Background <p>Obstructive azoospermia (OA) is a potentially treatable cause of male infertility. Point-of-care ultrasonography (POCUS) has emerged as a valuable adjunct in the evaluation of male infertility, enabling rapid identification of sonographic findings suggestive of reproductive tract obstruction. We describe the use of scrotal POCUS in the evaluation of OA in a man with a history of infantile bilateral Cohen cross-trigonal ureteral reimplantation for severe vesicoureteral reflux.</p> Case presentation <p>A 32-year-old man presented with primary infertility and azoospermia, with normal semen volume and pH. His medical history was notable for severe grade V vesicoureteral reflux treated with bilateral Cohen cross-trigonal ureteral reimplantation at 4 months of age. Physical examination demonstrated bilaterally palpable vasa deferentia and normal testes. Hormonal evaluation and genetic testing were unremarkable. Scrotal POCUS revealed multiple cystic structures in both epididymides with otherwise normal-appearing testes, findings highly suggestive of OA. A normal hormonal profile further supported an obstructive etiology. In the absence of alternative etiologies, OA was considered the most likely diagnosis. The patient subsequently underwent successful testicular sperm aspiration (TESA), yielding abundant motile sperm for cryopreservation, with histopathologic confirmation of normal spermatogenesis.</p> Conclusions <p>This case highlights the potential value of scrotal POCUS as a rapid bedside tool that can support the diagnosis of OA and facilitate timely clinical decision-making. In patients with a history of prior genitourinary surgery, characteristic sonographic findings may help guide management and expedite fertility treatment. Further studies are warranted to better define the role of POCUS in the diagnostic evaluation of male infertility.</p>