Transrectal ultrasound (TRUS) evaluates the distal components of the ejaculatory duct system including the ampullae of the vas deferens, the seminal vesicles, ejaculatory ducts, and the prostate. Patients with complete distal ejaculatory obstruction and partial distal obstruction are ideal candidates for TRUS evaluation. The examination can be performed with the patient in the lithotomy, knee-chest, or lateral decubitus position. Lateral decubitus position is the preferred position as this provides easy access for the operator and less discomfort for the patient. On TRUS examination, the seminal vesicles appear as hypoechoic areas with fine septations. Anteroposterior diameter up to 15 mm is considered normal. Importantly, TRUS can reveal the anatomical relationship between ejaculatory channels and calcifications. It can also detect proximal dilatation of the ejaculatory tract, which indirectly implies the presence of a distal obstruction. TRUS can also be used for therapeutic aspiration and reduction in the size of obstructive cysts.