中文題目: 單側腎臟發育不全合併對側輸精管阻塞：病例報告

薛丞勛、黃建勳、程威銘、張彰琦

臺北市立聯合醫院忠孝院區外科部泌尿科

英文題目: Ejaculatory duct obstruction with contralateral renal agenesis: a case report

Cheng-Hsun Hsueh, Chien-Hsun Huang, Wei-Ming Cheng, Chang-Chi Chang

Division of Urology, Department of Surgery, Zhongxiao Branch, Taipei City Hospital

Introduction:

Ejaculatory duct obstruction (EDO) is an uncommon, but often correctable, cause of male sexual dysfunction and infertility. Typical features include reduced ejaculate volume, painful or difficult ejaculation, hematospermia, or infertility, and the diagnosis can be missed when symptoms are mild or hormonal profiles are normal^[1]. Transrectal ultrasound (TRUS) and Magnetic Resonance Imaging (MRI) are key tools to detect ejaculatory duct narrowing and seminal vesicle dilatation suggestive of obstruction^[2]. Transurethral resection of the ejaculatory duct (TURED), sometimes combined with guidewire passage and balloon dilatation, is the standard minimally invasive treatment and can provide both symptomatic and fertility benefits. Unilateral renal agenesis is frequently associated with ipsilateral genital tract anomalies because of their shared embryologic origin, and this association should prompt careful evaluation of the seminal vesicles and ejaculatory ducts^[3].

We report a 39-year-old man with congenital left renal agenesis combined with left seminal vesicle agenesis who presented with difficult ejaculation and was found to have membranous obstruction at the right ejaculatory duct orifice. Endoscopic membrane resection and balloon dilatation led to radiologic improvement and resolution of symptoms.

Case:

A 39-year-old man with a history of congenital left renal agenesis and obesity, status post sleeve gastrectomy, presented to our urologic clinic with a several-month history of difficult ejaculation. He reported that he sometimes failed to ejaculate despite reaching orgasm and also noted poor penile rigidity during sexual activity. He denied dysuria, gross hematuria, hematospermia, or perineal pain.

Physical examination revealed normal external genitalia and testes. Digital rectal examination showed a normal-sized, non-tender prostate. Laboratory tests demonstrated serum prolactin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and total testosterone within normal limits. Transrectal ultrasound revealed dilatation of the right seminal vesicle. Subsequent prostate MRI demonstrated dilatation of the right seminal vesicle, with imaging findings suspicious for ejaculatory duct obstruction, and atrophy of the left seminal vesicle.

Diagnostic urethroscopy was performed. At the level of the verumontanum, a membranous obstruction was identified at the right ejaculatory duct orifice. Transurethral resection of the obstructing membrane at the right ejaculatory duct orifice was carried out. A safety guidewire was then advanced through the duct, over which a 3-French ureteral catheter was inserted. Balloon dilatation of the ejaculatory duct was performed to further relieve the obstruction.

The postoperative course was uneventful. Follow-up sonography demonstrated improvement in seminal vesicle dilatation. Clinically, the patient reported marked improvement in his symptoms with easier ejaculation.

Conclusion:

This case illustrates that ejaculatory duct obstruction should be considered in young men presenting with difficult ejaculation, even when hormonal studies are normal and symptoms are subtle. The coexistence of unilateral renal agenesis and seminal vesicle abnormalities highlights the close embryologic relationship between the urinary and genital tracts and the need for careful imaging in such patients. Endoscopic management with transurethral resection of the obstructing membrane, supplemented by guidewire passage and balloon dilatation, provided both radiologic and symptomatic improvement in this patient. Early recognition and minimally invasive treatment of EDO can significantly improve quality of life and may prevent long-term reproductive consequences.