A 27-year-old man presented with chronic hematospermia, painful ejaculation, and primary infertility due to a rare presentation combining Zinner syndrome with contralateral seminal vesicle abnormalities, according to a case report published in Cureus. Medical examinations, transrectal ultrasonography, and pelvic magnetic resonance imaging revealed a left seminal vesicle cyst alongside left renal agenesis and contralateral right seminal vesicle hypoplasia.
Clinical Presentation and Diagnostic Findings
The patient sought medical evaluation after experiencing hematospermia and painful ejaculation for eight months, accompanied by irritative lower urinary tract symptoms and primary infertility, according to the Cureus data. A physical examination showed normal bilateral testes and vas deferens, while a digital rectal examination revealed a large bulging mass near the prostate. Routine hormone workups—including luteinizing hormone, follicle-stimulating hormone, prolactin, and testosterone—returned normal results.
Semen analysis indicated an ejaculate volume of 1 mL alongside oligoasthenozoospermia, characterized by a total sperm count of 10,250,000 and 99% nonmotile sperm. Imaging studies, including transabdominal and transrectal ultrasonography, confirmed left kidney agenesis with contralateral compensatory hypertrophy, alongside a large cystic mass measuring 5 by 3.5 cm in the left seminal vesicle area. Pelvic MRI verified that the structure contained hemoglobin degradation products and confirmed that the right seminal vesicle was hypoplastic. Diagnostic cystoscopy established the absence of the left ureteral orifice and demonstrated a pronounced bulging effect from the left seminal vesicle cyst on the prostatic urethra near the verumontanum.
Surgical Management via Transurethral Resection
Initial medical treatment involving antibiotics, alpha-blockers, and anti-inflammatory agents administered over several weeks failed to resolve the patient’s symptoms. Consequently, clinicians opted for surgical intervention, selecting transurethral resection of the ejaculatory duct as the definitive therapy to avoid more invasive open or laparoscopic procedures.
To ensure surgical precision, the medical team delivered the left vas deferens through an incision over the left hemiscrotum and injected 20 mL of diluted methylene blue to guide correct positioning during rigid urethroscopy. Surgeons then resected the seminal vesicle cyst wall using a cutting loop through a rigid 24 Fr cystourethroscope. Following the procedure, the patient experienced complete resolution of hematospermia and painful ejaculation at a two-month follow-up evaluation, and his wife subsequently experienced a missed abortion, according to the Cureus report.
Understanding Zinner Syndrome Variants
Zinner syndrome represents a rare congenital malformation characterized by the triad of seminal vesicle cysts, ejaculatory duct obstruction, and ipsilateral renal agenesis, originating from abnormal embryological development of the mesonephric duct during the first trimester of pregnancy. While standard presentations involve unilateral abnormalities paired with ipsilateral renal agenesia, this documented case highlights an unusual variant featuring contralateral seminal vesicle hypoplasia. Minimally invasive approaches such as transurethral resection of the ejaculatory duct provide effective relief for refractory symptoms while preserving surrounding anatomical structures.
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