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An update on the diagnosis and management of ejaculatory duct obstruction

Nature Reviews Urology volume 13, pages 13–20 (2016)Cite this article

Subjects

Key Points

  • Ejaculatory duct obstruction (EDO) is a surgically reversible cause of male factor infertility, diagnosed in 1–5% of infertile men

  • EDO should be considered in the differential diagnosis of men presenting with nonspecific complaints related to sexual dysfunction such as periejaculatory pain, low volume ejaculate and haematospermia

  • Congenital causes of EDO include congenital atresia or stenosis of the ejaculatory ducts and Müllerian duct (utricular) or Wolffian duct (diverticular) cysts

  • The work-up of men presenting with possible EDO includes clinical examination, transurethral ultrasonography, semen analysis, chromotubation, seminal vesiculography and seminal vesicle aspiration

  • Transurethral resection of ejaculatory ducts (TURED) remains the mainstay of treatment for EDO; complications after TURED occur in approximately 13–26% of patients

Abstract

Ejaculatory duct obstruction (EDO) remains a rare but surgically correctable cause of male sexual dysfunction and male infertility due to obstructive azoospermia, diagnosed in up to 5% of infertile men. EDO should, therefore, be considered within the list of differential diagnoses for men undergoing infertility investigations, with work up including clinical examination, transurethral ultrasonography, semen analysis, chromotubation, seminal vesiculography and seminal vesicle aspiration. Obstruction can be limited to the distal ends of the ducts or it can extend proximally to include the terminal portions of the vasa deferentia, with the site and length of the obstruction having implications for surgical intervention. Early endoscopic treatment can reverse symptoms and prevent the progression of partial obstruction to bilateral, complete obstruction, and transurethral resection of the ejaculatory duct remains the main treatment option for EDO. Alternative treatment options include endoscopic laser-assisted resection of the ducts, antegrade seminal-vesicle lavage to relieve EDO secondary to inspissated material or calculi, or dilatation of the ejaculatory ducts using 9F seminal vesicoscopy or balloon.

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Figure 1: Ejaculatory duct anatomy.
Figure 2: Transrectal ultrasonography (TRUS) image showing a prostatic cyst.
Figure 3: MRI scan of a midline cyst.
Figure 4: Transrectal ultrasonography (TRUS) image of a Müllerian cyst.
Figure 5: The surgical approach in transurethral ejaculatory duct resection (TURED).
Figure 6: Picture of ejaculatory duct following resection.

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Authors and Affiliations

  1. Department of Urology, Worcestershire Acute Hospitals NHS Trust, Alexandra Hospital, Woodrow Drive, B98 7UB, Redditch, UK

    Vaibhav Modgil

  2. Department of Urology, Harrogate District Hospital, Lancaster Park Road, HG2 7SX, Harrogate, UK

    Sonpreet Rai

  3. Department of Andrology, University College London Hospital, 250 Euston Road, NW1 2PG, London, UK

    David J. Ralph & Asif Muneer

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V.M., S.R., and A.M. researched data for article, made substantial contributions to discussion of content, wrote the article, and reviewed/edited the manuscript before submission. D.J.R. reviewed/edited the manuscript before submission.

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Correspondence to Asif Muneer.

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Modgil, V., Rai, S., Ralph, D. et al. An update on the diagnosis and management of ejaculatory duct obstruction. Nat Rev Urol 13, 13–20 (2016). https://doi.org/10.1038/nrurol.2015.276

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