OVERVIEW

What is epididymal obstruction?

The epididymis is a reproductive organ located on the upper posterior edge of the testis. After sperm is formed in the testis, it enters the epididymal duct through the efferent ductules, where it further matures and gains motility, and finally converges into the vas deferens connected to the tail of the epididymis.

Epididymal obstruction refers to the blockage of the epididymal duct, which prevents sperm from passing smoothly into the vas deferens, leading to azoospermia or oligospermia. It is a significant cause of infertility.

Is epididymal obstruction common?

Epididymal obstruction accounts for 3%–6% of male infertility cases. Among patients with obstructive azoospermia, epididymal obstruction is the primary cause, accounting for 33%–67%^[1].

What are the types of epididymal obstruction?

Based on etiology, it can be classified as:

• Congenital epididymal obstruction: Congenital hypoplasia of the epididymis;

• Acquired epididymal obstruction: Obstruction caused by infection, surgery, trauma, etc.

Based on location, it can be classified as unilateral or bilateral epididymal obstruction.

Is epididymal obstruction contagious or hereditary?

Congenital epididymal obstruction is mainly related to cystic fibrosis gene mutations, which are hereditary but not contagious.

Acquired epididymal obstruction is not hereditary and is generally not contagious. However, epididymitis, a major cause of epididymal obstruction, can be acquired through high-risk sexual behavior.

SYMPTOMS

What are the common manifestations of epididymal obstruction?

Patients may have a history of scrotal surgery, injury, or previous scrotal swelling, pain, or high fever. Couples may have long-term normal intercourse but no signs of conception. Specific manifestations depend on the cause, such as:

• Patients with epididymitis may experience scrotal redness, swelling, tenderness, enlarged testicles and epididymis with unclear boundaries. After the acute phase, inflammation subsides, leaving hard nodules in the epididymis.

• Patients with epididymal tuberculosis may develop gradually enlarged epididymis with mild symptoms, slow progression, and possible hard nodules. In later stages, cold abscesses or skin sinuses may form, with beaded nodules appearing in the vas deferens.

What complications can epididymal obstruction cause?

Epididymal stasis may occur, manifested as a full and painful epididymis. This is caused by the obstruction preventing sperm and epididymal fluid from entering the vas deferens, leading to local accumulation in the epididymis.

Can men with epididymal obstruction still father children?

It varies by individual.

If unilateral epididymal obstruction occurs and the other testicle can produce normally motile sperm that are successfully discharged, the chance of conception is not significantly affected.

If bilateral epididymal obstruction occurs, sperm cannot be discharged, resulting in azoospermia and male infertility.

Can men with epididymal obstruction still ejaculate?

Yes.

Seminal fluid consists of seminal plasma and sperm. Seminal plasma accounts for over 95% of the semen volume and is mainly composed of secretions from the seminal vesicles, prostate, and bulbourethral glands, all located downstream of the epididymis.

Therefore, if the epididymis is obstructed, ejaculation can still occur normally, but the ejaculate will contain no sperm.

CAUSES

What are the causes of epididymal obstruction?

Epididymal obstruction can be classified as congenital or acquired based on its etiology ^[2].

Congenital epididymal obstruction includes:

1. Cystic fibrosis (CF): Congenital bilateral absence of the vas deferens (CBAVD) caused by CF gene mutations, presenting as absence of the distal epididymis and hypoplasia of the seminal vesicles. It is often diagnosed in childhood due to recurrent bronchial infections and airway obstruction.

2. Young's syndrome: Mostly manifests in childhood, characterized by chronic sinusitis, bronchiectasis, and epididymal obstruction.

3. Adult polycystic kidney disease: Typically occurs in young or middle-aged adults, with multiple cysts in internal organs. Obstructive cysts in the epididymis can lead to infertility.

Acquired epididymal obstruction is more common than congenital cases and includes:

1. Epididymitis: The most frequent cause, often seen in sexually active young men. Pathogens such as Escherichia coli, Neisseria gonorrhoeae, and Mycobacterium tuberculosis can infect the epididymis via retrograde spread from the vas deferens, lymphatic vessels, or bloodstream. Severe inflammatory responses lead to fibrous scarring, causing obstruction of the epididymal lumen.

2. Tumors: Rare. Tumors near the epididymis may compress the duct system, causing obstruction, while primary epididymal tumors are even rarer.

3. Surgery or trauma: Procedures such as epididymal cyst removal or scrotal surgery may result in adhesions and subsequent obstruction.

Additionally, some cases of epididymal obstruction have unclear causes and are classified as idiopathic ^[2].

DIAGNOSIS

Under what circumstances should epididymal obstruction be seen by a doctor?

Infertility can be diagnosed when a couple has regular sexual intercourse for more than one year without using any contraceptive measures but shows no signs of conception. Especially if the male has a history of epididymitis, epididymal tuberculosis, scrotal surgery, or cystic fibrosis, the possibility of epididymal obstruction should be considered, and medical attention should be sought promptly.

Which department should be consulted for epididymal obstruction?

Andrology or reproductive medicine department, or alternatively, urology.

How is epididymal obstruction diagnosed?

Since there are many factors that can lead to infertility, a detailed medical history and corresponding auxiliary examinations are required for careful investigation.

1. Medical history and physical examination: Includes whether there is a history of hematospermia, painful ejaculation, urethritis, prostatitis, or epididymitis; whether there is a history of scrotal, inguinal, or urethral surgery or trauma ^[3]. At the same time, a scrotal palpation is needed to preliminarily determine whether there is obstruction and its location.
2. Auxiliary examinations: Semen analysis, seminal plasma biochemistry, sex hormone testing, mycoplasma and chlamydia testing ^[3], genetic testing, as well as blood routine, liver and kidney function, blood sugar, etc.
3. Imaging examinations: Scrotal ultrasound, vasography, etc. ^[3].
4. Biopsy: Can evaluate whether testicular spermatogenesis function is normal ^[3].

If the patient has normal sex hormone levels and normal testicular size, but semen analysis shows low sperm count, scrotal ultrasound indicates bilateral epididymal fine reticular changes, and seminal plasma biochemistry shows a deficiency of a-neutral glycosidase, this strongly suggests bilateral epididymal obstruction.

TREATMENT

How to Treat Epididymal Obstruction?

Treatment options for epididymal obstruction include:

1. Surgical Treatment: Microscopic epididymovasostomy is the most common surgical procedure. The basic operation involves removing the obstructed segment and anastomosing the vas deferens to the proximal epididymal tubule under a microscope to restore patency of the reproductive tract.

2. Medication: Epididymitis requires prompt antibiotic treatment for infection. Other medications, such as anti-estrogen drugs (e.g., tamoxifen), androgen therapy, antioxidants (e.g., vitamin E, vitamin C, N-acetylcysteine), pancreatic kininogenase, and pentoxifylline, may promote sperm production, improve sperm motility, and increase the chances of conception. However, these drugs cannot restore patency to the obstructed epididymal tubule.

3. Assisted Reproductive Technology (ART): For cases where surgery fails, the female partner has infertility factors, or ovarian function declines, sperm can be retrieved from the testis or epididymis using microsurgical techniques or percutaneous methods for in vitro fertilization.

   For patients with congenital bilateral absence of the vas deferens (CBAVD), ART can be used for conception.

   For acquired epididymal obstruction, unilateral obstruction does not affect fertility and may not require treatment. For bilateral obstruction, surgery is the primary treatment to restore epididymal patency. If caused by infection or other factors, appropriate medications should be administered. If these treatments fail, ART may be considered.

Can Epididymal Obstruction Be Cured?

Congenital cases are difficult to treat and rarely cured.

For acquired epididymal obstruction, the success rate of microsurgical reconstruction is 60%–85% ^[1], with postoperative pregnancy rates of 20%–30% ^[4].

Surgical outcomes require monitoring. Semen analysis typically begins one month post-surgery, with most patients showing sperm presence within 3–5 months. A few may take 6–12 months. The average time for epididymal patency restoration is 2.8–6.6 months ^[2]. If no sperm is detected in ejaculate after 12–18 months, surgical reconstruction is considered unsuccessful.

What Precautions Should Be Taken After Surgery for Epididymal Obstruction?

1. Protect the surgical area to prevent wound contamination.
2. Apply ice packs and elevate the scrotum to reduce swelling and pain.
3. Rest in bed for 3–5 days post-surgery, with early resumption of diet and ambulation encouraged ^[2].
4. Avoid heavy lifting and strenuous physical activity ^[2].

What Is the Cost of Surgery for Epididymal Obstruction? How Long Is the Hospital Stay?

Surgical costs are approximately ¥8,000, varying by region and hospital.

Hospitalization typically lasts 8–10 days.

How Long After Treatment Can Sexual Activity Resume for Attempting Conception?

After reproductive tract reconstruction, abstinence for about 4 weeks is recommended to promote anastomosis healing ^[2].

Additionally, early post-surgery semen analysis in long-term obstruction cases may show weak or dead sperm. However, most patients improve gradually with medication and restored tract patency, so anxiety is unnecessary.

DIET & LIFESTYLE

What should be noted in daily life/diet for epididymal obstruction?

1. Epididymal obstruction can lead to infertility. Spouses and family members should adjust their mindset, show care and comfort to the patient, face the condition positively, and enhance confidence in treatment.
2. Maintain a regular lifestyle and healthy routine. Eat more fresh fruits, vegetables, and protein-rich foods such as meat, eggs, and dairy. Quit smoking and drinking, and engage in appropriate physical exercise. Although a healthy lifestyle cannot restore the patency of the epididymal duct, it can improve semen quality and support treatments like surgery to enhance fertility ^[4].
3. Avoid prolonged cycling, hot water sitz baths, wearing tight pants, prolonged exposure of the perineum to electromagnetic waves, microwaves, and other radiation. These harmful factors are not direct causes of epididymal obstruction but can affect sperm production and should be minimized.
4. Pay attention to personal hygiene habits and change underwear and bedding frequently.

Can epididymal obstruction recur? How to reduce recurrence?

Even after successful reconstructive surgery, there is still a risk of re-obstruction (1%–50%). If sperm count gradually decreases post-surgery, it often indicates possible recurrence ^[2].

To reduce the recurrence rate, pay attention to the following:

• Maintain a regular lifestyle and healthy routine;
• Focus on personal hygiene, avoid high-risk sexual behaviors, and practice safe sex in daily life;
• Seek timely treatment for reproductive tract infections ^[2].

PREVENTION

Can Epididymal Obstruction Be Prevented? How to Prevent It?

Acquired epididymal obstruction can be prevented by focusing on avoiding its underlying causes, such as maintaining perineal hygiene, changing underwear frequently, washing the perineal area regularly, and avoiding unsafe sexual practices. If symptoms like scrotal redness, swelling, pain, or fever occur, prompt medical attention is necessary.

For congenital epididymal obstruction, premarital health checkups and genetic screening are recommended.