Transrectal ultrasound (TRUS) is used to look for ejaculatory duct obstruction. The obstructions are suspected in cases of low ejaculate volumes, low pH, and cases of 0% or very low motility of the sperm seen on semen analysis. The rectal probe is inserted and the prostate is evaluated. Because the prostate is just on the other side of the rectal wall, the imaging is quite good. The ejaculatory duct traverses the prostate to end in the prostatic urethra.

If calcifications are seen within the duct, the duct measures 3 mm or more in diameter, or the seminal vesicles are dilated to 15 mm in AP diameter, then obstruction is suspected. In these cases, a seminal vesiculogram can be done to determine if an obstruction is present. The patient is asked to ejaculate the night prior to the procedure, and to take a prep consisting of Fleet’s enema and some antibiotics. A TRUS is performed, and a needle with an echo tip (one that is seen on ultrasound). The needle is inserted into the vesicle. The fluid is aspirated and examined under the microscope. If more than 5 sperm per field (at 400x magnification) are seen, the patient is felt to be obstructed. After the aspiration, the vesicle is injected with a combination of X-ray contrast material and dye. This is typically done under a dynamic X-ray called fluoroscopy.

The patient then undergoes cystoscopy (an examination of the urethra and bladder with a scope). If the dye appears in the bladder, the patient is not obstructed, or partially so. On X-ray, if the contrast makes it to the bladder, then the patient is not obstructed, or partially so. If obstructed, the X-ray tells the area of the blockage. If the patient is obstructed and it is in the place we can reach surgically, a laser is used to resect the ejaculatory duct until the blockage is relieved. We know we have relieved the blockage because the colored dye we injected into the seminal vesicle now comes through into the prostatic urethra. The surgery is then complete.

Complications of the surgery include urethral stricture (an abnormal narrowing of the urethra), bleeding, infection, and pain. In addition, in cases where there is partial blockage, there is potential to make it complete. If a relatively large defect is left in the urethra, then urine can pool there, and lead to an infection and watery ejaculate. The complication rates are low, and will be discussed in detail as with any surgery prior to being performed.