Ejaculatory duct obstruction

Ejaculatory duct obstruction presents with infertility, pain, or hematospermia. Partial or functional forms of ejaculatory duct obstruction can be difficult to diagnose. Transrectal ultrasound has replaced formal vasography as the first-line diagnostic test but is not specific. Adjunctive procedures such as seminal vesicle aspiration, seminal vesiculography, and chromotubation further delineate the diagnosis. Using an evidence-based approach, this article reviews how best to approach the diagnosis and treatment of ejaculatory duct obstruction.     

Seminal vesicle sperm aspiration in the diagnosis of ejaculatory duct obstruction

OBJECTIVE: To determine the effectiveness of seminal vesicle aspiration in the diagnosis and treatment of patients with ejaculatory duct obstruction. PATIENTS, SUBJECTS AND METHODS: Between March 1998 and February 1999, 10 infertile men with ejaculatory duct obstruction (EDO, mean age 32.7 years, range 25-47) and 10 fertile volunteers (mean age 33.2 years, range 25-42) underwent transrectal ultrasonography (TRUS) and TRUS-guided seminal vesicle aspiration. The volume of and presence of motile sperm in the aspirate was compared with the TRUS findings for both groups. RESULTS: From TRUS of the patients with EDO, the mean (sd, range) transverse diameter of the right and left seminal vesicles were 1.97 (0.54, 0.8-2.6) cm and 1.93 (0.53, 0.9-2.6) cm; the corresponding values in the control group were 1.03 (0.15, 0.8-1.3) cm and 1.0 (0. 12, 0.8-1.4) cm, respectively (P<0.001). In all, 20 aspirate samples were obtained from the patients with EDO by bilateral seminal vesicle aspiration and only one (10%) had no sperm within the aspirate fluid. Of these 10 patients, two had immotile sperm and the remaining seven (14 samples) had a mean motile sperm count of 0.63 (0.45, 0.1-1.0)x106 /mL, whereas seven of eight men assessed in the control group had no motile sperm (one patient had immotile sperm within the aspirate fluid); this difference was significant (P<0.01). CONCLUSIONS: The aspiration of significant numbers of motile sperm from the seminal vesicles suggests the presence of distal obstructions of the ejaculatory duct and enables infertile couples to be candidates for assisted reproduction. However, there is a need for further research to determine the use of this technique in the diagnosis of partial EDO.     

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。     

Ejaculatory duct obstruction in infertile men

OBJECTIVE: To analyse our experience of ejaculatory duct obstruction (EDO) in infertile men, evaluating the diagnostic steps and the outcome of management according to the aetiology. PATIENTS AND METHODS: Over a 7-year period, 50 infertile men were diagnosed with EDO as a contributory factor to male infertility. Diagnostic criteria included a history, physical examination, semen analyses, semen fructose measurement, hormonal study, testicular biopsy, transrectal ultrasonography (TRUS) and/or vasography. Thirty-one patients with EDO were treated by transurethral resection (26) or forced lavage via a vasotomy (five). RESULTS: In 45 of the 50 men, semen analyses showed the typical characteristics of complete EDO. Seminal values were variable in five cases of partial EDO; the semen fructose levels were < 1.4 g/L in all five. The main cause of EDO was a midline cyst in 16, Wolffian malformation in four, tuberculosis in 17, previous genitourinary infection in five and idiopathic in eight men. In 17 patients the seminal vesicles appeared to be atrophied on TRUS; 15 of these patients had a history of pulmonary tuberculosis and subsequent vasography in five showed multiple bilateral vasal obstruction. TRUS findings correlated well with vasography except in one case. The overall rate of improved semen values and paternity was 61% and 26%, respectively. Of 16 patients with midline cysts, 14 had improved semen variables and achieved paternity, seven after transurethral resection. CONCLUSIONS: TRUS should be the first diagnostic procedure used when infertile men are suspected of having EDO, but vasography should still be considered for a more comprehensive diagnosis. In patients with atrophic seminal vesicles on TRUS and with a history of pulmonary tuberculosis, further study is unnecessary and microscopic epididymal sperm aspiration is recommended for in vitro fertilization. The measurement of semen fructose may be helpful in diagnosing partial EDO. Patients with midline cysts who are treated by transurethral resection are expected to have the best outcome.     

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.     

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.     

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。     

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.     

经直肠超声检查对前列腺中线囊肿的诊断价值

目的:探讨经直肠超声在诊断前列腺中线囊肿中的价值。方法:回顾性分析87例前列腺中线囊肿的经直肠超声的表现。结果:经直肠超声法诊断前列腺中线囊肿87例患者,其中,苗勒管囊肿33例,射精管囊肿21例,不能明确性质者33例。伴有精囊腺扩张者19例,精囊缺如或发育不全者19例,精囊炎9例,射精管扩张5例。结论:经直肠超声简便、准确、安全、无创,是诊断前列腺中线囊肿的理想方法。     

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。     

Transurethral resection of ejaculatory ducts in the treatment of complete ejaculatory duct obstruction

Objectives To evaluate the value of transurethral resection of the ejaculatory duct (TURED) in the treatment of complete ejaculatory duct obstruction (EDO) as a treatable cause of male factor infertility. Materials and methods We retrospectively evaluated 12 azoospermic infertile men who were diagnosed as having complete EDO. The mean age of the patients was 32 years (range 24–40). Inclusion criteria were EDO in patients with azoospermia, normal serum levels of gonadotropins and testosterone and evidence of obstruction on transrectal ultrasonographic (TRUS) images. The definitive diagnosis was based on the absence of an efflux of methylene blue injected through the seminal vesicles during cystoscopy. All patients were treated by TURED. Results Before TURED, all patients were azoospermic and had been considered as candidates for in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI). Following the operation, sperms were seen in the ejaculates of 11/12 patients. After a mean follow-up period of 12 (range 4–36) months, five (41.6%) pregnancies were noted (three spontaneous, one with intrauterine insemination and one with IVF/ICSI). Conclusion Transurethral resection was found to be a safe and somewhat effective approach for the treatment of EDO. After TURED, a significant improvement was achieved in semen parameters, and spontaneous pregnancy resulted in three cases. In addition, TURED can reduce the need for expensive procedures such as IVF/ICSI as this modality allows IVF/ICSI to be performed with ejaculated instead of surgically retrieved sperm.     

Endoscopic extraction of an ejaculatory duct calculus to treat obstructive azoospermia.

Calculous obstruction of an ejaculatory duct is an uncommon cause of azoospermia or low-volume oligospermia in the infertile man. We report the case of a 32-year-old man with azoospermia, low ejaculate volume, and transrectal ultrosonography (TRUS) findings of bilateral seminal vesicle distention. On cystoscopy for planned transurethral resection of the ejaculatory ducts, a calculus obstructing the right ejaculatory duct at the verumontanum was discovered and removed. Three months later, semen analysis showed improvements in volume, sperm concentration, and sperm motility. An ejaculatory duct calculus should be included in the differential diagnosis of obstructive azoospermia or low-volume oligospermia. Magnetic resonance imaging or TRUS may be advisable to identify ductal calculi.     

Hematospermia: An investigation of the bleeding site and underlying lesions

Background : The site of hemorrhage and causative lesions in patients with hematospermia were evaluated using the puncture technique for seminal vesicles and/or müllerian duct cysts under ultrasound guidance.
Methods : Twenty-one patients aged 26–75 years (mean, 49.8 years) underwent transperineal needle aspiration of the seminal vesicles and/or müllerian duct cysts guided by transrectal ultrasonography (TRUS).
Results : Dark reddish seminal vesicle fluid was aspirated and the site of bleeding was considered to be the seminal vesicles in 11 patients (52%) (group A). In group A, abnormalities of the seminal vesicles were noted in nine patients (82%). These consisted of dilated seminal vesicles in seven (bilateral in four, unilateral in three), a seminal vesicle cyst in one and seminal vesicle amyloidosis in one. A müllerian duct cyst was confirmed to be the bleeding site in two patients (10%; group B). The bleeding site was estimated to be organs rather than the seminal vesicles in four patients (group C), in all of whom ectopic prostatic tissue was observed in the prostatic urethra. In groups B and C, seminal vesicle abnormalities were not detected by TRUS. In the remaining four patients (group D), failure to aspirate seminal vesicle fluid means that it is unclear whether hemorrhage was from the seminal vesicle or from another source. In group D, ectopic prostatic tissue was demonstrated in the prostatic urethra of three patients and unilateral seminal vesicle dilation was detected by TRUS in one patient.
Conclusion : Puncture of the seminal vesicles and/or müllerian duct cysts under ultrasonic guidance as well as cystourethroscopy is a useful and minimally invasive examination for determination of the bleeding site responsible for hematospermia.     

Management of ejaculatory duct obstruction: etiology, diagnosis, and treatment

Abnormalities of the distal ejaculatory ducts related to infertility have been well-documented. Although there are no specific findings associated with ejaculatory duct obstruction, several clinical findings are highly suggestive. A diagnosis of ejaculatory duct obstruction is suggested in an infertile male with oligospermia or azoospermia with low ejaculate volume, normal secondary sex characteristics, testes, and hormonal profile, and dilated seminal vesicles, midline cyst, or calcifications on TRUS. Other causes of infertility may be concomitantly present and need to be evaluated and treated. Trans urethral resection of ejaculatory ducts (TURED) has resulted in marked improvement in semen parameters, and pregnancies have been achieved. Proper patient selection and surgical experience are necessary to obtain optimal results. In case of testicular dysfunction, chances of success are minimal. Extended follow-up periods are needed after TURED to examine the long-term effects of this procedure. Better understanding of the anatomy and pathology of the ejaculatory ducts will continue to refine diagnostic and therapeutic procedures for this disorder.     

精道造影术在精道疾病诊断中的应用

精道造影术对精道疾病的诊断价值正逐渐被人们认识 ,但无论是采用经阴囊皮肤穿刺输精管行精道造影 ,还是经会阴直接穿刺精囊或是由射精管口逆行插管行精道造影 ,均应正确掌握其适应证和对X线征象的判断 ,这将大大推动对精道疾病的诊断和治疗。     

经尿道输尿管镜下逆行插管治疗慢性精囊腺炎

目的探讨慢性精囊腺炎的治疗方法。方法回顾性分析采用输尿管镜下经尿道逆行插管,C型臂X线下精囊造影,留置导管冲洗引流精囊腺等方法治疗的慢性精囊腺炎患者120例的临床资料。结果全部患者均有不同程度的症状改善,精液常规恢复正常80例,明显好转26例,14例精囊腺尾部囊肿精液常规部分好转,6例行腹腔镜下精囊腺部分或单侧切除治愈。随访3～36月,平均（12±6）月,复发24例。结论慢性精囊腺炎采用输尿管镜下逆行插管冲洗引流安全、有效。     

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。     

Infertility treatment in autosomal dominant polycystic kidney disease (ADPKD)--a case report

Autosomal dominant polycystic kidney disease (ADPKD) is a frequently occurring inherited condition with cysts in many organs including the kidneys. However, a combination of seminal vesicle cysts, cystic obstruction of ejaculatory duct and ADPKD is rarely encountered. The following case report presents an infertile ADPKD patient who had seminal vesicle cysts and ejaculatory duct cyst, and describes the treatment by transurethral resection of the ejaculatory duct.     

Transurethral seminal vesiculoscopy using a 6F vesiculoscope for ejaculatory duct obstruction: initial experience

Ejaculatory duct obstruction (EDO) is a surgically correctable condition that occurs in some infertile men. The standard therapy is transurethral resection of ejaculatory ducts (TURED). However, TURED has been associated with a high risk of complications, including the impairment of semen parameters and retrograde ejaculation. In our clinical practice, vesiculoscopy has demonstrated potential as a minimally invasive alternative technique for the diagnosis and treatment of EDO. Very few studies have examined transurethral seminal vesiculoscopy (TRU-SVS) in recent years, and no study has examined 6F vesiculoscopes. Therefore, we performed a retrospective study of TRU-SVS using a 6F vesiculoscope and its effect on the diagnosis and treatment of EDO. A total of 21 patients who underwent this procedure were included in the study. The mean patient age was 28.8 years (range, 23-36 years). The procedure was completed successfully in all patients within a mean time of 31.5 minutes and a mean hospital stay of 1.17 days. All patients had EDO. Calculi were found in the ejaculatory ducts or in the seminal vesicles of 5 patients. Sperm was detected in 11 patients 1-3 months postsurgery and in another 8 patients 3-12 months postsurgery. No sperm was detected in the remaining 2 patients by 12 months postsurgery. Epididymitis, retrograde ejaculation, urinary incontinence, and rectal injury were not observed. These data indicate that TRU-SVS using a 6F vesiculoscope affords direct access to the seminal vesicle and offers the advantages of fewer complications and more optimal sperm recovery as well as direct, dynamic video imaging.