What are the treatment options for low semen volume and pelvic pain?

Evaluation and Treatment of Low Semen Volume with Pelvic Pain

For a man presenting with low semen volume and pelvic pain, the most critical first step is to determine whether ejaculatory duct obstruction (EDO) is present, as this is a treatable structural cause that can restore natural fertility, while simultaneously evaluating for chronic prostatitis/chronic pelvic pain syndrome (CPPS) which commonly coexists with reproductive tract abnormalities. 1, 2

Initial Diagnostic Workup

Physical Examination Priorities

• Palpate for bilateral vas deferens to rule out congenital bilateral absence of vas deferens (CBAVD), which can be diagnosed by physical examination alone and requires no further imaging 1
• Assess testicular size and consistency: normal-sized testes suggest obstruction while atrophic testes indicate spermatogenic failure 1
• Perform digital rectal examination to evaluate prostate size, consistency, and tenderness (tenderness suggests prostatitis/CPPS) 1, 3
• Examine for palpable varicoceles, as treatment of clinical varicoceles improves semen parameters, but non-palpable varicoceles should not be treated 1

Critical Laboratory Tests

Order these tests immediately to distinguish obstructive from non-obstructive causes:

• Semen analysis with pH measurement: acidic semen (pH <7.0) with volume <1.4-1.5 mL strongly suggests ejaculatory duct obstruction or CBAVD 1
• Serum testosterone and FSH: low testosterone with low/normal FSH indicates hypogonadotropic hypogonadism; elevated FSH (>7.6 IU/L) suggests primary testicular failure 1
• Post-ejaculatory urinalysis when volume <1 mL (except in bilateral vasal agenesis or hypogonadism) to diagnose retrograde ejaculation 1

When to Order Advanced Imaging

Transrectal ultrasound (TRUS) or pelvic MRI is indicated specifically when:

• Semen is acidic (pH <7.0) AND
• Volume <1.4-1.5 mL AND
• Azoospermia or severe oligospermia with very low motility AND
• Normal serum testosterone AND
• Palpable vas deferens bilaterally 1

Do not perform TRUS or pelvic MRI as part of initial evaluation unless these specific criteria are met 1

Treatment Algorithm Based on Etiology

If Ejaculatory Duct Obstruction is Confirmed

Transurethral resection of ejaculatory ducts (TURED) is the definitive treatment when TRUS or MRI shows dilated seminal vesicles and ejaculatory ducts 1, 2

• TURED may result in significant improvement in sperm quality and spontaneous pregnancies in up to 25% of couples 2
• If TURED fails, proceed to sperm aspiration from epididymis with intracytoplasmic sperm injection (ICSI) 2
• Alternative option: surgical sperm extraction (TESE, TESA, or percutaneous epididymal sperm aspiration) for use with assisted reproductive technology (ART) 1

If Congenital Bilateral Absence of Vas Deferens (CBAVD)

No medical or surgical treatment restores ejaculatory volume; proceed directly to sperm retrieval (TESE/MESA) with ICSI 4

• CFTR gene testing for the female partner is mandatory before proceeding with assisted reproduction 4
• TRUS does not contribute to diagnosis or treatment in CBAVD and should not be performed 1

If Clinical (Palpable) Varicocele is Present

Varicocelectomy is indicated for palpable varicoceles with abnormal semen parameters 1, 4

• Varicocelectomy improves semen parameters and may restore sperm in ejaculate for men with azoospermia 4
• Do not treat subclinical (non-palpable) varicoceles, as this does not improve semen parameters or fertility rates 1, 4
• Do not use ultrasound to hunt for subclinical varicoceles—only palpable varicoceles benefit from treatment 4

If Chronic Prostatitis/CPPS is Suspected

The combination of pelvic pain with low semen volume raises concern for inflammatory-associated obstruction:

• Chronic prostatitis causes scarring of prostatic and ejaculatory ducts, resulting in low seminal volume with low fructose and alpha-glucosidase 2
• Infections are present in 22-50% of men with ejaculatory duct obstruction 2
• CPPS affects acrosome reaction and sperm function, with patients showing poorer sperm morphology and concentration 5
• Post-ejaculatory pain is associated with more severe symptoms and lower quality of life 3

Treatment approach:

• If TRUS shows abnormalities (edema, dilatation of seminal vesicles/ejaculatory ducts, intraprostatic calcifications), consider TURED 2
• Address inflammatory component with appropriate antimicrobial therapy if infection documented 2

If Hypogonadotropic Hypogonadism (Low T with Low/Normal FSH)

Refer to endocrinologist or male reproductive specialist 1

• Initiate hCG injections to normalize testosterone, then add FSH or FSH analogues to optimize sperm production 1
• Never prescribe testosterone monotherapy for males interested in current or future fertility, as it suppresses spermatogenesis 1

If Idiopathic with Normal Testosterone

Clinicians may use aromatase inhibitors (AIs), human chorionic gonadotropin (hCG), or selective estrogen receptor modulators (SERMs) for infertile men with low serum testosterone 1

• For men with normal testosterone and idiopathic infertility, inform that SERMs have limited benefits relative to ART 1
• Supplements (antioxidants, vitamins) are of questionable clinical utility; existing data are inadequate to recommend specific agents 1

Genetic Testing Before Proceeding with ART

Do not delay genetic testing—results impact counseling and treatment decisions:

• Karyotype testing is mandatory for azoospermia or severe oligospermia (<5 million/mL) 1, 4
• Y-chromosome microdeletion analysis is required for azoospermia or sperm concentration <1 million/mL 1, 4
• Genetic counseling should precede ICSI, as genetic abnormalities may be transmitted to offspring 4

Critical Pitfalls to Avoid

• Do not perform TRUS or pelvic MRI as part of initial evaluation—reserve for cases with clear clinical suspicion of EDO (low volume, acidic, azoospermic semen with normal testosterone and palpable vas) 1, 4
• Do not use ultrasound to identify subclinical varicoceles—only palpable varicoceles benefit from treatment 1, 4
• Do not prescribe testosterone to men desiring fertility—it suppresses spermatogenesis and worsens fertility 1
• Do not ignore the pelvic pain component—inflammatory-associated obstruction is a treatable cause that may restore natural fertility 2

When to Consider Assisted Reproductive Technology

For couples with low total motile sperm count (<5 million motile sperm after processing), IUI success rates are reduced; consider IVF/ICSI 1

• ART allows fertility for couples where natural pregnancy has not occurred, though it does not correct the underlying condition 1
• ICSI appears to overcome adverse effects of sperm quality as long as adequate viable sperm are present 1