Ejaculatory Duct Obstruction after Transurethral Resection of the Prostate

Transurethral resection of the prostate is currently the most commonly employed surgical procedure for benign prostatic hyperplasia. Although several complications after the procedure have been well documented, ejaculatory duct obstruction is a rare complication. We describe this unusual complication in a 77-year-old male who presented with severe pain and a feeling of fullness in the lower abdomen and with dry ejaculate on three occasions after undergoing post-transurethral resection of the prostate. The patient’s post-ejaculatory urinalysis demonstrated no sperm. Transrectal ultrasonography also showed no dilatation of the bilateral seminal vesicles or ejaculatory ducts. However, ejaculatory duct obstruction was finally diagnosed on vasovesiculography. The patient was successfully treated with transurethral resection of the ejaculatory duct and remained asymptomatic 6 months postoperatively. Although transrectal ultrasonography is currently widely used to evaluate ejaculatory duct obstruction, we suggest that vasovesiculo-graphy is still a feasible and useful tool that provides detailed anatomic information for the advanced confirmation of ejaculatory duct obstruction in patients with a high suspicion of ejaculatory duct obstruction who have normal transrectal ultrasonography findings.     

超声引导下无水乙醇硬化治疗伴有射精管梗阻症状的苗勒管囊肿

目的:评价经直肠超声引导下无水乙醇硬化治疗伴有射精管梗阻症状的苗勒管囊肿的安全性和有效性,探讨该方法的临床价值。方法:对3例伴有射精管梗阻症状的前列腺苗勒管囊肿行超声引导下20 G针穿刺无水乙醇硬化治疗,超声随访评价疗效。结果:治疗后6个月全部囊肿均消失,超声检查射精管梗阻解除,无严重并发症发生。结论:超声引导下的无水乙醇硬化治疗安全有效,可成为临床治疗伴有射精管梗阻症状的前列腺苗勒管囊肿的新方法。     

Transrectal ultrasonography in the evaluation of the infertile man: a report of 3 cases

The traditional evaluation of the infertile man with azoospermia or low ejaculate volume includes determination of serum testosterone and follicle-stimulating hormone levels, a seminal fructose test, post-ejaculate urinalysis and, sometimes, vasography. Transrectal ultrasonography, a technique currently familiar to most urologists, recently has been added to our diagnostic armamentarium. This office-based imaging procedure provides an accurate assessment of the prostate, ejaculatory ducts and seminal vesicles, which can be helpful in the evaluation of certain infertile patients. We describe 3 patients who presented with either azoospermia or decreased ejaculate volume in whom transrectal ultrasonography had a critical role in the fertility evaluation. The clinical indications for and interpretation of transrectal ultrasonography in the infertile population are described. Transrectal ultrasonography currently is the most accurate, inexpensive and readily available noninvasive imaging technique used to diagnose obstruction of the ejaculatory ducts in the infertile patient with either azoospermia or low ejaculate volume.     

Transrectal ultrasound-guided ethanol sclerotherapy for Müllerian duct cyst accompanied with ejaculatory duct obstruction]

OBJECTIVE: To evaluate the efficacy and safety of transrectal ultrasound-guided ethanol sclerotherapy in the treatment of Müllerian duct cyst accompanied with ejaculatory duct obstruction. METHODS: Under the transrectal ultrasound guidance, 3 cases of prostate Müllerian duct cyst were treated by 20 G needle puncture and ethanol injection, and closely followed up by ultrasonic monitored on follow-up examinations. RESULTS: All the cysts involuted completely 6 months after the treatment. Symptoms caused by ejaculatory duct obstruction were relieved in all the patients. No severe complications occurred. CONCLUSION: Transrectal ultrasound-guided ethanol sclerotherapy is an effective and safe method for the treatment of Müllerian duct cyst accompanied with ejaculatory duct obstruction.     

梗阻性无精子症经直肠B超声像表现及其临床意义

目的:探讨梗阻性无精子症经直肠B超的声像表现及其在梗阻定位诊断中的应用价值。方法:对248例临床诊断为梗阻性无精子症的男性患者行经直肠B超检查,观察前列腺、双侧精囊及射精管的声像表现。结果:本组病例前列腺体积平均13.2 ml。前列腺、双侧精囊及射精管形态正常111例。双侧精囊缺如39例,双侧精囊发育不全33例,单侧精囊发育不全、对侧精囊缺如23例,双侧精囊扩张28例,单侧精囊扩张14例。这42例精囊扩张者中射精管扩张18例、前列腺中线部位囊肿17例。结论:梗阻性无精子症的病变类型多样。经直肠B超可以清楚显示前列腺、精囊及射精管的形态与病变,对于判断梗阻性无精子症的病变类型及部位有一定的参考作用。     

经尿道射精管口电切术治疗射精管梗阻性无精子症

目的 探讨经尿道射精管口电切术（TURED）治疗射精管梗阻性无精子症的可行性和疗效。方法 对我院2003年6月—2004年12月收治的20例射精管梗阻性无精子症患者,采用精液常规分析、精浆果糖测定和经直肠前列腺精囊超声检查（TRUS）进行诊断,20例患者的精液量0．4～1．6ml,pH值6．0～7．2,精液中均未检出精子,精浆果糖为0～2．6μmoL／1次射精,其中16例的精浆果糖为0。TRUS显示前列腺中线囊肿11例,偏心性囊肿2例,双侧精囊及射精管扩张5例,一侧精囊及射精管扩张2例。所有者均使用TURED治疗,术后随访其疗效。结果 20例均完成手术,手术时间15～50min,术中出血约10～30m1,术后保留导尿管1～7d。术后随访超过3个月的15例患者中,10例（67％）术后精液质量改善,其中3例（20％）患者的配偶妊娠;随访不足3个月另尚未行精液检查。结论 TURED方法简单、安全、有效,是治疗射精管梗阻的有效手段。     

经尿道射精管切开术治疗射精管梗阻性无精子症

目的探讨经尿道射精管切开治疗射精管梗阻的安全性及临床疗效。方法分析2008年1月2011年12月收治的16例射精管梗阻性无精子症患者的临床资料,常规精液分析、精浆果糖、中性a葡萄糖苷酶测定及经直肠超声予以诊断,必要时行精道造影检查确诊。16例均采用经尿道射精管切开术治疗,术后随访其疗效。结果 16例均顺利完成手术,术后随访36月,14例（87.5%）精液各项指标均有明显改善,5例（31.3%）配偶妊娠。结论经尿道射精管切开术是治疗射精管梗阻性无精子症的安全有效的方法,值得临床推广。     

Transurethral treatment of ejaculatory duct obstruction in infertile men

Ten cases of ejaculatory duct obstruction with midline cyst, complaining of male infertility, were treated with transurethral incision. They had azoospermia or oligozoospermia, and physical examination did not show any abnormal findings. Serum levels of testosterone, LH, and FSH were within normal limits. The diagnosis of ejaculatory duct obstruction with midline cyst was made by transurethral ultrasonography and vasography. Thereafter, patients underwent transurethral incision of the verumontanum with a cold knife. Semen volume increased in all patients, and sperm concentration and/or motility improved in 7 patients (70%). Pregnancy was achieved by 3 couples (30%). Incision of the ejaculatory duct via an endoscopic technique could improve seminal findings and subsequent fertility.     

Transrectal ultrasound and partial ejaculatory duct obstruction in male infertility.

Partial ejaculatory duct obstruction, due to either a congenital or an acquired cyst or ejaculatory duct stenosis secondary to calcification, chronic inflammation, can produce a wide spectrum of seminal fluid abnormalities. Sperm density may range from azoospermia to normospermia while ejaculate volume can be low to normal. Sperm motility is consistently diminished (less than 30%). We have treated 2 patients with ejaculatory duct stenosis whose diagnosis was accurately made with transrectal ultrasonography (TRUS). We now suggest that TRUS be used when there is a low semen volume (less than 1.0 cc), or low motility (less than 30%), or oligospermia (less than 20 million sperm/mL), and normal findings on physical examination with normal serum gonadotropin values in the absence of any other explanation.     

Transurethral resection of cystic and non-cystic ejaculatory duct obstructions

Ejaculatory duct obstructions are diagnosed in ≈ 5% of azoospermic men and can be treated by transurethral resection (TURED) or incision of the ducts. Eight patients with azoospermia and ejaculatory duct obstructions were treated by TURED after clinical examination, semen analysis, biochemical analysis of seminal plasma, endocrine analysis, transrectal ultrasonography and testicular biopsy. In 3/3 cases of cystic and in 3/5 cases of non-cystic obstruction, TURED of the stenosis was possible. During a follow-up of 12 months there was an increase in semen volume and sperm count in 3/3 and 3/5 patients, respectively. No pregnancy was achieved during the period up to 12 months. Clinical symptoms such as haemospermia and pain disappeared in all cases. In our cases and another 98 cases of ejaculatory duct obstructions documented in the literature, men of semen quality improved in 38–60% with a pregnancy rate of men 22–31% after TURED. We conclude that there is a correlation between the aetiology of ejaculatory duct obstructions and success rate of TURED.     

Endoscopic management of ejaculatory duct obstruction

A total of 191 patients were evaluated at our department for azoospermia, and 11 were found to have azoospermia due to ejaculatory duct obstruction as proved by normal serum hormones, normal testicular biopsy, low ejaculate volume and absence of fructose in semen. Also transrectal ultrasound was performed, revealing distended seminal vesicles and dilated ejaculatory ducts. All these criteria together suggested ejaculatory duct obstruction as a cause of azoospermia. All patients underwent endoscopic management for treatment of their ejaculatory duct obstruction in the form of resection and/or incision of the ejaculatory duct ostium inside the urethra and patency was checked intraoperatively by injection of sterile methylene blue in the vas and visualizing the efflux of the blue dye endoscopically. Intraoperative patency was documented in 10 patients and postoperative patency by follow-up semen analysis in 7 patients (70% patency rate) of which 2 (20% pregnancy rate) were able to conceive within 2 years of endoscopic treatment. Postoperative complications included acute urinary retention in 1 patient, haematuria in 5 and recurrent epididymitis in 2 patients.     

经直肠超声检查在男性梗阻性无精子症病因筛查中的作用(附695例病例分析)

目的:探讨经直肠超声(TRUS)在男性梗阻性无精子症病因筛查中的作用。方法:回顾性分析我院2007年1月至2009年5月695例男性梗阻性无精子症患者的TRUS的病因诊断结果。结果:695例梗阻性无精子症患者中,TRUS检查发现病变以射精管病变(29.2%)、精囊腺病变(25.4%)以及前列腺中线囊肿病变(18.5%)为主。TRUS检查共发现射精管扩张203例;精囊腺病变177例,其中先天性精囊腺缺如或者发育不全108例,精囊腺扩张51例;另外,TRUS诊断发现前列腺中线囊肿128例,其中75例(58.5%)射精管囊肿,39例(30.5%)苗勒管囊肿。34例患者的梗阻性无精子症可能由于钙化性疾病导致。而153例患者(22.0%)TRUS检查未见明显异常。TRUS在本组梗阻性无精子症患者中,78.0%可以发现比较明确的病因。结论:TRUS可以比较清晰地观察射精管以及精囊腺等结构异常,可以为远端输精系统梗阻的病因诊断提供重要的参考信息。     

射精管梗阻的诊断与治疗：附5例报告

报告射精管梗阻引起的不育症５例，其主要表现为无精子或少精子症、精子活力降低以及射精量减少，其中２例有反复性泌尿系感染病史。５例均行经尿道射精管切开术，术后精液量均增多，３例精液质量恢复。并结合文献对其病因、诊断及治疗效果进行讨论，认为射精管梗阻引起的不育症应引起临床重视，经直肠Ｂ超检查是诊断射精管梗阻的有效手段，射精管切开术能有效地改善精液质量。     

Secondary ejaculatory duct obstruction: management by secondary transurethral resection of ejaculatory duct

Distal ejaculatory duct obstruction (EDO) is a relatively rare but surgically treatable cause of male infertility. Transrectal ultrasonography (TRUS) has been commonly used in infertility evaluation in recent years. These pathologies are more common than expected and treated with transurethral resection of ejaculatory duct (TURED). Although TURED is the recommended routine procedure for all cases of EDO, it has complications, such as iatrogenic obstruction, in 4% of the cases. Herein, we evaluated a patient who had developed EDO secondary to TURED.     

Transurethral endoscopic treatment for chronic hematospermia caused by müllerian duct cyst and ejaculatory duct obstruction

Between June 1997 and September 1999, we performed transurethral unroofing (TUUR) in three patients with hematospermia that recurred repeatedly for one year or more. Patient 1 (48 years old) and Patient 2 (59 years old) were diagnosed as having müllerian duct cysts that communicated with the left ejaculatory duct, and Patient 3 (36 years old) as an ejaculatory duct obstruction with the right ejaculatory duct dilation. A mixture of water-soluble contrast medium and indigocarmine blue dye was injected into the cysts and the ejaculatory duct cavity after incision of the vas deferens in Patients 1 and 3, and by cyst puncture under transrectal ultrasound (TRUS) guidance in Patient 2. Then the urethra was incised between the bladder neck and the verumontanum using a Collins' hot knife electrode, and spouting of the dye from the incision was judged to indicate successful unroofing. In Patient 2, safe and simple TUUR was possible by identifying the cyst location and its distance from the knife electrode under TRUS guidance. Hematospermia resolved after surgery in all three patients and there has been no recurrence for 1.3-3.5 years (mean: 2.6 years). Thus, TUUR was effective for treating chronic hematospermia caused by müllerian duct cyst and ejaculatory duct obstruction. For safe and reliable performance of this treatment, TRUS guidance and injection of the dye into the cyst and ejaculatory duct cavity can be recommended.     

梗阻性无精子症的外科治疗(附56例报告)

目的:探讨梗阻性无精子症的诊断和外科治疗方法。方法:分析2004年10月至2008年11月间收治的56例梗阻性无精子症患者的临床资料,其中43例为射精管梗阻性无精子症,13例疑为附睾水平梗阻性无精子症。常规精液分析、精浆果糖和中性α葡糖苷酶测定以及经直肠超声检查(TRUS)对其进行诊断,必要时行输精管造影检查。43例为射精管梗阻性无精子症使用经尿道射精管切开术(TURED)治疗,13例疑为附睾水平梗阻性无精子症行阴囊探查术,对其中11例确定为附睾水平梗阻行双侧或单侧附睾输精管端侧吻合术,术后随访其疗效。结果:所有患者均完成手术,术后随访3～51个月。43例射精管梗阻性无精子症TURED术后,36例(83.7%)精液检查有不同程度的改善,11例(25.6%)妻子妊娠。11例附睾水平梗阻性无精子症行输精管附睾吻合术后,6例(54.5%)精液检查检出活精子,3例(27.3%)妻子妊娠。结论:精液分析、精浆果糖和中性α葡糖苷酶测定,TRUS和输精管造影是诊断梗阻性无精子症的主要方式。TURED和输精管附睾吻合术分别是治疗射精管梗阻性无精子症和附睾水平梗阻性无精子症的有效方法。     

Fertility Restoration by Seminal Tract Washout in Ejaculatory Duct Obstruction

A complex case of secondary sterility due to excretory azoospermia-dry ejaculation is reported. Transrectal ultrasonography and vaso-vesiculography revealed post-inflammatory total obstruction of the right ejaculatory duct. Excluding small radiolucent concrements in the seminal vesicle, no anatomical anomalies were identified on the left side. By performing antegrade seminal tract washout with saline solution it was possible to clear both seminal ducts and restore fertility in our patient. In select cases seminal tract washout may be a valid alternative to the conventional transurethral surgical approach for acquired obstruction of the ejaculatory ducts.     

Novel methods for the diagnosis and treatment of ejaculatory duct obstruction

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVES

? To investigate a new method of vas deferens radiography for ejaculatory duct obstruction (EDO). ? To evaluate the effect of a procedure involving dilation of the ejaculatory duct by F9 seminal vesicoscopy.

PATIENTS AND METHODS

? Twenty‐two patients with EDO were diagnosed using semen analysis, semen fructose measurement, transrectal ultrasonography (TRUS) and vas deferens radiography. ? Of these, 18 patients were successfully treated by dilation of ejaculatory duct using F9 seminal vesicoscopy and four patients, whose treatment was unsuccessful, were treated by transurethral resection of the ejaculatory ducts (TURED). ? All patients were followed up for at least 3 months after treatment.

RESULTS

? Semen analyses in all 22 patients showed oligoasthenozoospermia or azoospermia, low semen volume (0–1.9 mL), low pH level (5.6–7.0) and absent or low semen fructose. TRUS and radiography showed pure dilated seminal vesicles on both sides in three patients, partial dilated seminal vesicles in one patient, dilation of both the ejaculatory duct and seminal vesicles in ten patients, dilated seminal vesicles and a prostatic cyst in four patients, and dilated ejaculatory duct or cystic lesions without dilated seminal vesicles in the remaining four patients. ? At >3‐month follow‐up after dilation or TURED, the semen characteristics of 18 patients were improved and sperm were present in the semen in 13 cases. Normal semen analyses were found in 7 patients and 6 patients had conceived. ? Voiding urethral radiography showed that no patients who had undergone dilation by seminal vesicoscopy had urine reflux into the ejaculatory duct. Only one patient showed urine reflux into the seminal vesicle after TURED. ? All patients felt that their symptoms had improved after treatment.

CONCLUSIONS

? The approach to vas deferens radiography using vas deferens aspiration has proved to be an effective and safe method for EDO diagnosis. ? The procedure involving the dilation of the ejaculatory duct using F9 seminal vesicoscopy is equally effective but has fewer postoperative complications than TURED.     

Diagnosis and treatment of ejaculatory duct obstruction in male infertility

OBJECTIVE: To discuss the diagnosis and treatment of ejaculatory duct obstruction in male infertility. PATIENTS AND METHODS: Twenty-four males were treated for ejaculatory duct obstruction between 1994 and 1998 in our clinic. Patients' age varied between 20 and 40 (mean=29). Ejaculatory duct obstruction was considered in patients with low to normal ejaculate volume, azoospermia or oligospermia, decreased motility, normal serum gonadotropin and testosterone levels, absent or low fructose in the ejaculate and evidence of obstruction on transrectal ultrasonography. The definitive diagnosis was made by the absence of efflux of methylene blue injected through the vas during cytoscopy. All the patients were subjected to transurethral resection of ejaculatory ducts and spermograms before and 3 months after resection were compared. RESULTS: Before transurethral resection mean sperm count was 1.66x10(6)/ml compared to 25.4x10(6)/ml postoperatively. The difference was statistically significant (p=0.001). After the operation, 58.3% of the cases had improvement in sperm motility, and 62.5% had increased ejaculate volume. No significant complications occurred, and in only 1 (4.17%) patient, there was persistent hematuria. After a mean follow-up period of 9 (6-18) months, 6 (25%) pregnancies were noted. CONCLUSION: Although transurethral resection is an effective method for the treatment of ejaculatory duct obstruction, the pregnancy rate is low, which could be related to the hazardous effects of urinary reflux into ejaculatory ducts or functional abnormalities of seminal vesicles.     

Transurethral resection of ejaculatory duct in infertile men: outcome and predictors of success

Objectives

To evaluate the outcome of transurethral resection of the ejaculatory duct (TURED) in the treatment for ejaculatory duct obstruction (EDO) and define predictors of success.

Materials and methods

We retrospectively evaluated 23 infertile men between 2006 and 20011, who were diagnosed as having EDO. Inclusion criteria were azoospermia or oligozoospermia, low ejaculate volume, low ejaculate PH, little or no fructose in seminal plasma with normal serum levels of gonadotropins and testosterone and evidence of obstruction on transrectal ultrasonography (TRUS) or magnetic resonance images (MRI). Seventeen patients were diagnosed as complete EDO, and the remaining 6 were considered as having partial EDO. All patients were treated by TURED.

Results

Midline cysts were diagnosed in seven cases, and the remaining 16 patients had postinflammatory obstruction of ejaculatory ducts (ED). Overall, a significant improvement of semen quality was achieved after surgery. All patients with partial EDO showed improvements in semen parameters after TURED compared to 23.5?% (4/17) in those with complete EDO. Improvement in sperm count was 71.5?% and 31?% for patients with midline cysts and patients with non-cystic causes of EDO, respectively. Six (26?%) patients developed complications including epididymo-orchitis in 2, watery ejaculate in 3 and conversion to azoospermia in 1. Spontaneous pregnancies were achieved in 3 (13?%) cases: 2 (33.3?%) men with partial and 1 (5.9?%) with complete obstruction.

Conclusion

Partial EDO, whatever the etiology, has an excellent outcome after TURED. Complete EDO due to cysts appears to respond better than postinflammatory obstruction to TURED.