A rare case of abdominal pain
A 23-year-old man with continuous pain in the lower abdominal quadrants (predominantly the left lower quadrant) over the last month, without identifiable maneuvers that cause relief or worsen the pain. He also referred increasing urinary frequency. He denied fever, weight loss, or changes in bowel habits. His past medical history included the diagnosis of a solitary kidney (congenital renal agenesis).
The physical examination depicted a soft and depressible abdomen, which was painful on palpation in both lower quadrants, without any mass, swelling, or signs of peritoneal irritation.
The ultrasound showed a simple cystic image in the pelvis, adjacent to the left common iliac vessels, with the maximum size of 40 mm. The computed tomography (CT) scan confirmed left renal agenesis (
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This development anomaly is rare and generally asymptomatic. The ZS results from an insult occurring between the 4th and 13th gestational week.
This anomaly is the result of an incomplete migration of the ureteric bud that fails to fuse with the metanephros, which leads to renal agenesis/dysplasia, atresia of the ejaculatory duct, and obstruction and cystic dilatation of the seminal vesicle.
The symptomatic cases are characterized by perineal pain, painful ejaculation, lower urinary tract symptoms, and other urinary symptoms.
The diagnosis of ZS can be incidental, such as in the work-up of infertility.
The symptoms, when present, start by the second to fourth decade of life (during highest sexual activity), and mostly when cysts exceed 50 mm.
The differential diagnosis of cystic image in the pelvis in males includes: cyst or cystic dilatation of the prostatic utricle, ejaculatory duct cysts (all three in midline), abscess, ectopic ureterocele, prostatic cysts, ejaculatory duct cyst, diverticulosis of the ampulla of the vas deferens, and all cystic pathology of the seminal vesicle (mega vesicles, hydatic cyst, hemorrhage, and hypotonic neuropathy).
The diagnostic work-up and the differential diagnosis may be aided by several imaging modalities, such as like abdominal or transrectal ultrasonography, which show the cystic nature and evaluate the relationships with pelvic organs. An abdominopelvic CT scan is better to confirm renal agenesis and to define the anatomy of pelvic structures. Magnetic resonance imaging is better than CT in delineating the anomalies, in demonstrating peripheral pelvic structures, and in planning the surgery.
The treatment of ZS depends on the presence or absence of symptoms as well as the cyst size. In an asymptomatic patient, the treatment can be conservative with follow-up. For symptomatic patients or cysts greater than 50 mm, the best approach is laparoscopic (as proposed to our patient) or robotic techniques, with surgical excision of the seminal vesicle cysts.