An infertile male with dilated seminal vesicles due to functional obstruction

not visualized on initial contrast injection, but was observed on later injection. The ejaculatory ducts were balloon dilated using a 5 French angioplasty balloon, and both ducts were cannulated and explored visually using a flexible ureteroscope, revealing markedly dilated SVs. Contrast injection demonstrated bilaterally enlarged SVs and no apparent vasal obstruction. A right vasotomy was performed and indigo carmine was injected, with subsequent appearance of blue dye in the bladder, confirming patency. Right testicular sperm aspiration was then performed, which revealed whole nonmotile sperm on microscopy. A semen analysis performed 5 days postprocedure again demonstrated an ejaculate volume of 0.5 ml with azoospermia, indicating a failure of the surgical intervention. Repeat imaging showed persistent dilation of the seminal vesicles (Figure 1b), which lead to the diagnosis of functional ampullo-vesicular obstruction, as opposed to a physical obstruction. For the next several months, the patient continued to experience pain with ejaculation, which was localized to the epididymis. Eleven months after our original encounter, the patient returned to undergo sperm aspiration and bilateral epididymectomy, which resulted in complete resolution of his symptoms. In this unusual case, a patient presented with symptoms of painful ejaculation and infertility, which are typical of ampullo-vesicular obstruction. However, the patient's symptoms failed to improve after a TURED procedure, and vesiculogram showed complete patency, with no evidence of physical obstruction along the ampullo-vesicular tract. This unusual finding led to the diagnosis of seminal vesicle dysfunction. Congenital causes of EDO include congenital agenesis or atresia of the ejaculatory ducts, 1 mutations in the cystic fibrosis transmembrane Dear Editor, The patient is a 45-year-old male who presented to an outside clinic in 2014 for evaluation of painful ejaculation, infertility, and difficulty with urination for as long as he could remember. He reported no past significant medical or surgical history and no family history of infertility. He was given a trial of tamsulosin without improvement in his symptoms. Initial semen analysis demonstrated azoospermia. A subsequent MRI showed bilaterally enlarged seminal vesicles, and the patient then underwent transurethral resection of the ejaculatory ducts (TURED) for presumed ejaculatory duct obstruction (EDO), also without symptomatic improvement. When the patient's symptoms persisted, he was referred to our clinic for further evaluation. On presentation, he denied a history of urinary tract or sexually transmitted infections, prostatitis, or prior related medical history, was taking no medications, and denied other surgical history beyond TURED. He complained of persistent pain …