What Is Ejaculatory Duct Obstruction

Did you know that those assigned male at birth (AMAB) infertility is more common than you might think? It is estimated that (AMAB) factors contribute to infertility in about 40-50% of all cases. Did you know that in some cases of infertility, the tubes that carry sperm during ejaculation can get blocked? This condition is called ejaculatory duct obstruction.

Ejaculatory duct obstruction (EDO) is the medical term for the obstruction of the ejaculatory duct, which connects the vas deferens, the tube that transports sperm from the testicles to the urethra and urine and semen out of the body. The vas deferens to the urethra during ejaculation travels through the ejaculatory duct.

The reproductive health of males (AMAB) can be significantly affected by ejaculatory duct obstruction. EDO is not contagious or life-threatening, though it may be challenging. Proper knowledge can aid in a more accurate understanding of the situation.

Overview

When a clinical pregnancy fails to occur after 12 months of regular, unprotected sexual activity, it is said to be infertility. Between 8 and 12% of couples of reproductive age are expected to be affected globally. Males (AMAB) appear to be solely at fault in 20–30% of infertility cases, yet they are involved in 50% of all instances.

The most prevalent type of assigned female at birth (AFAB) infertility is secondary infertility, which usually comes by infections of the reproductive system. Ejaculatory duct obstruction (EDO) is a rare cause of male (AMAB) infertility across many other disorders. The reported incidence of EDO among infertility patients ranges from 1 to 5%. Azoospermia (no sperm in the ejaculate) or severe oligozoospermia (less than 5 million sperm per mL), when combined with a small amount of sperm (less than 1.5 mL), is a sign of EDO.

To fully comprehend the condition, one must first have an in-depth knowledge of the ejaculatory duct. Testosterone and androstenedione, sexual hormones secreted by the interstitial cells, influence the production of spermatozoa in the seminiferous tubules. The ejaculatory ducts (EDs), formed by the vas deferens joining the seminal vesicle ducts when they emerge, are continuous with the epididymis. The EDs often enter the prostate's core zone and discharge into the prostatic urethra on either side of the seminal colliculus. While about 0.5mL of the ejaculate is composed of prostatic fluid (produced by the prostate gland), 1.5–2.0mL (50–80%) of the seminal fluid is formed up of the seminal vesicles (SVs), which also produce prostaglandins and fructose.

Like the epididymis body and tail, vas deferens, and seminal vesicles (SV), the ED is a product of the Wolffian duct. On the contrary, the endoderm (innermost layer of cells in the early embryo) from which the prostate develops penetrates the mesenchyme around it. The ED often extends obliquely for 1-2 cm inside the prostate at a 75-degree angle, despite anatomic differences. Sperm cells depend on the ductus (vas) deferens and ejaculatory duct to propel them into the urethra and out of the penis during ejaculation after they are created in the testis and collected in the epididymis. ED serves as an interface between the male reproductive and urinary systems by delivering sperm into the urethra and adding prostate-derived additives and secretions essential for sperm activity.^1,2

Types of ejaculatory duct obstruction

Causes of ejaculatory duct obstruction

​​Ejaculatory duct obstruction (EDO) has a variety of potential causes, some of which include:

Congenital abnormalities 

Atresia (complete blockage) or ED stenosis (partial blockage), müllerian duct cysts, and Wolffian duct cysts are among the inherent causes of EDO.

Inflammation and infections

Infectious aetiologies like genital/urinary tuberculosis infections, stones and prostatic abscesses, and even prostate cancer may result in SV stones, inflammation, and scarring.

Surgery or trauma

Acquired causes include pelvic trauma, iatrogenic injury (harm or damage caused to a patient due to medical treatment, intervention, or procedures) from prolonged catheterisation, pelvic or bladder outlet surgeries damaging the vas deferens, SVs and EDs.

Abnormalities in surrounding structures

Conditions like utricular cysts and ejaculatory duct cysts can clog ejaculatory ducts and impede the natural passage of semen.³

Signs and symptoms of ejaculatory duct obstruction

Bilateral and overall EDO have the following typical clinical features:

• An acidic semen specimen
• Lack or low fructose levels 
• Absence or low-volume ejaculate (hypospermia, less than 1.5 mL)
• One typical EDO sign is infertility despite frequent unprotected sex
• Some people could feel pain or discomfort in the perineum or pelvis while ejaculating
• Hematospermia, a condition with blood in the semen, can occur in some situations due to EDO²

Management and treatment for ejaculatory duct obstruction

It is vital to successfully remove the barrier to provide men with EDO-related fertility problems a chance at spontaneous conception. The best course of action may depend on the cause of EDO, and other methods have been researched and reported.

Conservative management

In some situations, conservative therapy is suggested if the obstruction is minor or not producing noticeable symptoms. This method includes passively observing the state of affairs over time.

Surgical interventions

• Transurethral Resection of Ejaculatory Duct (TURED)
  Traditionally, TURED has been used to treat EDO. Resecting the EDs at the level of the seminal colliculus entails using a 24F resectoscope and an electrocautery loop. This procedure is still considered the best available for treating patients. TURED is beneficial in symptomatic non-infertile individuals experiencing painful ejaculation or hematospermia.
• Transutricular Seminal vesiculoscopy (TSV)
  For example, painful ejaculation and hemospermia, among other symptoms, can be treated with TSV in people who are not infertile. Blood clots, strictures, and seminal vesical stones can all be detected, treated, and excised with TSV.
• Ballon Dilation
  This EDO treatment technique aims to increase fertility and semen parameters.  Midline Prostatic Cyst Aspiration
  
  Based on this, it is possible that treating these cysts will lead to better results.
• Use of assisted reproduction techniques
  Sperm from the testis, seminal vesicles, epididymis, or ejaculated sperm are used for sperm injections. Ejaculated spermatozoa can serve as the foundation for ICSI in cases of incomplete EDO or when postoperative semen parameters are still insufficient. In contrast, comprehensive EDO, including situations where surgical therapy has failed, requires sperm retrieval. Sperm retrieval is successful almost always in EDO since normal spermatogenesis is present in this condition.^2,3
  

Diagnosis of EDO

Physical examinations, diagnostic tests, and an analysis of medical history are used to assess ejaculatory duct obstruction (EDO). Here are a few standard methods for finding EDO:

Medical history and physical examination

Medical professionals will review your symptoms, medical background, and other EDO data. Physicians will conduct a medical examination to evaluate the reproductive organs and check for any obstructions or abnormalities.

Semen analysis

The suction of a significant quantity of motile sperm from the seminal vesicles indicates the presence of distal obstructions of the ejaculatory duct, which qualifies couples for assisted reproductive technology as infertile.⁴

Transrectal Ultrasonography (TRUS) 

Is used to diagnose ejaculatory duct obstruction and identify the extent of blockage inside the prostatic parenchyma at its distal level. Evaluation and treatment of azoospermia brought on by ejaculatory duct occlusion are made quicker by prostate ultrasonography.⁵

Vasography

Vasography is performed by cutting or puncturing the vas deferens and injecting a contrast material. Radiologic/fluoroscopic assessment of a normal vasa deferentia, enlarged seminal vesicles, and a lack of contrast in the bladder and urethra confirm the occlusion.²

Magnetic resonance imaging (MRI)

Endorectal coil MRI is a vital adjuvant in diagnosing the disease.⁶

Seminal vesiculography

It is a minimally invasive diagnostic option to vasography that can be commonly employed to document the patency of the pelvic and inguinal parts of the vas deferens in certain patients.⁷

Manometry

Men with clinically suspected ejaculatory duct obstruction had higher ejaculatory duct opening pressure than fertile men and ejaculatory duct pressure reduces after transurethral ejaculatory duct resection, according to manometry baseline values defined in fertile men.⁸

Risk factors

Some AMAB may have structural defects in their ejaculatory ducts or surrounding organs like the prostate gland or seminal vesicles at birth, which can put them at risk for EDO. 

Some diseases, such as prostatitis (inflammation of the prostate gland) or epididymitis (inflammation of the epididymis), can cause scarring or inflammation that can block the ejaculatory ducts. The most typical kind of prostatitis is known as chronic pelvic pain syndrome (CPPS).⁹

Any operation or trauma to the reproductive system has the potential to harm the ejaculatory ducts and induce blockage. Conditions affecting the prostate gland can cause the ejaculatory ducts to expand or get blocked. Prostate cysts are associated with atrophy and other variables such as inflammatory illness, benign prostatic hyperplasia (BPH), ejaculatory duct obstruction, and malignancy.¹⁰  

The prostate, bladder, seminal vesicles, and vas deferens all have alpha-1a receptors. Seminal fluid is produced and transported as an outcome of the smooth muscle contraction in these areas. On the contrary, medications such as alpha-1a blockers result in smooth muscle relaxation, which generates a drop in fluid emission and could result in an incompletely closed bladder neck, which may cause obstruction.¹¹

Complications

Infertility, erectile dysfunction, and pain or discomfort in the pelvic area, including the testicles, prostate, or perineum, are some of the complications associated with the illness. EDO-related infertility and sexual dysfunction can have a significant emotional and psychological impact on people and their relationships. It could cause anger, depression, or anxiety.¹²

FAQs

Can EDO be prevented?

Since genetic defects or scarring are the primary causes of EDO, it cannot be averted. However, preserving general reproductive health, preventing infections, and using safe sexual practices may help lower the chance of some underlying causes.

How common is EDO?

EDO is relatively rare, accounting for about 1-5% of male infertility cases.¹³

When should I see a doctor?

If you and your partner have been actively trying to conceive for a year without success, it may be a good idea to consult a doctor or a fertility specialist. Your ability to make the best decisions for your health can assist by open communication with your physician.

Summary

AMAB fertility is often severely affected by ejaculatory duct obstruction. It's crucial to speak with a healthcare professional for a diagnosis and treatment if you're exhibiting symptoms of sperm obstruction. The proper sperm blockage treatment allows many men (AMAB) with ejaculatory duct obstruction to become parents and regain their ability to conceive.