MRI in Azoospermia-Interesting Case Report

36 years old male with primary infertility being investigated with CT scan being normal and azoospermia. MR of the region of interest suggests normal KUB, two relatively well defined small (less than 5 mm) cysts seen on either side of the midline symmetrically at the level of the ejaculatory ducts opening. The seminal vesicles are not identified. A convoluted fluid signal intensity heterogeneous lesion on the left, could represent dilated vas deferens.  Right vas, is not identified.   Rest of the study including the prostate gland and the testes are unremarkable. Transrectal ultrasonography corroborates the same.

Teaching Points:

Dr MGK Murthy, Dr Sumer Sethi. 

Contributors- Mr Hariom, Mr Gupta.

Ejaculatory ducts (ED) are, paramedial symmetrical structures, located in the central portion of the prostate in verumontanum region. Act as conduits through which vas deferens and seminal vesicles fluid enters prostatic urethra during ejaculation.

Obstruction to ED could be congenital or  acquired (Post urethral catheterisation,  uretheritis, TURP and Idiopathic), as well as complete or  incomplete.

D/D  includes  Mullerian duct cysts (can reach very large size and present as pelvic masses, usually in midline with no sperm on aspiration, can obstruct the ED opening by their size), Utricle cyst (small, not beyond the prostate usually, and in the midline), Prostatic retention cysts (seen usually in BPH, as cystic dilatations of prostatic acini of 2 to 6 mm size in central zone or central / peripheral zone junction), Seminal vesicular cysts ( small, less than 5 cms, occur in inflammatory and obstructive conditions, associated with renal agenesis), Ejaculatory duct cysts (cystic structures along the course of the ED just lateral to the midline at the verumontanum, with definitive diagnosis possible by trans-rectal aspiration showing sperms).

Treatment includes : Transurethral resection of the ejaculatory duct cysts with good results. However in our case reconstruction would be needed in view of possible absence of right Vas and both seminal vesicles.