Ejaculatory duct obstruction presents with a low ejaculate volume on semen analysis in association with no sperm count or very low sperm motility. Ejaculatory duct obstruction is the cause of infertility in 1-5% of infertile men. Although unusual, ejaculatory duct obstruction is diagnosed and treated with minimally invasive techniques, many of them pioneered by Dr. Turek.
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The Problem: Ejaculatory Duct Obstruction
Male fertility doctor, Dr. Turek, is one of the world’s thought leaders on the diagnosis of ejaculatory duct obstruction, having written and published extensively about this problem in the past 18 years. Ejaculatory duct obstruction is suspect with low ejaculate volume and abnormal semen quality with normal FSH and testosterone as well as normal testis size (20cc). The diagnosis is confirmed by transrectal ultrasound (TRUS) showing large seminal vesicles or dilated ejaculatory ducts in association with a cyst, calcification or stones along the duct. Once diagnosed, it is treated surgically in 1 hour by a procedure performed through the penile urethra near the prostate (transurethral resection of the ejaculatory ducts, TURED). According to Dr. Turek’s infertility research, over 75% of men who undergo the procedure will achieve a significant improvement in semen quality and at least a 30% pregnancy rate can be expected. Complications include temporary blood in the ejaculate, blood in the urine requiring another catheter to clear and urinary tract infection. Less frequently, epididymitis and a “watery” ejaculate can result.
- Purohit R, Wu R, Shinohara K, Turek PJ. J Urol. 2004; 171: 232-236.
Ejaculatory Duct Anatomy
The ejaculatory ducts are paired tubules that begin near the vas deferens behind the prostate and next to the seminal vesicle. They course through the prostate and empty into the prostatic urethra at the verumontanum. Although the ejaculatory duct contains an outer muscular layer in as it enters the prostate, Dr. Turek’s research has shown that there is no valve-like, muscular “sphincter” at the ejaculatory duct orifices that could cause obstruction, as was once thought.
Interestingly, Dr. Turek’s prior animal studies suggest that the seminal vesicle and ejaculatory ducts are much like the bladder and urethra. The seminal vesicle is a smooth muscular organ similar to the bladder and the ducts act like a conduit, but for ejaculate instead of urine. It is well known that ejaculatory duct obstruction can result from blockage of the ducts. But this analogy to the bladder and urethra suggested to Dr. Turek that it is also conceivable that “functional,” and not physical, obstruction could exist. This observation had 2 important implications: 1) anatomical imaging really needs to define both of these forms of “obstruction,” and 2) the evaluation of this condition should consider medication use and review conditions that might predispose to seminal vesicle dysfunction.
Definition of Ejaculatory Duct Obstruction (EDO)
Ejaculatory duct obstruction (EDO) can take several forms (Table 1). Complete or classic EDO is the physical blockage of both ejaculatory ducts and presents with low volume azoospermia. Incomplete or “partial” EDO is the unilateral, physical blockage of one of the ducts or the partial blockage of both ducts. This is generally associated with low ejaculate volume and low sperm concentrations and severely impaired motility. Functional EDO is a form of ejaculatory dysfunction that presents as classic EDO but without anatomical evidence of physical blockage.
Table 1: Classification of Ejaculatory Duct Obstruction By Semen Analysis
|Incomplete or Partial||Complete||Functional|
|Ejaculate volume||Low or Low-normal||Low||Low|
|Sperm count||Low||Absent||Absent or low|
|Sperm motility||Low||Absent||Absent or low|
|Ejaculate fructose||Present||Absent||Absent or low|
The Diagnosis of Ejaculatory Duct Obstruction
The causes of EDO can be divided into congenital and acquired disorders. EDO can result from stones, Mullerian duct (utricular) or Wolffian duct (diverticular) cysts, surgical or inflammatory scar tissue, calcification near the veru montanum, or congenital absence of the ducts. In cases of congenital blockage, a genetic evaluation for cystic fibrosis gene mutations is recommended. Classically, EDO presents with blood in the ejaculate (hematospermia), painful ejaculation, or infertility. Associated risk factors include prior urinary tract infection, epididymitis, perineal injury, and testis pain. It is important to discontinue medications that may impair ejaculation. A physical examination may reveal enlarged seminal vesicles on rectal examination. The diagnosis is confirmed by laboratory findings: an ejaculate volume < 2.0 ml and a pH <7.2 that contains no sperm or fructose, a transrectal ultrasound (TRUS) demonstration of dilated seminal vesicles (>1.5 cm width) or dilated ejaculatory ducts (>2.3 mm) in association with a cyst, calcification, or stones along the duct. Importantly, no single TRUS finding is classic for EDO. To complete the evaluation for infertility, it is important that the serum FSH and testosterone and testicular volume are normal. In cases of partial EDO, patients not have symptoms but can have low or low-normal ejaculate volume. Sperm concentration is generally below normal but characteristically motility is severely impaired (<30%).
Tests to Confirm Ejaculatory Duct Obstruction
One problem with using transrectal ultrasound to diagnose EDO is that not all patients with EDO have dilated seminal vesicles and not all patients with dilated seminal vesicles have EDO. In fact, Dr. Turek published that treating EDO based simply on TRUS findings will lead to unnecessary treatment in as many as half of cases. This has led to further refinements diagnostic techniques to help define obstruction.
Seminal Vesicle Sperm Aspiration. This procedure involves looking at the fluid within the seminal vesicle after tapping the system with a fine needle. The finding of >3 sperm/hpf in the seminal vesicle fluid is suggestive of obstruction. Importantly, seminal vesicle aspiration should be performed with <24 hours of sexual abstinence. Although this technique does not localize the site of blockage or tell the difference between physical blockage and functional obstruction, it confirms that sperm are being made.
TRUS guided-seminovesiculography. An injection of dye followed by an X-ray of the pelvis can also inform the diagnosis of EDO. A nice modification of this is to inject colored dyes (chromotubation) that provide visual evidence of obstruction without the use of X-rays.
In Dr. Turek’s prospective study of all of these techniques, chromotubation was deemed the most accurate way to diagnosis EDO. However, the diagnosis of partial EDO was still difficult to make with these techniques.
Ejaculatory Duct Manometry. To solve the problem of how to best diagnose both complete and incomplete or partial EDO, Dr. Turek invented the technique of ejaculatory duct manometry. This is a test that can differentiate between partial and complete, as well as physical from functional forms of obstruction. Similar to using urodynamics to study bladder outlet obstruction, Dr. Turek felt that that measuring ejaculatory duct opening pressures, defined as the pressure above which fluid enters the prostatic urethra, could distinguish among the various forms of EDO. Indeed, in his prospective, comparative study of fertile men and men with confirmed EDO, ejaculatory duct opening pressures were significantly higher in untreated EDO patients (mean 116 cm H20) compared to fertile men (mean 33 cm H20). Thus, ejaculatory duct manometry has the most potential to differentiate complete from partial, and physical from functional forms of EDO. Dr. Turek now routinely performs this procedure on all men suspected of having ejaculatory duct obstruction.
Treatment of Ejaculatory Duct Obstruction
Indications for treatment of EDO include painful intercourse, blood in the ejaculate and infertility. Discontinuation of medications in Table 2 may improve ejaculatory dysfunction. However, definitive treatment due to obstruction is transurethral resection of the ejaculatory ducts (TURED), a procedure performed in an outpatient setting under general or regional anesthesia in about an hour. TRUS assists with precise localization of the obstruction and confirms the depth of resection. Typically, TURED can successfully treat lesions within 1 to 1.5 cm of the verumontanum.
Table 2: Medications associated with impaired ejaculation
|Antihypertensive agents||α-Adrenergic blockers (Prazosin, Phentolamine Thiazides|
|Antipsychotic agents||Mellaril (Thioridazine) Haldol (haloperidol)|
The technique combines cystourethroscopy with resection of the verumontanum in the midline (for complete obstruction) or laterally (hemi-TURED, for unilateral obstruction). Postoperatively, a small Foley bladder catheter is placed for 24 hours and removed on an outpatient basis. Intercourse may be resumed after 5 days. A formal semen analysis is examined at 2 weeks and at regular intervals thereafter, until semen quality stabilizes.
Patients demonstrate a 20% to 30% natural pregnancy rate after TURED. Men treated for either complete or partial EDO are equally likely to show improvements in semen quality after TURED. Obstruction due to cysts responds better to TURED than that due to calcification. Long-term relief of postcoital and perineal pain after TURED can be expected in 60% of patients. While hematospermia has been effectively treated with TURED, this literature remains anecdotal. Complications from TURED occur in 10- 20% of cases and include watery ejaculate, blood in the urine, epididymitis and, rarely, incontinence or rectal perforation. Epididymitis and “watery” ejaculate occur less frequently, but typically are a cause of greater concern. The patient should understand several possible alternative outcomes from TURED surgery. Four percent of patients treated for partial EDO may become azoospermic after TURED, presumably from scar formation. It may be prudent to advise sperm banking before TURED in this instance.
- Purohit R, Wu R, Shinohara K, Turek PJ. J Urol. 2004; 171: 232-236.