Primary infertility secondary to a hidden posterior urethral valve representing a diagnostic challenge in the fifth decade

Discussion

The current report presents a case of PUV that was diagnosed lately in the fifth decade of life. This condition was diagnosed while evaluating the primary infertility with obstructive azoospermia. The PUV was suspected during assessments with the VCUG findings, which was carried out to evaluate the voiding dysfunction that was associated with the anatomical finding depicted at the time of the other radiological evaluations, as described above. Furthermore, presence of voiding and storage symptoms at a younger age for long time duration urged us to look for the presence of functional voiding problem that could contribute to his infertility. Surgical management consisted of valve ablation using the hook of the resectoscope. Our patient reported improved urinary flow and ejaculation, followed by successful full-term pregnancy.

The abnormal urogenital anatomical findings were recognized after the initial radiological evaluation of obstructive azoospermia with the MRI, which showed a thick bladder wall, and the initial office cystoscopy, which revealed an abnormal prostatic urethra and severe bladder trabeculations. Subsequently, the findings of the VCUG obligated us to repeat the cystoscopy to look explicitly for any obstructive valves, which was confirmed.

The PUVs result in a wide spectrum of disease severity, ranging from incompatibility with life to a minimal impact that may not manifest during infancy.1 The management of PUVs remains a clinical challenge, requiring long-term management that differs among patients, based on severity and management time. Our patient presented with primary infertility with mild lower urinary tract symptoms, which were discovered due to attention to fertility. In fact, most of the reported cases of delayed presentation with PUVs are from countries where healthcare services are limited, with a lack of optimal programs for antenatal care.5

Taskinen et al6 reported adult sexual function among patients with PUVs. The patient and control groups in their cohort were similar in term of erectile function, except for patients with higher age due to the presence of secondary comorbidities to PUVs, such as renal impairment with chronic kidney disease, hypertension and renal transplants. However, their report was limited to a small sample size. Furthermore, the PUV group showed difficulties in achieving orgasms and reported ejaculatory problems. Nevertheless, paternity and ejaculatory problems were similar to those of the general population, except in the older age groups, which cannot be explained up to date. However, many factors could explain the sexual dysfunction among PUV patients, including renal impairments, embryological malformations of the prostate and seminal vesicles, chronic urinary reflux to ejaculatory ducts and recurrent epididymo-orchitis and prostatitis.7 Our patient was investigated for retrograde ejaculation as part of low ejaculate volume workup which revealed no sperms in the post-ejaculation urine analysis. However, based upon previous literature about the pathophysiology of the valve obstruction,7 chronic urine reflux to the genital organs secondary to obstruction might contribute to the abnormal environment for sperm storage and seminal fluid production.

The present case supports the wide spectrum of causes of male infertility that mandate detailed clinical evaluations. Systematic assessment and management of all urological complaints, including minor details, are essential to optimize patient condition for any hidden post-testicular urological factor of male infertility. In our report, the etiological factor in our patient was not diagnosed initially due to its rare occurrence at this age. However, this report addresses the diagnostic dilemma that could happen during infertility evaluation.

Obstructive azoospermia could result from obstruction at different levels in the urogenital tract. The high index of suspicion for PUVs should be considered for different age groups, especially for clinical presentation and radiological investigations suggestive of PUVs. In this patient, the associated urogenital tract abnormalities, including associated anatomical genital abnormalities and seminal fluid production, with PUV were surgically correctable and considered not to be barriers to achieve fertility after valve ablation.