What are the symptoms and treatment options for ejaculatory duct obstruction?

Ejaculatory Duct Obstruction: Symptoms and Treatment

Ejaculatory duct obstruction (EDO) presents with a characteristic triad: low ejaculate volume (<1.4 mL), acidic semen (pH <7.0), and azoospermia or severe oligospermia with very low motility, in the setting of normal testosterone and palpable vas deferens. 1

Clinical Presentation and Symptoms

Primary Infertility Symptoms

• Low ejaculate volume (<1.4 mL) is the hallmark finding that should raise suspicion for distal genital tract obstruction 1
• Azoospermia or severe oligospermia with markedly reduced sperm motility 1
• Acidic semen (pH <7.0) due to absence of alkaline seminal vesicle fluid 1
• Absent fructose in semen, though fructose testing is relatively unreliable and not necessary when clinical suspicion is high 1

Additional Symptoms

• Chronic pelvic pain may be present in some patients 2
• Post-ejaculatory pain can occur with EDO 2
• Normal secondary sex characteristics and testicular size on examination distinguish this from primary testicular failure 3

Diagnostic Workup

Physical Examination Findings

• Palpable vas deferens bilaterally confirms the ducts are present (distinguishes from congenital bilateral absence of vas deferens) 1
• Normal testicular size and consistency suggests obstruction rather than spermatogenic failure 4
• Normal serum testosterone rules out hypogonadotropic hypogonadism 1

Imaging Studies

Clinicians should recommend TRUS or pelvic MRI in males with semen analysis suggestive of EDO (acidic, azoospermic semen with volume <1.4 mL, normal testosterone, palpable vas deferens). 1

Key Imaging Findings Suggesting Obstruction:

• Seminal vesicle anterior-posterior diameter >15 mm 1
• Ejaculatory duct caliber >2.3 mm 1
• Dilated vasal ampulla (>6 mm) 1
• Prostatic cysts: midline prostatic cyst or paramedian/ejaculatory duct cyst 1

Important caveat: TRUS or pelvic MRI should NOT be performed as part of the initial evaluation of all infertile males—reserve these studies only for cases with clear clinical suspicion based on the characteristic semen parameters described above. 1

Adjunctive Diagnostic Procedures

• Seminal vesicle aspiration can confirm the presence of sperm in an azoospermic male, documenting intact spermatogenesis and confirming obstruction 1, 5
• Ejaculatory duct manometry demonstrates elevated opening pressures (mean 116 cm H₂O in EDO vs. 33 cm H₂O in fertile controls) 6
• Chromotubation and seminal vesiculography provide anatomic information helpful for surgical planning 7, 5

Treatment Options

Surgical Management

For infertile males with confirmed or suspected EDO based on TRUS or pelvic MRI findings, clinicians may consider transurethral resection of ejaculatory ducts (TURED) and/or surgical sperm extraction. 1

Transurethral Resection of Ejaculatory Ducts (TURED)

• TURED remains the standard treatment for EDO, with the goal of resolving obstruction to allow sperm to enter the ejaculate for unassisted conception, IUI, or ART 1, 7
• Best outcomes occur with central cystic lesions and partial obstructions 3
• Post-resection improvements: 80% of patients show increased ejaculate volume and/or at least 100% improvement in total motile count 6
• Ejaculatory duct opening pressure decreases from mean 118 cm H₂O to 53 cm H₂O after successful resection 6

Common Pitfalls with TURED:

• Low rate of natural conception despite technical success 2
• High complication rates including reflux of urine into ejaculatory ducts and epididymitis 2
• Early endoscopic treatment can prevent progression from partial to complete bilateral obstruction 7

Alternative Surgical Approaches

• Endoscopic laser-assisted resection of the ejaculatory ducts 7
• Antegrade seminal vesicle lavage for EDO secondary to inspissated material or calculi 7
• Balloon dilation of ejaculatory ducts using 9F seminal vesicoscopy, particularly for extraprostatic obstruction 2, 7, 5
• Percutaneous transgluteal ejaculatory ductoplasty (PTED) represents an emerging less invasive approach 2

Assisted Reproductive Technology

If seminal vesicle aspiration reveals sperm in an azoospermic male, TURED may be offered; alternatively, surgical sperm extraction can be performed for use with ICSI. 1

• Testicular sperm extraction (TESE) or testicular sperm aspiration (TESA) can retrieve sperm for ICSI when surgical correction is unsuccessful or not desired 1
• IVF with ICSI allows for a 37% live delivery rate per initiated cycle, though success decreases with increasing female age (>35 years) 1

Clinical Algorithm for Management

Step 1: Identify Suspicious Semen Parameters

• Volume <1.4 mL + acidic pH (<7.0) + azoospermia or severe oligospermia with very low motility 1

Step 2: Confirm Physical Findings

• Normal testosterone + palpable vas deferens bilaterally + normal testicular size 1

Step 3: Obtain Imaging

• TRUS or pelvic MRI to identify dilated seminal vesicles, ejaculatory ducts, or prostatic cysts 1

Step 4: Consider Confirmatory Testing

• Seminal vesicle aspiration to document sperm presence if azoospermic 1, 5

Step 5: Treatment Decision

• If imaging confirms EDO: Offer TURED as first-line treatment 1, 7
• If TURED unsuccessful or declined: Proceed to surgical sperm extraction (TESE/TESA) with ICSI 1
• For partial obstruction: Consider early intervention to prevent progression 7

Key Clinical Pearls

EDO is rare, diagnosed in approximately 5% of infertile men, making it a diagnosis that requires high clinical suspicion 2, 7, 3

Fructose testing is unreliable and unnecessary when clinical presentation is classic for EDO 1

Do not routinely image all infertile males—reserve TRUS/MRI only for those with the characteristic semen profile described above 1

Central cystic lesions and partial obstructions respond best to surgical intervention 3

Genetic counseling should precede ICSI if proceeding directly to sperm extraction, as genetic abnormalities may be transmitted to offspring 8