Ejaculatory Duct Obstruction

Ejaculatory duct obstruction is blockage of one or both ejaculatory ducts, where the seminal vesicles and vasa join at the verumontanum. It accounts for about 1 to 5% of male infertility and about 5% of azoospermia.

It presents with low volume, acidic ejaculate, azoospermia or oligospermia, and sometimes pain or blood on ejaculation. It can be treated surgically in a proportion.

Pathophysiology. Causes:

• Congenital: midline Müllerian duct cysts and lateral Wolffian duct cysts, atresia, and absent seminal vesicle or vas with CFTR mutation.
• Acquired: prostatitis and seminal vesiculitis, calculi, post-inflammatory fibrosis, tuberculosis, schistosomiasis, trauma, catheter or urethral surgery, and prostate surgery.

Obstruction may be complete (azoospermia, low volume, absent fructose) or partial (low volume and reduced sperm count). Seminal vesicle fluid supplies about 60% of semen volume and fructose.

Infertility with low semen volume (under 1.4 mL). Painful ejaculation, perineal or suprapubic pain, haemospermia, recurrent prostatitis or epididymitis and lower urinary tract symptoms. Some men have no symptoms. Prostate examination may be normal, with a palpable midline cyst in some.

• Semen analysis (at least two samples): volume under 1.4 mL, acidic pH (under 7.2), absent fructose in complete obstruction, and azoospermia or severe oligospermia.
• FSH, LH and testosterone: normal in obstruction. Testicular volume is normal.
• Transrectal ultrasound: seminal vesicle anteroposterior diameter over 1.5 cm, ejaculatory duct width over 2.3 mm, midline cysts, calculi and calcification.
• Pelvic MRI with an endorectal coil for cysts and the level of obstruction.
• Seminal vesicle aspiration under ultrasound for sperm and fructose, and seminal vesiculography or vasography with contrast or dye (indigo carmine or methylene blue) to prove patency. This is done at the time of surgery.
• CFTR analysis and renal ultrasound when the vasa or seminal vesicles are absent or hypoplastic.
• Urine nucleic acid tests, culture, and schistosomiasis or tuberculosis testing when exposure suggests.

Differential diagnosis.

• Congenital bilateral absence of the vas deferens
• Retrograde ejaculation
• Hypogonadism with low volume
• Anejaculation
• Chronic prostatitis
• Prostatic or seminal vesicle cyst (incidental)
• Incomplete semen collection

• Treat infection: doxycycline 100 mg orally twice daily for 7 to 14 days for chlamydia and mycoplasma, and ciprofloxacin 500 mg orally twice daily for 14 days or longer for chronic prostatitis, with the dose reduced when eGFR is under 50.
• Transurethral resection of the ejaculatory ducts, for confirmed obstruction with infertility or pain:
  • Resection of the verumontanum and ductal orifices, or cyst unroofing, under cystoscopic control, with chromatic confirmation by dye injection into the vesicle.
  • Semen quality improves in about 50 to 75%, and pregnancy follows in about 20 to 30%.
  • Complications: epididymitis, reflux of urine into the ducts (leading to low sperm quality, haematospermia and chemical epididymitis), retrograde ejaculation, bladder neck or rectal injury, and stricture.
  • Perioperative cefazolin 2 g intravenously (3 g if over 120 kg) as a single dose.
• Seminal vesicle sperm aspiration or testicular and epididymal sperm retrieval with intracytoplasmic sperm injection, when resection is not suitable or has failed.
• Pain: ibuprofen 400 mg every 8 hours for up to 2 weeks with food, tamsulosin 400 micrograms orally once daily after a meal, and pelvic floor physiotherapy.
• Asymptomatic cysts without infertility need no treatment.

Monitoring. Semen analysis at 3 and 6 months after resection, and then every 6 months for 1 year. Early review for infection or pain.

Referral and escalation. Refer to urology with experience in ejaculatory duct surgery, and a fertility unit. Urgent referral for fever with perineal pain or retention after surgery.