巨大射精管囊腫導致之嚴重下泌尿道症狀

吳冠儒¹、鄭鼎耀¹

¹台灣基督長老教會馬偕醫療財團法人馬偕紀念醫院泌尿科

Lower Urinary Tract Symptoms Caused by a Huge Ejaculatory Duct Cyst

Kuan-Ju Wu¹, Ting-Yao Cheng¹

¹Department of Urology, MacKay Memorial Hospital, Taipei, Taiwan

Introduction –

Ejaculatory duct cysts are rare congenital or acquired lesions that can manifest with a variety of clinical presentations, ranging from pelvic pain to hematospermia. While often discussed in the context of male infertility, their role as a primary driver of severe lower urinary tract symptoms (LUTS) is frequently overlooked. These cysts can lead to significant bladder outlet obstruction by exerting extrinsic pressure on the prostatic urethra or the bladder neck. This case report focuses on a patient whose predominant complaint was refractory LUTS, ultimately traced to a massive ejaculatory duct cyst and successfully treated with minimally invasive laser surgery.

Case presentation –

A 46-year-old male presented with a long-standing history of debilitating LUTS, including a persistent sensation of residual urine, urinary frequency, and terminal dribbling. His medical history was significant for obstructive azoospermia, yet his immediate concern was the failure of alpha-blockers and other medical therapies to alleviate his voiding dysfunction. Physical examination and initial screening showed a PSA of 1.45 ng/ml. Uroflowmetry demonstrated an obstructive pattern with a Qmax of 11 ml/s. Transrectal ultrasound (TRUS) revealed a large, midline cystic structure involving the left ejaculatory duct and seminal vesicle, protruding toward the prostatic urethra. Diagnostic cystoscopy confirmed a prominently bulging and hyperemic verumontanum, which acted as a physical barrier to urinary flow, explaining the patient's symptomatic profile.

Result –

The patient underwent transurethral Thullium laser unroofing of the ejaculatory duct cyst on February 25, 2026. Under TRUS guidance, the laser was used to create a 1-cm opening at the most prominent point of the verumontanum. This resulted in the immediate evacuation of turbid cystic fluid and the subsequent collapse of the cyst wall, verified in real-time by ultrasound. The procedure was completed with minimal blood loss. The patient’s recovery was rapid; the urinary catheter was removed on the first postoperative day, and he reported immediate improvement in his urinary stream. Although a follow-up semen analysis two weeks later confirmed persistent azoospermia, his primary complaint of LUTS was completely resolved, significantly enhancing his quality of life.

Discussion –

This case underscores the importance of considering ejaculatory duct cysts in the differential diagnosis of LUTS in middle-aged men, particularly when standard treatments for benign prostatic hyperplasia (BPH) fail. The mechanical obstruction caused by the cyst at the level of the verumontanum can mimic the symptoms of urethral stricture or prostatic enlargement. The integration of TRUS and cystoscopy is vital for a definitive diagnosis and for guiding precise surgical intervention. We found that Thullium laser unroofing offers a safe and highly effective treatment modality, providing superior hemostasis and precision compared to traditional electroresection. While the impact on long-term fertility remains complex, this approach is excellent for relieving the primary obstructive symptoms associated with large ejaculatory duct cysts.