1990;53:528-536.
14 Berger R E, Karp LE, Williamson RA, Koehler J, Moore DE, Holmes KK. The relationship of pyospermia and seminal fluid bacteriology to sperm function as reflected in the sperm penetration assay. Fertil Steril 1982; 37:557-564.
15 Bar-Chama N , Fisch H. Infection and pyospermia in male infertility. World J Urol 1993; 11:76-81. 16 McDonough PG. Observer Variation and Clinical Decision Making (editorial comment) Fertil.Steril
1997;68:383.
17 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159-174.
