Ejaculatory duct obstruction
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Ejaculatory duct obstruction (EDO) is a congenital or aquired pathologic condition which is characterized by the obstruction of one or both ejaculatory ducts.
Prevalence, etiology and symptoms
If both ejaculatory ducts are completely obstructed, affected men will recognize the symptoms of male infertility and aspermia/azoospermia. Ejaculatory duct obstruction is the underlying cause for 1 - 5 % of male infertility [1].
In addition, it is reported to be a cause for pelvic pain, especially shortly after ejaculation. In case of proven fertility but unresolved pelvic pain, even one or both partially obstructed ejaculatory ducts may be the origin of pelvic pain and oligospermia.[2]
Ejaculatory duct obstruction may result in a complete lack of semen (aspermia) or a very low-volume semen (oligospermia) which may be only comprised of the secretion of accessory prostate glands downstream to the orifice of the ejaculatory ducts.
In addition to the congenital form which is often caused by cysts of the müllerian duct the obstruction can be aquired due to an inflammation caused by chlamydia, tuberculosis of the prostate and other pathogens.
Diagnosis
Low-volume, runny/fluid semen (oligospermia)or no semen at all (dry ejaculation/aspermia) are a logical consequence of an obstruction downstream of the seminal vesicles which contribute most to the volume of the semen. Usually, men will be able to diagnose a runny/fluid, low-volume semen by themselves during masturbation. Since the seminal vesicles contain a viscous, alkaline fluid rich in fructose, a chemical analysis of the semen of affected men will result in a low concentration of fructose and a low pH-value. A microscopic semen-analysis ([spermiogram]) will reveal aspermia/azoospermia.
Attempts are being made to diagnose this condition by means of medical imaging, e.g. transrectal ultrasound or MRI, transrectal needle-aspiration of the seminal-vesicles (if the seminal-vesicles contain spermatozoa, but the semen does not, the obstruction must be downstream of the seminal vesicles and the ejaculatory ducts are very likely to be obstructed), provided that other causes for a dry ejaculation/aspermia such as an retrograde ejaculation are ruled out. [3]
Treatment
A common method to treat ejaculatory duct obstruction is transurethral resection of the ejaculatory ducts (TURED). This operative procedure is relatively invasive but led to natural pregnancies in approx. 20 % of affected men.[4] A disadvantage is the destruction of the valves at the openings of the ejaculatory ducts into the urethra such that urine may flow backwards into the seminal vesicles. Another, experimental approach is the recanalization of the ejaculatory ducts by transrectal or transurethral inserted balloon catheter[5] Though much less invasive and preserving the anatomy of the ejaculatory ducts, this procedure is probably not completely free of complications either and success-rates are unknown. There is a clinical study currently ongoing in Kiel, Germany to examine the success-rates of recanalization of the ejaculatory ducts by means of balloon dilation[6].
Usually, affected men have a normal production of spermatozoa in their testes, so that after spermatozoa were harvested directly from the testes e.g. by TESE, or the seminal vesicles (by needle aspiration) they and their partner are potentially candidates for some treatment-options of assisted reproduction e.g. in-vitro fertilisation. Note that in this case, most of the treatment, e.g.hormonal stimulation and harvesting of oocytes, is transferred to the probably healthy wife/girlfriend.
References
- ^ Pryor, Henry: "Ejaculatory duct obstruction in subfertile males: analysis of 87 patients" Fertil Steril, 56:725, 1991
- ^ Transrectal US-guided seminal vesiculography and ejaculatory duct recanalization and balloon dilation for treatment of chronic pelvic pain. Lawler LP, Cosin O, Jarow JP, Kim HS. J Vasc Interv Radiol. 2006 Jan;17(1):169-73.
- ^ Purohit, Wu, Shinohara, Turek: "A prospective comparison of three diagnostic methods to evaluate ejaculatory duct obstruction", The journal of urology, Vol. 171,(232-236), Jan 2004
- ^ "Surgical therapy in infertile men with ejaculatory duct obstruction: technique and outcome of a standardized surgical approach."Schroeder-Printzen I, Ludwig M, Köhn F, Weidner W. Hum Reprod. 2000 Jun;15(6):1364-8.
- ^ Transrectal US-guided seminal vesiculography and ejaculatory duct recanalization and balloon dilation for treatment of chronic pelvic pain. Lawler LP, Cosin O, Jarow JP, Kim HS. J Vasc Interv Radiol. 2006 Jan;17(1):169-73.
- ^ http://www.uk-sh.de/output/La3/676.406.3/676.2651/_/tx%7C676.6887.3%7C1595.1.3/_/_.html