Infertility case presentation in Zinner syndrome: Can a long-lasting seminal tract obstruction cause secretory testicular injury?

Zinner syndrome, a rare congenital urogenital tract malformation: the first reported case in Indonesia

Zinner syndrome (ZS) is a rare urogenital anomaly characterized by cystic seminal vesicles, obstructed ejaculatory duct, and ipsilateral renal agenesis, complicating diagnosis and management due to its rarity and nonspecific symptoms.　ZS incidence is 0.0021%, with symptoms typically appearing in the 2nd and 3rd decades of life, including dysuria, urinary frequency, perianal pain, and infertility.　MRI is the gold standard for diagnosis, while surgery is reserved for symptomatic patients.　Mildly symptomatic patients receive conservative management, including antibiotics and regular monitoring.　We report the first case of ZS in Indonesia, involving a 36-year-old male presenting with perineal pain similar to an episode a decade earlier.　MRI revealed right kidney agenesis, ejaculatory duct obstruction, a 4.95 cm cyst on the right seminal vesicle, and a right ectopic ureter.　Semen analysis was unremarkable.　Diagnosis of ZS was confirmed, and the patient opted for conservative management.This case highlights the importance of diagnosing ZS in underrepresented regions, where limited awareness and access to advanced tools delay identification.　The conservative approach reflected the patient's preference to avoid surgical risks while achieving effective symptom relief through tailored, patient-centered care.　Clinicians should consider ZS in cases of unilateral renal agenesis with cystic pelvic masses.

Zinner syndrome in childhood and adolescence: Report of four cases and review of the literature

Zinner syndrome is a rare congenital malformation of the urinary system that occurs exclusively in males. It consists of renal agenesis, ipsilateral obstruction of the ejaculatory duct, and cystic changes in the seminal vesicles. It is rarely described in the pediatric population due to the absence of symptoms, as well as the failure to recognize it due to masking by other morphological changes and conditions. Four patients from the pediatric population are presented. Two patients were asymptomatic, and the changes were detected incidentally or during other diagnostic procedures. The other two patients exhibited symptoms and signs such as testicular pain, abdominal pain, hematuria, and hematospermia, along with megaureter. Ultrasound serves as the initial diagnostic method, while confirmation of Zinner's syndrome is established by MR urography. In cases that ultrasound verified kidney agenesis and ipsilateral anechoic, avascular tubulocystic structures, it is necessary to perform follow-up MR urography to confirm or exclude Zinner's syndrome. Following diagnosis, asymptomatic pediatric patients should be monitored every 6 months to a year, using ultrasound, with particular attention to cyst size and content.

A rare variant of zinner syndrome with ejaculatory duct cyst: case report and challenges in diagnosis and management

BACKGROUND

Zinner syndrome (ZS) is a congenital malformation characterized by a triad of mesonephric (Wolffian) duct dysplasia, first identified by Zinner in 1914. The classical presentation of ZS includes unilateral renal hypoplasia or dysplasia, ipsilateral seminal vesicle cysts, and obstruction of the ejaculatory duct. This case presents a rare variant of the syndrome, where an ejaculatory duct cyst is observed instead of the typical ipsilateral seminal vesicle cyst. The ejaculatory duct cyst affected the vas deferens bilaterally, leading to bilateral atrophy or erosion of the seminal vesicle glands, and resulted in the absence of seminal fluid, ultimately causing azoospermia and infertility.

CASE PRESENTATION

Prior to surgery, the patient experienced a sensation of incomplete defecation, accompanied by mild anal distension. Two semen analyses revealed azoospermia, and magnetic resonance imaging/magnetic resonance urography indicated the absence of the left renal component and suggested the presence of a seminal vesicle cyst. It was hypothesized that the azoospermia resulted from compression of the contralateral ejaculatory duct by the seminal vesicle cyst on the affected side. Consequently, a decision was made to proceed with laparoscopic resection.During the surgical procedure, no seminal vesicle cyst was identified; however, an ejaculatory duct cyst was discovered, wherein the bilateral vasa deferentia converged without any alternative outlet. The cyst was subsequently resected. Postoperatively, the patient's clinical symptoms resolved, although the issue of infertility remained unaddressed.

CONCLUSION

This case describes a rare Zinner syndrome variant where an ejaculatory duct cyst replaces the seminal vesicle cyst, leading to seminal vesicle atrophy, azoospermia, and infertility. An unreported variant was discovered during surgery, underscoring the importance of preoperative imaging. Laparoscopic removal alleviated symptoms but not infertility, indicating that assisted reproduction might be necessary for ZS-related azoospermia. This case expands knowledge of ZS variants and their impact on fertility.

Zinner Syndrome in Young Adult Males: A Case Series and Literature Review

Zinner syndrome (ZS) is a highly uncommon congenital or developmental urogenital anomaly characterized by the triumvirate of unilateral renal agenesis or dysplasia, ipsilateral ejaculatory duct obstruction, and ipsilateral seminal vesicle cyst. We present three cases of ZS in a 21-year-old male, a 20-year-old male, and a 24-year-old male. The diagnostic evaluation revealed unilateral renal agenesis associated with hypertrophy of the ipsilateral seminal vesicle with cystic changes on investigation by ultrasonography (USG), computed tomography (CT), and magnetic resonance imaging (MRI). The patients underwent surgical management, resulting in symptom resolution and enhanced quality of life. This case report highlights the diagnostic challenges, management options, and long-term outcomes for patients with ZS.

Role of magnetic resonance imaging in evaluation of ejaculatory duct in Zinner’s syndrome: case series of five patients and review of the literature

Background

Zinner's syndrome is a mesonephric duct anomaly characterized by unilateral renal agenesis, ipsilateral seminal vesicle cyst, and ipsilateral ejaculatory duct obstruction due to insult occurred at urogenital tract embryogenesis during the first trimester. In the third and fourth decades of life, it is frequently diagnosed when patients begin to be symptomatic, such as lower urinary tract symptoms, infertility and painful ejaculation.

Case presentation

Herein we illustrate case review including five patients diagnosed as Zinner’s syndrome, three of them complaining from infertility; however, the remaining two cases were fertile and incidentally diagnosed.

Conclusions

Radiological investigations play significant role in the diagnostic and management processes including US, CT and MRI for detecting ipsilateral renal agenesis and unilateral seminal vesicles dilatation, but evaluation of ejaculatory duct can be done only by MRI and transrectal ultrasound; however, the latter may be sometimes nonconclusive or intolerable by patients, so MRI is considered the golden modality with its high capability to assess the lower male genital tract which played a significant role in our case series starting with detection of the presence or absence of the ejaculatory duct obstruction as well as the high delineation of the origin and nature the seminal vesicle cyst including also its size and content and finally by detection of the communication between ureteral bud and the seminal vesicles cystic dilatation.

Zinner Syndrome-A Rare Cause of Recurrent Epididymitis and Infertility

Zinner syndrome (ZS) is a rare disorder that affects only men. It is characterized by a triad of abnormalities, including unilateral renal agenesis, ipsilateral seminal vesicle cysts, and atresia of the ejaculatory tract. Unfortunately, there is no consensus on the best treatment modality. We describe a case of a young male patient with recurrent epididymitis, dysuria, and frequent urination. In the diagnostic evaluation, we found an extended right seminal vesicle in the ultrasound with hyperechoic fluid inside and an absence of the right kidney. We performed magnetic resonance imaging, computed tomography, and semen analysis confirming Zinner syndrome and deteriorated semen parameters. Urethroscopic evaluation and ultrasound-guided puncture of the seminal vesicle were performed. An abscess was excluded. The cytologic evaluation showed hemosiderophages. Tamsulosin was introduced. We found no signs of relapse in a six-month observation, and the patient had no further symptoms. Therefore, minimally invasive treatment is a feasible option in young patients found with early-stage Zinner syndrome.

Zinner's syndrome, a retrospective series of three cases: different strategies to the same problem

A 106 years have passed since Zinner's syndrome was first described and current knowledge is still almost exclusively based on case reports. This article presents three patients with Zinner's syndrome with different clinical presentations and consequent different treatment options, showing the possible full spectrum of this condition. The first patient presented with storage lower urinary tract symptoms and benefited from laparoscopic removal of the seminal vesicle. The second patient has an incidental diagnosis on CT and remains asymptomatic on follow-up. The third patient presented with persistent lumbar pain and underwent open surgical removal of the seminal vesicle. The authors further present a literature review of the current knowledge on this topic, hopefully to clarify the state of art and improve the management of these patients.

Sperm retrieval by conventional testicular sperm extraction for assisted reproduction in patients with Zinner syndrome

We present data from three Caucasian men with Zinner syndrome who attended our center for the treatment of primary couple’s infertility. Each patient was scheduled for conventional testicular sperm extraction (cTESE) and cryopreservation. Sperm analysis confirmed absolute azoospermia. Patient 1 had right and left testis volumes of 24 mL and 23 mL, respectively; left seminal vesicle (SV) agenesis, severe right SV hypotrophy with right renal agenesis. Follicle-stimulating hormone (FSH) was 3.2 IU/L. Patient 2 exhibited right and left testis volumes of 18 mL and 16 mL, respectively; a left SV cyst of 32 × 28 mm, ipsilateral kidney absence, and right SV agenesis. FSH was 2.8 IU/L. Patient 3 showed a testicular volume of 10 mL bilaterally, a 65 × 46 mm left SV cyst, right SV enlargement, and left kidney agenesis. FSH was 32.0 IU/L. Sperm retrieval was successful in all patients. Nevertheless, cTESE should be performed on the day of oocyte retrieval.

A wide spectrum of rare clinical variants of Zinner syndrome

Congenital malformations of the seminal vesicles (SVs) are rare and are associated with abnormalities of the ipsilateral urinary tracts as embryologically both the ureteral buds and SVs arise from the mesonephric ducts. The triad of SV cysts, ipsilateral renal agenesis and ejaculatory duct obstruction is known as the Zinner syndrome. We, herein, present three very rare presentations of Zinner syndrome. Case 1 presented with haematuria, and was found to have a large SV cyst with stones and underwent a robotic cyst excision. Case 2 presented with primary infertility, and was found to have a variant of Zinner syndrome. Case 3 was a known case of chronic kidney disease on maintenance haemodialysis who presented with fever and oliguria. He was found to have Zinner syndrome and underwent aspiration of SV abscess. To the best of our knowledge, such varying presentations of Zinner syndrome have been rarely reported thus far.

Zinner syndrome and infertility─a literature review based on a clinical case

Zinner syndrome (ZS) is a rare congenital malformation associated with seminal vesicle cysts, ejaculatory duct obstruction, and ipsilateral renal agenesis. The main treatment focus so far has been on symptomatic patients. Therefore, surgery has been reserved for these patients, and surgical treatment is mainly aimed at pain relief. ZS seems to be frequently associated with infertility, but diagnosing is challenging, particularly during adolescence. This literature review of ZS and infertility is based on the medical report of one adolescent patient.