Ejaculatory Duct Obstruction: The Case for Aggressive Diagnosis and Treatment

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THE

Vol. 134, November Printed in U.S.A.

JOURNAL OF UROLOGY

Copyright © 1985 by The Williams & Wilkins Co.

EJACULATORY DUCT OBSTRUCTION: THE CASE FOR AGGRESSIVE DIAGNOSIS AND TREATMENT BENAD Z. GOLDW ASSER, JOHN L. WEINERTH

CULLEY C. CARSON, III*

AND

From the Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina

ABSTRACT

Ejaculatory duct obstruction is considered a rare cause of infertility. Based on the results of treatment in our 5 patients and a review of 14 additional well documented cases we were able to classify these patients prognostically. Whereas congenital and acquired noninfectious obstructions are amenable to a transurethral operation in as many as 57 to 67 per cent of the cases, all obstructions secondary to genital infections failed treatment. Male infertility is the causative factor in about 50 per cent of all childless marriages. 1 The incidence of ductal obstruction among infertile men has been reported to be 3 to 7.4 per cent. 1• 2 The importance of diagnosing this entity is in its potential reversibility. 3 The obstruction may occur anywhere from the pre-epididymal ductuli efferentes to the ejaculatory ducts. No satisfactory treatment exists for obstruction within the testes, although improvement occasionally may be observed following treatment with a low dose of steroids or a prolonged course of antibiotics. 4 Epididymal obstruction may be either congenital or secondary to infection due to gonorrhea, tuberculosis, small pox or schistosomiasis, or nonspecific infections. This type of obstruction may be corrected by epididymo-vasostomy, with patency rates reported in up to 73 per cent and a pregnancy rate of 31 per cent of the cases. 5 The results obtained from congenital obstructions are inferior to those obtained when the obstruction followed infection. Postgonorrheal obstruction has the best prognosis. The possibility of reconstructing a vasal obstruction depends upon the number, length and location of the blockage. The reversal of vasectomy is associated with an excellent chance of subsequent patency (80 to 97 per cent) and fertility (40 to 50 per cent within 2 years). 4 ' 6 A long area of vasal sclerosis is not amenable to surgical correction. Infertility caused by bilateral ejaculatory duct obstruction is rare. Azoospermia, low semen volume, absent fructose and poor semen coagulation are characteristic of this type of obstruction and patients may benefit from investigation. Four such cases have been reported recently from our institution. We have since encountered an additional case. A review of our experience and that of others suggests that this is a heterogeneous entity, with results of treatment depending on the type of obstruction and its etiology.

ducts demonstrated on bilateral vasography. Testis biopsies were normal. The patients were treated by transurethral resection of a small area of the prostate lateral to the verumontanum, care being taken to avoid injury to the external sphincter or penetrating the prostatic capsule. In all cases contrast material or indigo carmine could be seen flowing from resected ejaculatory ducts and confirmed radiographically with a repeat vasogram. Three patients had sperm in the postoperative ejaculates with return of normal semen volume and fructose. However, only 1 of these 3 patients had sperm counts at fertile levels. This patient, who had a history of prolonged Foley catheterization, reported that his wife was pregnant 8 months postoperatively (see table). CASE REPORT

A 24-year-old white man was referred for evaluation of primary infertility. Physical examination was normal. A number of semen analyses all demonstrated azoospermia with low semen volumes and negative fructose. Absent semen coagulation was noted in all specimens. A first post-coital urine specimen was negative for the presence of sperm cells. Serum testosterone, luteinizing hormone, follicle-stimulating hormone and prolactin levels were normal. The patient underwent unilateral left vasography through a left scrotal incision. The vasogram, performed by injection of a Summary of reported cases of ejaculatory duct obstruction Infectious Form of Etiology Obstruction

Reference

Acquired ejaculatory duct obstruction

Carson7 PATIENTS, METHODS AND RESULTS

Four patients (28, 33, 38 and 40 years old, respectively) suffering from ejaculatory duct stenosis and oligospermia have been reported on in detail recently. 7 All 4 patients had sperm counts of less than 5 million on 2 semen analyses and semen volumes of less than 1.5 ml. The semen pH averaged 6.8 and fructose was negative. Diminished semen coagulation was noted in 5 of 11 specimens. All patients had normal serum testosterone, luteinizing hormone and follicle-stimuh1.ting hormone levels. Two patients had a history of prostatitis and gonococcal urethritis, 1 had a history of prostatitis and 1 had prolonged urethral catheterization after abdominal trauma. All 4 patients had distinct obstruction of the ejaculatory Accepted for publication June 14, 1985. * Requests for reprints: Box 3274, Division of Urology, Duke University Medical Center, Durham, North Carolina 27710. 964

Normal Sperm Count After Pregnancy Treatment

Amelar and Dubin 12

W eintraub 14

No Yes Yes Yes No No Yes Yes Yes No No No

Yes No No No Yes No No No No Yes Not known No

Yes No No No Yes No No No No Yes Yes No

Congenital ejaculatory duct obstruction

Sharlip 8 Hassler and Weber8 Stanley'° Amelar and Dubin 12 Porch 13 Present study

Cyst Cyst Cyst Cyst Noncystic Noncystic Cyst

Yes No Yes Yes No Yes Yes

Yes No No Yes No Yes Yes

EJACULitTO-llY DUCT OBSTR1JCTI0l\J

mixture of uc,uc,,,,,aum and methylene revealed a smooth level of the junction with the seminal vesicle, vas deferens to at which point the vas became dilated. Then, a large midline cyst directly posterior to the prostate was noted, with reflux of contrast medium into the contralateral right seminal vesicle and vas deferens (figs. 1 and 2, A). There was no passage of contrast medium or methylene blue into the posterior urethra or bladder as confirmed radiologically and endoscopically. Cystourethroscopy showed a normal anterior urethra, normal external sphincter, a small verumontanum close to the bladder neck and no obvious ejaculatory ducts. The bladder neck and bladder were normal. With the aid of simultaneous fluoroscopy and cystoscopy the limits of the cyst were found to be from just distal to the bladder neck to the verumontanum. With a resectoscope this portion of the prostatic urethra was resected until a large cavity was opened, releasing methylene blue and murky material (fig. 2, B ). Complete emptying of the seminal vesicles and the diverticulum could be seen on fluoroscopy. Two months following this procedure the patient's wife became pregnant and a semen analysis revealed a sperm count of 258 million per ml., with a volume of 1 ml., normal coagulation and 96 per cent normal forms. DISCUSSION

While the treatment of male infertility may be discouraging at times due to the inability to help many of these patients one should refrain from a nihilistic attitude. With passing time physicians have learned to recognize the various etiologies and success rates in the treatment of the obstructive type of azoospermia are increasingly encouraging. While infertility caused

FIG. l. Left vasogram reveals smooth vas deferens and ejaculatory duct leading into large midline cyst. There is efflux of contrast material into contralateral right ejaculatory duct, seminal vesicle and vas deferens.

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ejaculatory obstruction is rare accurate uu,;,;",v"·"' vasography is important, since these obstructions may be treatable. On review of our experience and that in the literature it became clear that treatment efficacy may depend upon the etiology of the obstruction. Of our patients 2 had fully successful results and both fathered children: 1 had a urogenital sinus cyst (that is mullerian duct cyst, ejaculatory duct cyst and so forth) and 1 had obstruction following prolonged Foley catheterization. We found 3 additional reports of midline cysts involving both ejaculatory ducts and seminal vesicles. 8 - 10 The origin and definition of such cysts were reported recently by Elder and Mostwin, who suggested the use of the term urogenital sinus cysts for all of these midline retroprostatic/retrovesical cysts that communicate with the vasa and seminal vesicles.n Five cases of urogenital sinus cysts presenting with infertility and treated by transurethral unroofing of the cyst were reported and 4 were treated successfully, establishing normal sperm counts with 3 reported pregnancies (see table). We found reports of 14 additional well documented cases of ejaculatory duct stenoses presenting with infertility and treated transurethrally. 7• 12- 14 Of these cases 2 were believed to be congenital, since there was no history of infection, inflammation or trauma. The case reported by Amelar and Dubin as congenital was treated by transurethral resection but no patent channel could be established and this patient remained azoospermic. 12 The other case reported by Porch had good postoperative results with normal sperm counts and reported pregnancy.13 Of the 12 patients believed to have acquired obstruction 6 were known to have suffered from prostatitis, epididymitis and/ or gonorrhea, and 6 had histories of either prolonged Foley catheterization or trauma, with no related infection (see table). None of the patients in the infectious group had postoperative normal counts and none reported pregnancy. Of the 6 patients with noninfectious acquired obstructions 3 reportedly had normal postoperative sperm counts and had achieved pregnancy. In an additional patient a sperm analysis was not obtained but a pregnancy was reported. The 2 remaining patients were reported to be azoospermic. Vicente and associates reported 9 cases of ejaculatory duct obstruction, all of which were treated transurethrally with improved semen quality being reported in 3, increased semen volume in 5 and confirmation of patency of the ejaculatory ducts in 5. 15 Pregnancy was reported in only 1 of the 9 cases, with followup of 6 months to 3 years. However, it was impossible to divide these patients according to etiolo~; of the obstruction and to correlate further the results with any subgroup of patients. Farley and Barnes first reported the treatment of ejaculatory duct stenosis by endoscopic resectiono 16 However, they diagnosed this entity clinically, without proper documen-

FIG. 2. A, schematic sagittal view of midline cyst laying posteriorly between level of bladder neck and verumontanum. B, following transurethral resection of that part of prostatic urethra overlying cyst there was release of methylene blue and murky material. Complete emptying of seminal vesicles and diverticulum could be seen by fluoroscopy.

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GOLDW ASSER, WEINERTH AND CARSON

tation by vasography. In addition, their patients did not present for the treatment of infertility. Patients suffering from ejaculatory duct obstruction should not be regarded as a homogeneous group. Results of treatment depend on the etiology. Congenital obstructions treated by transurethral surgery resulted in normal sperm counts in 71 per cent of the patients and pregnancies in 57 per cent. Acquired obstruction not associated with genital tract infections resulted in normal sperm counts in 50 per cent of the patients (1 patient not analyzed) and pregnancy in 67 per cent. Obstructions secondary to genital infections seem not to be amenable to this treatment, with none of the patients achieving normal counts or pregnancy. This may be a result of more proximal epididymal or pre-epididymal obstruction caused by the infection. Cases of ejaculatory duct obstruction do not appear in the literature as scattered reports but rather as small series of patients, yet this entity is considered rare and the number of reports is scarce. The reason for this finding may be that the condition is underdiagnosed. The results of treatment reported support more aggressive attempts at diagnosis and treatment of ejaculatory duct obstruction. REFERENCES 1. Dubin, L. and Amelar, R. D.: Etiologic factors in 1294 consecutive cases of male infertility. Fertil. Steril., 22: 496, 1971. 2. Wagenknecht, L. V.: Obstruction in the male reproductive tract. In: Treatment of Male Infertility. Edited by J. Brain, W.-B. Schill and L. Schwarzstein. Berlin: Springer-Verlag, sect. III, chapt. 16, p. 221, 1982. 3. Lipshultz, L. I. and Howards, S. S.: Surgical treatment of male infertility. In: Infertility in the Male. New York: Churchill Liv-

ingstone, part III, chapt. 17, p. 343, 1983. 4. Pryor, J. P.: Azoospermia. In: Male Infertility. Edited by T. B. Hargreave. Berlin: Springer-Verlag, part III, chapt. 12, p. 212, 1983. 5. Schmidt, S. S., Schoysman, R. and Steward, B. H.: Surgical approaches to male infertility. In: Human Semen and Fertility Regulation in Men. Edited by E. S. E. Hafez. St. Louis: The C. V. Mosby Co., part 7, chapt. 47, p. 476, 1976. 6. Weinerth, J. L.: Long-term management of vasovasostomy patients. Fertil. Steril., 41: 625, 1984. 7. Carson, C. C.: Transurethral resection for ejaculatory duct stenosis and oligospermia. Fertil. Steril., 41: 482, 1984. 8. Sharlip, I. D.: Obstructive azoospermia or oligozoospermia due to miillerian duct cyst. Fertil. Steril., 41: 298, 1984. 9. Hassler, R. D. and Weber, C. H., Jr.: Oligospermia secondary to miillerian duct cyst: simple surgical cure. Urology, 11: 386, 1978. 10. Stanley, K. E., Jr.: Miillerian duct cyst variant: utriculocele and inclusion of ejaculatory ducts. Report of a case. J. Urol., 102: 233, 1969. 11. Elder, J. S. and Mostwin, J. L.: Cyst of the ejaculatory duct/ urogenital sinus. J. Urol., 132: 768, 1984. 12. Amelar, R. D. and Dubin, L.: Ejaculatory duct obstruction. In: Current Therapy of Infertility 1982-1983. Edited by C.-R. Garcia, L. Mastroianni, Jr., R. D. Amelar and L. Dubin. St. Louis: The C. V. Mosby Co., part I, p. 80, 1982. 13. Porch, P. P., Jr.: Aspermia owing to obstruction of distal ejaculatory duct and treatment by transurethral resection. J. Urol., 119: 141, 1978. 14. Weintraub, C. M.: Transurethral drainage of the seminal tract for obstruction, infection and infertility. Brit. J. Urol., 52: 220, 1980. 15. Vicente, J., del Portillo, L. and Pomerol, M. M.: Endoscopic surgery in distal obstruction of the ejaculatory ducts. Eur. Urol., 9: 338, 1983. 16. Farley, S. and Barnes, R.: Stenoses of ejaculatory ducts treated by endoscopic resection. J. Urol., 109: 664, 1973.