Hypogonadotropic hypogonadism with Zinner syndrome: a coincidence or a consequence?

This case report describes a man in his 20s presenting with bilateral crypto-orchidism, micropenis and underdeveloped secondary sexual characteristics. The patient also exhibited hyposmia, eunuchoid stature and gynecomastia. Biochemical investigations revealed low levels of testosterone, luteinising hormone and follicle-stimulating hormone. Hence, he was diagnosed with Kallmann syndrome. Imaging studies showed an absent right kidney and cystic dilatation of the distal ureteric bud, seminal vesicle and absent/hypoplastic ejaculatory duct. The association of hypogonadotropic hypogonadism with Zinner syndrome, a rare condition characterised by renal agenesis, seminal vesicle cyst and ejaculatory duct obstruction, was noted.

[Visualisation of the ejaculatory tract in a patient with empyema of the seminal vesicles]. / Een patiënt met empyeem van de zaadblazen.

BACKGROUND: Fever and malaise without the possibility of an adequate anamnesis has a broad differential diagnosis. Under these conditions in male patients several rare urogenital disorders need to be considered. CASE DESCRIPTION: A 26-year-old mentally disabled young man was examined because of a fever, altered behaviour and elevated infection parameters. A CT-scan of the abdomen showed signs of prostatitis. Transrectal ultrasonography was performed under general anaesthesia to rule out a prostatic abscess. This showed prominent, dilated seminal vesicles. Under transurethral sight, large amounts of pus was drained from the ejaculatory ducts by digital rectal examination (unique video). Intravenous antibiotic therapy was continued and the patient successfully recovered. CONCLUSION: Acute bacterial prostatitis is diagnosed based on the clinical presentation of the patient. When there is fever without a focus or no recovery following antibiotic therapy, an abscess of the prostate or empyema of the seminal vesicles should be considered.

A rare abnormality of ejaculatory duct opening in the bladder trigone in a 33-year-old male associated with primary infertility: Case report and literature review.

Genitourinary anomalies constitute a large proportion of congenital malformations. However seminal tract anomalies, particularly ejaculatory duct (ED) anomalies are very rare and little information exists on the topic. We are reporting a very rare case of bilateral ectopic EDs opening in the bladder trigone in a 33-year-old gentleman presenting for evaluation for primary infertility. The patient's semen analysis showed low-ejaculate-volume, fructose negative, acidic pH and azoospermia. His hormonal profile was normal. Cystoscopy revealed an empty posterior urethra, and the verumontanum and the openings of the EDs could not be identified in the posterior urethra. The ED openings were found inside the bladder trigone. Vasography combined with cystoscopy confirmed the opening of the ED in the trigone following Intra-vasal injection of methylene blue. Our patient had a successful intracytoplasmic sperm injection using testicular spermatozoa that resulted in a healthy baby boy. We also did a formal literature review through PUBMED, MEDLINE and Google Scholar with the search term (ectopic ED). Search results were filtered to exclude vas deferens ectopia. Our literature search revealed five studies comprising 24 patients with ectopic EDs. Mean age at diagnosis was 29.88 ± 12.88 years. The most common presenting symptom was hemospermia. The ectopic EDs most commonly opened in a midline cyst (21 cases), bladder trigone (1 case), or bladder neck (1 case). The most common management used for symptomatic patients with ectopic EDs opening in the midline cyst was through transurethral fenestration. In conclusion, ectopic ED openings in the bladder trigone are very rare. Management varies by case depending on the presentation, anatomy of underlying anomaly, associated complication/s and desire for fertility.

Diagnostic value of transrectal combined scrotal ultrasonography in acquired obstructive azoospermia.

OBJECTIVE: To investigate the transrectal and scrotal ultrasonographic features of acquired obstructive azoospermia and evaluate the role of ultrasonography in the location diagnosis of acquired obstructive azoospermia patients. METHODS: Retrospectively analysis of 92 cases of acquired obstructive azoospermia in recent years. All the patients underwent transrectal and scrotal ultrasonography. The ultrasonographic features were observed of testis, epididymis, scrotal segment of vas deferens, seminal vesicle, ejaculatory duct and prostate. Eighty cases with normal semen were taken as control group. RESULTS: Among the 92 cases of acquired obstructive azoospermia, 28 cases were prostate midline cyst, 32 cases were stone or calcification of the ejaculation duct and 21 cases were chronic seminal vesicle inflammation, which were found through transrectal ultrasonography; 27 cases were vas deferens dilation, 30 cases had abnormal mass of epididymis tail, 31 cases were epididymis thickness with reticular change, 8 cases were cystic dilatation of rete testis, which were found through scrotal ultrasonography. Compared with the control group, ultrasound examination increased the detection rate of distal seminal duct lesions and epididymal lesions in acquired obstructive azoospermia patients (p<.01). Comparison of testicular volume between case group and control group did not reveal significant difference (p>.05). The thickness of the head, body and tail of epididymis in case group was significantly bigger than that in control group (p<.01). CONCLUSION: Transrectal and scrotal ultrasonography can find lesions in different parts of the seminal passage. Acquired obstructive azoospermia patients have increased rate of distal seminal duct lesions, epididymal lesions and epididymis volume. Transrectal and scrotum ultrasonography can provide reliable imaging evidence for the location diagnosis of acquired obstructive azoospermia.

[Real-time transrectal ultrasound-guided seminal vesiculoscopy for the treatment of azoospermia secondary to ejaculatory duct obstruction].

OBJECTIVE: To evaluate the effect of real-time transrectal ultrasound-guided seminal vesiculoscopy (TRUS-SVS) in the treatment of azoospermia secondary to ejaculatory duct obstruction. METHODS: This retrospective study included 40 cases of azoospermia secondary to bilateral ejaculatory ducts obstruction treated by TRUS-SVS from June 2016 to June 2018 after failure to enter the vesiculoscope through the ejaculatory duct or prostatic utricle. We analyzed the success rate of surgery, operation time, postoperative complications, treatment results, and application value of TRUS-SVS. RESULTS: Real-time TRUS-SVS was successfully performed in 36 (90.0%) of the cases, 33 through bilateral and the other 3 through unilateral seminal vesicle, with a mean operation time of (32.8 ± 16.6) min. Thirty-seven of the cases were followed up for 6－15 (mean 9.3) months, of which sperm were found in 31 at 1－3 months and in 25 at 3－12 months, and pregnancies achieved in 9 cases within 12 months after surgery. No serious complications as retrograde ejaculation, urinary incontinence and rectal injury were observed postoperatively, except 2 cases of epididymitis and 2 cases of hematuria, which were all cured. CONCLUSIONS: For the patients who failed in seminal vesiculoscopy through the ejaculatory duct or prostatic utricle, real-time TRUS-SVS is a recommended procedure with the advantages of a high success rate, less damage to the prostate and rectum, and benefit to the improvement of semen quality.

Surgical procedures for male infertility: an update.

PURPOSE OF REVIEW: The aim of this review is to provide an overview of surgical treatment options for male infertility including varicocelectomy, treatment of ejaculatory duct obstruction, vasovasostomy, and sperm extraction, and to review recent advances in techniques and technologies that may improve operative outcomes. RECENT FINDINGS: Microscopic subinguinal varicocelectomy has been shown to have the highest success rates with lowest rates of complications, and may be facilitated by the use of Doppler, indocyanine green angiography, and the 4K3D operating video microscope. The standard treatment for ejaculatory duct obstruction by transurethral resection of the ejaculatory ducts has changed little over time, but vesiculoscopy may allow for temporary dilation of an obstruction to allow for natural conception, while also offering diagnostic capabilities. Use of the robotic platform has gained popularity for vasectomy reversals but controversy remains regarding the cost-effectiveness of this option. Recently, a reinforcing suture technique has been described for vasovasostomy to minimize anastomotic breakdown and reversal failure. Finally, gray-scale and color-enhanced ultrasound may improve ability to predict successful sperm retrieval during extraction procedures. SUMMARY: Though the fundamentals of surgical treatment options for male infertility have changed little with time, technological advancements have contributed to improved surgical outcomes over recent years.

The management and composition of symptomatic seminal vesicle calculi: aetiological analysis and current research.

OBJECTIVE: To report our experience in the diagnosis, minimally invasive treatment, and composition of seminal vesicle calculi (SVC). PATIENTS AND METHODS: In the present study, we evaluated 20 patients who were admitted to our hospital from January 2013 to January 2018. All the patients were diagnosed with intractable haematospermia and SVC. The diagnosis was further confirmed by seminal vesiculoscopy. SVC were removed by basket extraction; with larger SVC fragmented by holmium laser before extraction. Scanning electron microscopy, X-ray diffraction, and infrared spectroscopy were used to determine the SVC composition. RESULTS: All operations were completed successfully without surgical complications. SVC were mostly composed of hydroxyapatite and protein, suggesting that they were produced by infections. CONCLUSIONS: Seminal vesiculoscopy is a simple, minimally invasive technique that can be used for diagnostic confirmation and treatment of seminal vesiculitis with SVC. This study improves our understanding of SVC and provides a theoretical basis for the prevention of postoperative recurrence of SVC.

Transurethral resection of the ejaculatory ducts: etiology of obstruction and surgical treatment options.

Ejaculatory duct obstruction is an uncommon but surgically correctable cause of male infertility. With the advent and increased use of high-resolution transrectal ultrasonography, anomalies of the ejaculatory ducts related to infertility have been well documented. Although there are no pathognomonic findings associated with ejaculatory duct obstruction, the diagnosis should be suspected in an infertile male with oligospermia or azoospermia with low ejaculate volume, normal secondary sex characteristics, testes, and hormonal profile, and dilated seminal vesicles, midline cyst, or calcifications on transrectal ultrasound (TRUS). Although additional larger prospective and comparative studies are needed, it appears that TRUS with aspiration is the most effective method for diagnosis. While intrusive, it is less invasive than vasography. The most robust and published evidence for treatment involves transurethral resection of ejaculatory duct (TURED). More recent experience with antegrade endoscopic approaches are promising and may also be considered. An alternative to surgeries for reversal of obstruction is sperm retrieval for in vitro fertilization/intracytoplasmic sperm injection. A thorough discussion of all alternatives, including risks and benefits, should be held with couples facing this uncommon condition to allow them to make informed decisions regarding management.

Etiology of 305 cases of refractory hematospermia and therapeutic options by emerging endoscopic technology.

To investigate the surgical outcomes of vesiculoscopy on refractory hematospermia and ejaculatory duct obstruction (EDO), the clinical data (including pelvic magnetic resonance imaging (MRI) examinations and the long-term effects of endoscopic treatment) from 305 patients were analyzed. Four main etiologic groups were found on MRI. We found that 62.0% (189/305) of patients showed abnormal signal intensity in MRI investigations in the seminal vesicle (SV) area. Cystic lesions were observed in 36.7% (112/305) of the patients. The third sign was dilatation or enlargement of unilateral or bilateral SV, which were observed in 32.1% (98/305) of the patients. The fourth sign was stone formation in SV or in an adjacent cyst, which was present in 8.5% (26/305) of the patients. The transurethral endoscopy or seminal vesiculoscopy and the related procedures, including fenestration in prostatic utricle (PU), irrigation, lithotripsy, stone removal, biopsy, electroexcision, fulguration, or transurethral resection/incision of the ejaculatory duct (TURED/TUIED), chosen according to the different situations of individual patients were successfully performed in 296 patients. Fenestrations in PU+ seminal vesiculoscopy were performed in 66.6% (197/296) of cases. Seminal vesiculoscopy via the pathological opening in PU was performed in 10.8% (32/296) of cases. TURED/TUIED + seminal vesiculoscopy was performed in 12.8% (38/296) of cases, and seminal vesiculoscopy by the natural orifices of the ejaculatory duct (ED) was performed in 2.4% (7/296) of cases. Electroexcision and fulguration to the abnormal blood vessels or cavernous hemangioma at posterior urethra were performed in 7.4% (22/296) of cases. Two hundred and seventy-one patients were followed up for 6-72 months. The hematospermia of all the patients disappeared within 2-6 weeks, and 93.0% of the patients showed no further hematospermia during follow-up. No obvious postoperative complications were observed. The transurethral seminal vesiculoscopy technique and related procedures are safe and effective approaches for refractory hematospermia and EDO.

Clinical Consultation Guide on Imaging in Male Infertility and Sexual dysfunction.

Imaging can benefit clinicians in evaluating men with infertility or sexual dysfunction by giving an overview of a patient's overall clinical condition before undertaking an invasive procedure. An understanding of the limitations and advantages of image modalities used in clinical practice will ensure that clinicians can optimize patient care with imaging when necessary. PATIENT SUMMARY: The objective of this article was to review the current literature on imaging modalities used for the diagnosis and management of male infertility and sexual dysfunction. An understanding of the advantages and limitations of these imaging modalities will ensure that clinicians can optimize patient care with imaging when necessary.

[Clinical application of the disposable vasographic interventional therapy kit in vasoseminal vesiculography].

OBJECTIVE: To investigate the success rate and safety of percutaneous vasoseminal vesiculography with the disposable vasographic interventional therapy kit (VITK). METHODS: This study included ninety-six 19－65 (mean 43) years old male patients with infertility, hematospermia, seminal vesicle cyst, ejaculatory duct cyst, ejaculatory dysfunction, or vas deferens injury, with disease courses varying from 1 month to 7 years. With an open, multi-centered, single-group, self-controlled design and using the disposable VITK, we treated the patients by percutaneous vasoseminal vesiculography via injection of contrast medium into the vas deferens cavity under local anesthesia. RESULTS: Percutaneous vasoseminal vesiculography was successfully performed in 92 (97.87%) of the patients, which revealed abnormal seminal ducts in 51 cases (54.3%). Among the 28 infertile patients, 3 were found with bilateral and 5 with unilateral vas deferens obstruction. Vesiculitis was detected in 36 (81.8%) of the 44 hematospermia patients and bilateral vas deferens abnormality in 5 (38.5%) of the 13 patients with ejaculatory dysfunction. Transectional damage was observed in 2 patients with vas deferens injury induced by bilateral inguinal hernia repair. Three cases of seminal vesicle cyst and 4 cases of ejaculatory cyst were definitely diagnosed by vasoseminal vesiculography. CONCLUSIONS: The disposable vasographic interventional therapy kit, with the advantages of simple operation and high safety, deserves a wide clinical application in vasoseminal vesiculography.

[Diagnosis and treatment of ejaculatory duct cyst: A report of 2 cases and review of the literature].

OBJECTIVE: To investigate the diagnosis and treatment of ejaculatory duct cyst. METHODS: This study included 2 male patients present at the hospital for hemospermia and abnormal sensation in the perineal region in July and August 2014. Both underwent transrectal ultrasonography, routine semen examination, CT, MRI, cystoscopy, and vesiculography before transurethral fenestration of the cysts and pathological examination of the cyst wall specimens. Analyses were made on the clinical presentations, imaging features, pathological characteristics, differential diagnosis and treatment of ejaculatory duct cyst and relevant literature was reviewed. RESULTS: The cyst wall was mainly composed of smooth muscle, the inner wall lined with pseudostratified ciliated columnar epithelia, and with positive expressions of CD10 and Muc6 proteins on immunohistochemical staining, which indicated renal iatrogenic ejaculatory duct cyst. The patients were followed up for 18 and 20 months, respectively. All symptoms disappeared and no recurrence occurred after surgery. Routine semen examination for the two patients showed the semen volumes to be 3.5 and 3.1 ml, sperm concentrations 35 and 32 ×106/ml, grade a sperm 32.0 and 26.0%, grade b sperm 18.0 and 31.0%, and semen liquidation time 30 and 34 minutes, respectively. CONCLUSIONS: Pelvic cystic masses can be detected by transrectal ultrasonography, CT and MRI, but definite diagnosis relies on vesiculography, pathological examination and immunohistochemical staining. Transurethral fenestration is safe and effective for the treatment of ejaculation duct cyst.

Transurethral seminal vesiculoscopy for recurrent hemospermia: experience from 419 cases.

We summarized our experience in transurethral seminal vesiculoscopy (TSV) for recurrent hemospermia by introducing surgical techniques, intraoperative findings, and treatment outcomes. TSV was performed in 419 patients with an initial diagnosis of persistent hemospermia at Shanghai Changhai Hospital (Shanghai, China) from May 2007 to November 2015. TSV was successfully performed in 381 cases (90.9%). Hemospermia was alleviated or disappeared in 324 (85.0%) patients by 3 months after surgery. Common intraoperative manifestations were bleeding, obstruction or stenosis, mucosal lesions, and calculus. Endoscopic presentation of the ejaculatory duct orifice and the verumontanum was categorized into four types, including 8 (1.9%), 32 (7.6%), 341 (81.4%), and 38 (9.1%) cases in Types A, B, C, and D, respectively. TSV is an effective and safe procedure in the management of seminal tract disorders. This study may help other surgeons to become familiar with and improve this procedure. However, further multicentric clinical trials are warranted to validate these findings.

Large bilateral seminal vesicle calculi presenting with spermolithiasis.

A 34-year-old male presented with an 8-month history of passing increasingly painful 'grit' in his ejaculate. Semen analysis was normal as were urinary and blood tests. T1-weighted MRI revealed several bilateral high-signal areas measuring up to 1 cm in diameter, located in the seminal vesicles. These were confirmed as calculi on T2-weighted imaging and a seminal vesiculogram, with no drainage from the left ejaculatory duct and only minimal from the right duct. He is currently awaiting a robot-assisted laparoscopic vesiculotomy after completion of family.

Transurethral resection of ejaculatory ducts: a step-by-step guide.

OBJECTIVE: To demonstrate the key components for completing a successful transurethral resection of ejaculatory ducts (TURED) for completely obstructed ejaculatory ducts (EDs). DESIGN: Video presentation. SETTING: University Hospital. PATIENT(S): A 40-year-old man presenting with primary infertility and abnormal semen analysis (pH 6.4, volume of 0.7 cc, concentration 16 million/cc, and 7% motility) in whom a transrectal ultrasonography revealed dilated seminal vesicles measuring more than 1.5 cm and seminal vesicle aspiration detected no sperm in the aspirate. INTERVENTION(S): Transurethral resection of ejaculatory ducts. MAIN OUTCOME MEASURE(S): Intraoperative technique with commentary highlighting tips for a successful TURED. RESULT(S): This video provides a step-by-step guide for TURED, including transrectal ultrasonography-guided seminal vesicle puncture for instillation of methylene blue to allow more precise identification of EDs. Vesiculography was performed near the end of the procedure to assess for patency of EDs and confirm both sides had been opened. (Institutional review board approval was obtained for this presentation.) CONCLUSION(S): The key portions for performing a successful TURED includes seminal vesicle instillation of methylene blue for easier identification of EDs. Vesiculography is performed near the end of the procedure to ensure both EDs have been opened as well as to assess for passive drainage of the seminal vesicles through the newly open EDs.

Multicystic seminal vesicle with ipsilateral renal agenesis: two cases of Zinner syndrome.

The association of ipsilateral renal agenesis and cystic seminal vesicle is a rare congenital syndrome described by Zinner in 1914. The cases of two patients with this syndrome are presented, one of them associated with infertility, the other with cryptorchidism and testicular pain. A brief review of the literature is undertaken, regarding the main clinical and imaging implications, and the developmental anomalies that are involved in this unusual congenital anomaly are analyzed.