For over 20 years, transurethral resection of the ejaculatory ducts (TURED) has been used to relieve pain due to ejaculatory duct obstruction. More recently, it has become obvious that ejaculatory duct obstruction causes infertility in 5% of azoospermic men. Ejaculatory duct obstruction is suspected when the ejaculate volume is < 2.0 mL and no sperm or fructose is present. Clinical suspicion can be confirmed by TRUS demonstration of dilated seminal vesicles or dilated ejaculatory ducts. Patients with ejaculatory duct obstruction sufficient to cause coital discomfort, recurrent hematospermia, or infertility should be considered for treatment.

Transurethral resection of the ejaculatory ducts is performed cystoscopically (

Figure 42-15). A small resectoscope and electrocautery loop are inserted, and the verumontanum is resected in the midline. Since the area of resection is at the prostatic apex, near the external urethral sphincter and the rectum, careful positioning of the resectoscope is essential. Long-term relief of postcoital pain after TURED can be expected in 60% of patients. Hematospermia has also been effectively treated with TURED, but this literature is anecdotal. There is convincing evidence from several large studies of patients treated for infertility that 65-70% of men show significant improvement in semen quality after TURED and that a 20-30% pregnancy rate can be expected. The complication rate from TURED is approximately 20%. Most complications are self-limited and include hematospermia, hematuria, urinary tract infection, epididymitis, and a watery ejaculate. Rarely reported complications include retrograde ejaculation, rectal perforation, and urinary incontinence.