The Truth About a Man’s Veru

The Case of the Month is an actual patient of The Turek Clinic
He hailed from Phoenix with 4 years of infertility. When first checked 3 years ago, his sperm count was very low as was the sperm motility. His sperm DNA fragmentation was elevated, adding further insult to injury. Since they had given a seriously good try at conceiving naturally, they moved to in vitro fertilization (IVF), also known as the “big hammer.”
However, IVF with single sperm injection (ICSI) also failed. Embryo growth in the IVF culture dish “stalled at 4 days” and there were no good embryos to use. The dreaded “dissolving embryo syndrome” strikes again.
To try to avoid IVF, they circled back with his care and checked his reproductive hormones (normal) and genetics for Y chromosome deletions and chromosomes (normal). He had a left varicocele successfully treated with embolization, and he was also given clomiphene citrate and anastrazole for 6 months. All to no avail. Even worse, his sperm count was now zero, which sent frustration levels through the roof.

TeleHealth Help

As a telehealth patient, he contacted me for a Second Opinion. On reviewing his case, I explained that the finding of low sperm counts trailing to zero over a several year period is uncommon and needs further investigation. He lived a clean life and his history was entirely negative for medications, recreational drugs, hot baths or any other gonadotoxin exposure. Squeaky clean from a fertility risk point of view.
After listening to his story, I asked a simple question: “What is your ejaculate volume?” Funny I should ask. He related a history of having several bloody ejaculates (hematospermia) 20 years ago, and of a relatively normal semen volume until 2-3 years ago. “Since then, the amount of semen has gone down a lot! It’s almost nothing now,“ he noted. I had him look up the recent semen analysis volumes and read them to me: “1.3 mL” “1.1 ml” “0.9 mL.” Bingo!

Sperm Traffic Jam

I suspected ejaculatory duct obstruction, a blockage that had likely progressed from partial to complete form. Made perfect sense with the decline in sperm counts and motilities along with low ejaculate volume and the lack of response to prior treatments. The only place in the male reproductive tract where a single blockage in the system can affect sperm flow on both sides is in the veru montanum, a little bump in the prostatic urethra where the paired ejaculatory ducts empty into the penis. These delicate, tiny ducts can be compressed (cyst), plugged (stone) or blocked by scar tissue.
That led to an office visit during which I performed a transrectal ultrasound. Not something that you want to have very often, the ultrasound confirmed that he had a small cyst near the veru that was blocking the flow of semen from the ducts into the urethra. We performed incisionless, endoscopic day surgery a few days later and unroofed the cyst near the veru.
Three weeks later we spoke by phone. I reviewed his first postsurgical semen analysis, which he obtained locally. It was entirely normal, including the volume, count and motility.
“Good to know Doc,” he said, “because my wife’s pregnancy tests keep coming back positive, and now I know why.” And so it goes. Life is, and begins, in the details.

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