Spermatocele

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Background

A spermatocele is a benign cystic accumulation of sperm that arises from the head of the epididymis. Although often disconcerting to the patient when noticed, these lesions are benign. Spermatoceles can develop in varying locations, ranging from the testicle itself to locations along the course of the vas deferens. Nevertheless, in common usage, spermatoceles are intrascrotal, paratesticular cystic collections of sperm that arise from the epididymis.

Usually smooth, soft, and well-circumscribed, spermatoceles are broadly described as scrotal masses. The differential diagnoses include hydrocele, varicocele, hernia, simple epididymal cyst, and neoplasm. History, examination, and ultrasonography can aid in the differentiation.

Spermatoceles typically arise from the caput (head) of the epididymis, which is located on the superior aspect of the testicle. Conversely, hydroceles are fluid collections that cover the anterior and lateral surfaces the testicle. A varicocele is a dilated plexus of veins along the spermatic cord. A hernia results from persistent patency of the processus vaginalis allowing intraabdominal contents to pass into the abnormal intrascrotal peritoneal extension. In contrast to spermatoceles, both varicoceles and hernias may enlarge with the increased intraabdominal pressure generated during Valsalva. Epididymal cysts are often grouped with spermatoceles, and the two may be impossible to differentiate based on gross anatomy. In contrast to the epididymal cyst, spermatocele fluid typically contains sperm.

History of the Procedure

The term spermatocele is derived from the Greek spermatos (sperm) and kele (cavity or mass). It has been recognized for more than 100 years.

Problem

A spermatocele is a cystic accumulation of sperm that contains fluid typically arising from the head of the epididymis. It is a common benign finding on routine physical examination and is usually smaller than 1 cm. Less commonly, they may enlarge to several centimeters. Pain, discomfort, or resultant significant scrotal distortion may prompt surgical intervention.

Epidemiology

Frequency

Spermatoceles have been incidentally identified in 30% of patients undergoing scrotal ultrasonography for other reasons. The exact prevalence of this common condition has not been defined.

Etiology

The etiology of spermatoceles in humans remains undefined. Multiple etiologies have been proposed, although none is universally accepted. Some hypotheses include that spermatoceles may arise from efferent ductules, may be aneurysmal dilations of the epididymis, or may be dilation secondary to distal obstruction. In a mouse model of spontaneous spermatocele, distal efferent ducts were found to be occluded by agglutinated germ cells.

Pathophysiology

The specific pathophysiology remains to be elucidated. Although distal obstruction has been theorized as a potential mechanism, the presence of motile sperm in up to 80% of spermatoceles suggests maintenance of proximal patency.

Presentation

Typically, spermatoceles are asymptomatic. They are often incidental findings on testicular self-examination or routine physical examination. As they usually arise from the head of the epididymis, they are found superior to the testicle. They are smooth and spherical and transilluminate on examination. Failure to transilluminate suggests a solid lesion, which warrants further evaluation, including scrotal ultrasonography and possible inguinal exploration.

Indications

Surgical intervention is not indicated for the incidental asymptomatic spermatocele. However, if discomfort, pain, or progressive enlargement is bothersome to the patient, discussion regarding excision may ensue.

Relevant Anatomy

The first image below demonstrates a cross-section of the testicle, epididymis, and vas deferens. The second image is an illustration of a spermatocele. The last two images are intraoperative photographs of a large symptomatic spermatocele.


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A sagittal section of the testicle. Idiopathic obstruction of the epididymal ducts is one hypothesis that explains the formation of spermatoceles.


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Diagram of a spermatocele.


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Spermatocele as seen prior to incision.


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Intraoperative view of spermatocele with adjacent testicle and spermatic cord.

Contraindications

Needle aspiration of a spermatocele should be avoided, as it may lead to infection, spillage of irritating sperm within the scrotum, and reaccumulation of the spermatocele. Spermatocelectomy may be offered to symptomatic patients who are reasonable surgical candidates. Anticoagulation is a relative contraindication. Sclerotherapy is usually not performed in reproductive-aged men because of the risk of chemical epididymitis and resultant epididymal damage, which may contribute to future infertility.

Laboratory Studies

Imaging Studies

Histologic Findings

Microscopic examination reveals a fibromuscular wall that is lined by cuboidal epithelium, as illustrated in the image below.


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Microscopic view of spermatocele lined with cuboidal epithelium.

A gross specimen of a spermatocele is shown in the images below.


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Intraoperative view of spermatocele with adjacent testicle and spermatic cord.


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Spermatocele after complete excision.

Medical Therapy

No specific medical therapy is indicated for treatment of a simple spermatocele. Oral analgesics may be prescribed for symptomatic relief. If an underlying epididymitis is responsible for discomfort, antibiotics may be indicated. Observation is usually used for simple, small asymptomatic spermatoceles.

Surgical Therapy

Spermatocelectomy via a transscrotal approach is the primary operative intervention for spermatocele, and it may be offered to any reasonable surgical candidate. Systemic anticoagulation and desire to father children are relative contraindications.

Sclerotherapy is an alternative to excision, but results appear to be less effective. Sclerotherapy is usually reserved for men who have no desire for future paternity, as the risk of ensuing chemical epididymitis and resultant epididymal damage may impair fertility. Because aspiration of spermatocele alone is associated with a high recurrence rate, a sclerosing agent is used to cause coaptation of the walls of the cyst. Several sclerosant materials have been used, including tetracycline, fibrin glue, phenol, sodium tetradecyl sulfate (STS), quinine,talc powder, polidocanol,[2] and ethanolamine oleate, all with degrees of success varying from 30%-100%. With polidocanol instillation, success rates of 34-59% were noted after a single instillation. With repeated treatments, up to 89% were ultimately considered successful. Comparative trials have not established any one agent as a superior spermatocele sclerosing agent.[3] Similarly, no standard dosing for maximal benefit is currently available.

Preoperative Details

Spermatocelectomy

Spermatocelectomy is typically performed on an outpatient basis, with either regional or general anesthesia. The choice is based on the preference of the patient, surgeon, and anesthesiologist. The patient must be counseled regarding the risks of infertility, as well as the more common complications of hematoma, infection, swelling, recurrence, and pain.[4]

Sclerotherapy

Sclerotherapy is performed on an outpatient basis after the potential complications are discussed. The administration of anesthesia is provided locally, although the timing may vary according to surgeon preference. Some have reported administration at the puncture site prior to initiating the procedure, while others instill the anesthetic during the instillation of the sclerosant, after aspiration has occurred.

Intraoperative Details

Spermatocelectomy

The scrotum is prepared and sterilely draped. In addition, a folded sterile towel placed beneath the scrotum supports and elevates it into the surgical field. Either a vertical median scrotal raphe or a transverse hemiscrotal incision may be used. The dissection is continued to the level of the tunica vaginalis with electrocautery. The testicle, epididymis, and spermatocele may then be delivered from the dartos with gentle blunt dissection, leaving the tunica intact. Alternatively, some surgeons instead incise the tunica vaginalis in situ and deliver the testicle and epididymis out of the wound. Using both blunt and sharp dissection, the spermatocele is isolated from the body of the epididymis, and, typically, a narrow neck is found attaching the spermatocele to the rest of the epididymis. This neck is ligated with a 3-0 absorbable suture and divided.

If a multiloculated spermatocele is present or the neck is not readily found, the spermatocele is ideally kept intact while it is gently dissected away from normal tissue. Preventing perforation may be difficult because of the adherent nature of surrounding tissues but is advantageous, as it simplifies dissection and limits the spillage of potentially locally irritating sperm. When a plane cannot be readily developed, some advocate excision of adjacent normal epididymis with the specimen (partial epididymectomy); however, this increases the risk of epididymal obstruction.

Once the spermatocele has been dissected free and removed, hemostasis must be obtained. Because of the capacious nature of the scrotum, bleeding does not readily tamponade. Dramatic postoperative hematomas can result.

After achieving hemostasis, the tunica/dartos layer is closed with a 2-0 or 3-0 absorbable running suture, and the skin is closed with 3-0 absorbable suture in a subcuticular, interrupted, or running stitch. Dry gauze fluffs and an ice pack are placed on the scrotum, and the patient is discharged with a scrotal supporter.

Sclerotherapy

The scrotum is prepared and sterilely draped. The scrotal skin is punctured at the most prominent point of protrusion with a 16-gauge intravenous cannula. Fiber optic lighting or ultrasound guidance may be used at the discretion of the surgeon. If the spermatocele is multicystic, ultrasound guidance may also be used to ensure that all cavities are aspirated. The needle is withdrawn from the plastic sheath of the cannula, and all of the cystic fluid is withdrawn with a syringe. Manual manipulation of the scrotum is needed to ensure complete evacuation of the spermatic fluid.

A sclerosant is then instilled through the cannula after the spermatocele fluid has been evacuated. The amount and type of sclerosant varies, depending on an individual practitioner's preference. The amount of sclerosant used depends on the amount of fluid aspirated from the spermatocele and the adopted technique. Volumes for one such technique are shown in Table 1.

Table 1. Volume of Sclerosant Solution Used for Sclerotherapy


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See Table

After sclerosant installation, the cannula is removed and the scrotum massaged by hand to ensure adequate distribution of the sclerosant solution throughout the injection cavity.

Postoperative Details

Spermatocelectomy

Postoperatively, patients are encouraged to continue scrotal support, using an athletic supporter for a minimum of 48 hours after discharge. Additionally, gentle scrotal elevation while the patient is supine may decrease the risk of uncomfortable postoperative edema. Intermittent application of cold or ice packs to the dressing is commonly used. Oral analgesics (eg, acetaminophen and codeine [Tylenol #3] or hydrocodone and acetaminophen [Vicodin] 1-2 tabs PO q4-6h prn) should provide adequate postoperative pain relief. Patients are instructed to keep the dressing in place, to allow the wound to dry for 48 hours, and to avoid strenuous activity for 2 weeks.

Sclerotherapy

Direct pressure to the scrotum should be avoided. Patients often do not require narcotic analgesics and, after being observed for 1-3 hours, may be discharged without any physical restrictions.

Follow-up

Spermatocelectomy

Patients are scheduled to return 2-6 weeks postoperatively to evaluate the wound and address any additional concerns.

Sclerotherapy

Each patient is assessed 1 month after surgery and reassessed at 4-6 months. If the spermatocele has recurred or is bothersome, imaging studies are obtained, and, if a spermatocele is present, the patient is offered an additional course of sclerotherapy or surgical excision.

For excellent patient education resources, visit eMedicineHealth's Men's Health Center. Also, see eMedicineHealth's patient education article The Male Anatomy.

Complications

Spermatocelectomy

As should be routinely discussed preoperatively, any invasive surgical procedure has inherent risks. Epididymal injury and obstruction may occur. Gross injury to the epididymis, confirmed histologically based on its presence in the spermatocele specimen, has been reported in as many as 17% of patients. Inadvertent epididymal obstruction without excision certainly may exceed this. Infertility may result from either injury. The authors routinely counsel patients that infertility may result. Additional risks include scrotal hematoma formation, superficial wound infection, swelling, and recurrence of the spermatocele.

Sclerotherapy

Following sclerotherapy, potential complications include epididymal injury, infertility, bleeding, infection, chemical epididymitis, and spermatocele recurrence. Postprocedure, minor pain was noted in 10%, moderate pain in 4%, and severe pain in approximately 3% of patients.[5] A 65% success rate is quoted, although patients with large or multiloculated spermatoceles were more likely to have a recurrence that required additional intervention. Finally, as result of the chemically induced inflammatory reaction, scrotal wall thickening may develop postsclerotherapy.

Outcome and Prognosis

The expected outcome and prognosis of spermatocelectomy are excellent. A recent study revealed that of patients who underwent excision of an uncomfortable spermatocele, 94% were rendered pain-free. Spermatocelectomy remains the best surgical treatment for symptomatic spermatoceles.

Conversely, although sclerotherapy may carry a decreased incidence of wound complications and potentially lower associated costs, its efficacy is generally considered inferior.

Future and Controversies

To date, no prospective randomized trial has compared the outcomes of spermatocelectomy with those of sclerotherapy. Similarly, sclerosing agents have not been subjected to this degree of evaluation in order to demonstrate whether one agent or dosing regimen is superior to others.

Author

Vernon M Pais Jr, MD, Assistant Professor, Department of Surgery, Section of Urology, Dartmouth Medical School

Disclosure: Nothing to disclose.

Coauthor(s)

Shaun E Wason, MD, Resident Physician, Department of Surgery, Division of Urology, Dartmouth-Hitchcock Medical Center

Disclosure: Nothing to disclose.

Specialty Editors

Allen Donald Seftel, MD, Professor of Urology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School; Head, Division of Urology, Director, Urology Residency Training Program, Cooper University Hospital

Disclosure: lilly Consulting fee Consulting; abbott Consulting fee Consulting; auxilium Consulting fee Consulting; actient Consulting fee Consulting; journal of urology Honoraria Board membership; endo Consulting fee Consulting

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Shlomo Raz, MD, Professor, Department of Surgery, Division of Urology, University of California at Los Angeles School of Medicine

Disclosure: Nothing to disclose.

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Associate Chair for Clinical Operations, Director, Division of Endourology and Stone Disease, Department of Urology, University of Michigan Medical School

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Disclosure: Lilly None Advisor; Astellas Honoraria Speaking and teaching; Watson Honoraria Speaking and teaching; Warner Chilcott Honoraria Speaking and teaching; Auxilium Honoraria Speaking and teaching; Eli Lilly Honoraria Speaking and teaching

References

  1. Sista AK, Filly RA. Color Doppler sonography in evaluation of spermatoceles: the "falling snow" sign. J Ultrasound Med. Jan 2008;27(1):141-3. [View Abstract]
  2. Jahnson S, Sandblom D, Holmäng S. A randomized trial comparing 2 doses of polidocanol sclerotherapy for hydrocele or spermatocele. J Urol. Oct 2011;186(4):1319-23. [View Abstract]
  3. East JM, DuQuesnay D. Sclerotherapy of idiopathic hydroceles and epididymal cysts: a historical comparison trial of 5% phenol versus tetracycline. West Indian Med J. Dec 2007;56(6):520-5. [View Abstract]
  4. Kauffman EC, Kim HH, Tanrikut C, Goldstein M. Microsurgical spermatocelectomy: technique and outcomes of a novel surgical approach. J Urol. Jan 2011;185(1):238-42. [View Abstract]
  5. Shan CJ, Lucon AM, Pagani R, Srougi M. Sclerotherapy of hydroceles and spermatoceles with alcohol: results and effects on the semen analysis. Int Braz J Urol. May-Jun 2011;37(3):307-12; discussion 312-33. [View Abstract]
  6. Davis RS. Intratesticular spermatocele. Urology. May 1998;51(5A Suppl):167-9. [View Abstract]
  7. Gray CL, Powell CR, Amling CL. Outcomes for surgical management of orchalgia in patients with identifiable intrascrotal lesions. Eur Urol. Apr 2001;39(4):455-9. [View Abstract]
  8. Gutman H, Golimbu M, Subramanyam BR. Diagnostic ultrasound of scrotum. Urology. Jan 1986;27(1):72-5. [View Abstract]
  9. Itoh M, Li XQ, Miyamoto K. Degeneration of the seminiferous epithelium with ageing is a cause of spermatoceles?. Int J Androl. Apr 1999;22(2):91-6. [View Abstract]
  10. Moloney GE. Comparison of results of treatment of hydrocele and epididymal cysts by surgery and injection. Br Med J. Aug 23 1975;3(5981):478-9. [View Abstract]
  11. Nash JR. Sclerotherapy for hydrocele and epididymal cysts: a five-year study. Br Med J (Clin Res Ed). Jun 2 1984;288(6431):1652. [View Abstract]
  12. Nashan D, Behre HM, Grunert JH. Diagnostic value of scrotal sonography in infertile men: report on 658 cases. Andrologia. Sep-Oct 1990;22(5):387-95. [View Abstract]
  13. Rubenstein RA, Dogra VS, Seftel AD, Resnick MI. Benign intrascrotal lesions. J Urol. May 2004;171(5):1765-72. [View Abstract]
  14. Tammela TL, Hellstrom PA, Mattila SI. Ethanolamine oleate sclerotherapy for hydroceles and spermatoceles: a survey of 158 patients with ultrasound followup. J Urol. Jun 1992;147(6):1551-3. [View Abstract]
  15. Walsh TJ, Seeger KT, Turek PJ. Spermatoceles in adults: when does size matter?. Arch Androl. Nov-Dec 2007;53(6):345-8. [View Abstract]
  16. Zahalsky MP, Berman AJ, Nagler HM. Evaluating the risk of epididymal injury during hydrocelectomy and spermatocelectomy. J Urol. Jun 2004;171(6 Pt 1):2291-2. [View Abstract]

A sagittal section of the testicle. Idiopathic obstruction of the epididymal ducts is one hypothesis that explains the formation of spermatoceles.

Diagram of a spermatocele.

Spermatocele as seen prior to incision.

Intraoperative view of spermatocele with adjacent testicle and spermatic cord.

A scrotal ultrasound demonstrating a spermatocele visible to the left of a normal testis.

Microscopic view of spermatocele lined with cuboidal epithelium.

Intraoperative view of spermatocele with adjacent testicle and spermatic cord.

Spermatocele after complete excision.

A sagittal section of the testicle. Idiopathic obstruction of the epididymal ducts is one hypothesis that explains the formation of spermatoceles.

Diagram of a spermatocele.

Spermatocele as seen prior to incision.

Intraoperative view of spermatocele with adjacent testicle and spermatic cord.

Spermatocele after complete excision.

A scrotal ultrasound demonstrating a spermatocele visible to the left of a normal testis.

Microscopic view of spermatocele lined with cuboidal epithelium.

Fluid Aspirated from Spermatocele

(Volume in mL)

Sclerosant Solution Injected

(Volume in mL)

< 202
20-503
51-1005
101-20010
201-30015
301-40020
401-80025
>80030