Nima Baradaran, MD
James S. Rosoff, MD
BASICS
DESCRIPTION
• The spermatic cord extends from the internal inguinal ring to the testicle, passing through the inguinal canal.
• Cord structures consist of vas deferens, internal and external spermatic arteries, artery to the vas deferens, pampiniform plexus, lymphatics, nerves, investing layer of fascia, and cremaster muscle.
• Considered paratesticular tissue
• Masses or swelling can be cystic or solid:
– Most cystic (70–75%)
– Most benign (75–80%)
– Usually asymptomatic
– Most solid spermatic cord masses are also benign
EPIDEMIOLOGY
Incidence
Varies by type (see Pathophysiology)
Prevalence
Varies by type (see Pathophysiology)
RISK FACTORS
Varies by type (see Pathophysiology)
Genetics
Varies by type (see Pathophysiology)
PATHOPHYSIOLOGY
• Cord mass can arise from cord contents or from structures above or below the cord
• Generally nonacute and benign
• Most common malignant tumors are sarcoma
• Varicocele
– Enlarged, tortuous spermatic veins above the testis; most common on the left side
– Isolated right-sided varicocele is rare and may suggest retroperitoneal pathology
– Asymptomatic, often found on routine exam
– Grade I: Palpable, grade II: Palpable without Valsalva, grade III: Visible
– May cause infertility; likely increasing scrotal temperature, impairing spermatogenesis
• Hydrocele
– Patent processus vaginalis causes collection of peritoneal fluid between the visceral and pariet al layers of tunica vaginalis
– Painless groin mass contiguous with the cord structures that transilluminates
– Communicating hydrocele with “indirect hernia”; more commonly seen in infancy
– Congenital; incidence of 4%, seen in early adolescence. May have associated inguinal hernia (usually children)
• Spermatic cord hydrocele
– Loculated fluid collection along the spermatic cord, separated from and located above the testicle and the epididymis
– Rare congenital anomaly from abnormal closure of the processus vaginalis distally and in some cases proximally; 2 types:
Encysted hydrocele of the cord: The fluid collection does not communicate with the peritoneum/tunica vaginalis
Funicular hydrocele of the cord: Distal closure of the processus vaginalis with fluid collection along the cord, communicating with the peritoneum at the internal ring
• Spermatocele:
– Cloudy fluid and sperm-filled cyst arising from epididymal tubules; usually at the head of epididymis
– Very common (up to 30% of general population), usually asymptomatic; incidental finding on ultrasound
• Inguinal hernia in adults:
– Late-onset communicating “indirect” hernia in adults
– “Direct” through the floor of the inguinal canal
– Indirect presents as mass in inguinal cord or extends through external ring into scrotum
• Lipoma of the cord:
– Benign; most common tumor of the cord and paratesticular tissues
– From adipose tissue of the cord; fat collections around hernia sac; not true lipomas
• Adenomatoid tumor:
– Benign neoplasms; most common epididymal tumor; no reliable echo pattern for diagnosis; can involve the spermatic cord
• Sarcomas:
– Rare lesions of spermatic cord, epididymis, and paratesticular soft tissue, from muscle, adipose, or connective tissue
– Incidence peaks: Adolescence and >40.
– Rhabdomyosarcoma and leiomyosarcoma most common
– High rate of recurrence after excision
• Other malignant tumors of spermatic cord:
– Melanoma and metastatic cancers are rare.
• TB of spermatic cord:
– Rare; 70% of cases have history of TB; usually in young, sexually active males
– Presents as TB epididymitis; difficult to differentiate from acute epididymoorchitis
– Usually secondary to infection of epididymis via direct extension
• Sarcoidosis:
– Systemic granulomatous disease; increased intestinal adsorption of calcium; hypercalcemia and hypercalciuria
• Funiculitis:
– Inflammation of spermatic cord secondary to severe epididymitis or due to trauma
• Filarial hydroceles:
– Caused by Wuchereria bancrofti; often have a thickened spermatic cord and epididymis
• Undescended testicle
• Retractile testicle
ASSOCIATED CONDITIONS
• Renal tumor invading renal vein or retroperitoneal mass compressing right gonadal vein with isolated right-sided varicocele or any acute onset of varicocele
• TB with spermatic cord involvement
• Filariasis
GENERAL PREVENTION
N/A
DIAGNOSIS
HISTORY
• Patients present with symptomatic or asymptomatic mass with or without swelling.
• Most masses are painless at onset.
• Presence or absence of pain does not differentiate benign or malignant mass.
• Scrotal elevation may provide relief.
• Recumbent position may resolve mass and pain in varicocele and communicating hydrocele.
• History of cryptorchidism is important.
ALERT
Always rule out torsion of cord if pain is acute.
PHYSICAL EXAM
• Examine patient in warm room in both upright and supine positions (1).
• Cord mass can be palpated in the inguinal region or the upper scrotum.
• Palpate mass with thumb and 1st 2 fingers of both hands and note character (hard, firm, cystic).
• Transillumination signifies cystic mass:
– Cystic mass may not transilluminate if thick wall, chronic inflammation, or blood present.
• Spermatic cord can be followed to the internal inguinal ring by palpitation.
• Verify both testicles present in scrotum.
• The vas deferens can be felt in the scrotum by 1st encircling the cord with the fingers and allowing small amounts of cord to pass through.
• Valsalva maneuver performed with patient in supine and standing positions for varicocele or hernia:
– Usually palpable posterior to and above the testicle and can mimic solid mass.
– Crucial to assess testicular volume and consistency in boys with varicocele.
– Ipsilateral testis may be atrophic.
– Palpation can determine superior and inferior extent of mass (unlike inguinal hernia).
• Communicating hydrocele:
– Enlarges when upright and with activities that increase intra-abdominal pressure.
– Supine position drains fluid into peritoneal cavity and decreases size.
– Abdominal contents may be found in the sac: Small intestine, omentum, or bladder.
– Proximal limit not palpable since contents extend through internal ring.
• Adult inguinal hernia:
– May be direct or indirect, reducible or incarcerated.
– Superior extent of the mass not palpable.
– May have bowel sounds over the mass.
– Attempt to reduce hernia with gentle pressure in supine or Trendelenburg position.
– After reduction, insert finger through external ring into inguinal canal.
– Cough or Valsalva maneuver produces impulse, caused by abdominal contents felt at fingertip.
• Lipoma of the cord is palpated as smooth, firm mass in inguinal canal or upper scrotum:
– Nontender; does not transilluminate.
– Usually incidental finding during inguinal procedures.
– Important to rule out concomitant inguinal hernia by noting the intact external inguinal ring on exam.
• Adenomatoid tumors found on routine exam:
– Painless, well-circumscribed, hard; nearly 50% at the head of the epididymis
– Most common solid paratesticular mass.
– Usually asymptomatic and slow growing.
• Sarcomas present as firm to hard mass, occasionally tender:
– May be distinct and well circumscribed or invade the surrounding tissues.
– Explore all solid masses for malignancy.
ALERT
No clinical signs or symptoms reliably distinguish between benign or malignant solid mass.
DIAGNOSTIC TESTS & INTERPRETATION
Lab
Urinalysis to rule out infectious processes
Imaging
• Scrotal US: Solid vs. cystic mass (2)
– Cannot differentiate benign or malignant mass
• MRI or CT in certain clinical scenarios
Diagnostic Procedures/Surgery
Solid masses: Biopsy (mostly excisional) with surgical exposure
Pathologic Findings
Distinguish leiomyosarcoma from leiomyoma based on occasional or absent mitotic figures and uniform cellular arrangement
DIFFERENTIAL DIAGNOSIS
• Adenomatoid tumor of the cord (1,2)
• Epidermoid cyst, epididymitis/epididymo-orchitis, funiculitis, tuberculoma
• Hernia
• Hydrocele
• Hydrocele of the cord
• Hemangioma
• Inguinal lymphadenopathy
• Leiomyoma
• Malignant tumor: Liposarcoma, rhabdomyosarcoma, leiomyosarcoma, malignant fibrous histiocytoma, metastatic melanoma, and others
• Undescended/retractile testicle, polyorchidism
• Sperm granuloma, spermatocele
• Testis tumor
• Varicocele
• Vasitis and vasitis nodosa (usually associated with epididymitis)
ALERT
Torsion of the cord or incarcerated/strangulated hernia is surgical emergency.
TREATMENT
GENERAL MEASURES
• Distinguish testis and epididymis (physical exam, transillumination, scrotal US).
• Most cystic masses do not need treatment.
• Investigate pain as presenting feature; sarcoma is often misdiagnosed as inflammatory lesion.
MEDICATION
First Line
Anti-TB drug therapy for 6–9 mo for TB (tuberculoma) in spermatic cord
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Spermatocelectomy if painful or symptomatic
• Hydrocelectomy (only if large or symptomatic)
• In children, repair hydrocele by age 2 if it does not resolve; usually associated with indirect hernia
– Communicating hydrocele often resolves in children within 1st yr
• Inguinal hernia (adults): Herniorrhaphy
• Communicating hydrocele with hernia:
– Explore through inguinal incision
– Exploration of asymptomatic contralateral inguinal canal in children with inguinal hernia or communicating hydrocele is controversial
• Varicocele:
– Varicocelectomy may relieve pain and improve fertility
– Standard testis volume measurements are mainstay of assessing need for surgical management of varicocele
• Explore solid masses for malignancy:
– Inguinal incision; testis is delivered and inspected
– Early control of cord at internal ring
– Biopsy to confirm diagnosis
• TB of cord: Excision of the mass
• Sarcoma: Radical orchiectomy with high ligation of the cord (wide resection margins if possible); possible flaps to reconstruct large anatomic defects
ADDITIONAL TREATMENT
Radiation Therapy
Retroperitoneal lymphadenopathy with adjuvant radiation or chemotherapy indicated for malignant tumor
Additional Therapies
N/A
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
Excellent for benign lesions
COMPLICATIONS
Risk of infertility in varicocele
FOLLOW-UP
Patient Monitoring
• None for benign masses
• Liposarcoma, leiomyosarcoma, and rhabdomyosarcoma may recur; closely monitor (physical exam, imaging)
Patient Resources
N/A
REFERENCES
1. Eble JN, Sauter G, Epstein JI, et al., eds. Pathology and genetics of tumours of the urinary system and male genital organs. World Health Organization classification of tumours. Lyon, France: IARC Press; 2004.
2. Dogra V, Gottlieb RH, Oka M. Sonography of the scrotum. Radiology. 2003;227:18–36.
ADDITIONAL READING
Wieder J, Hu J, Bui M, et al. Case scenario: 69-year-old male with left spermatic cord mass. Rev Urol. 2002 Summer;4(3):153–156.
See Also (Topic, Algorithm, Media)
• Groin/Inguinal Mass, Male and Female
• Lipoma, Spermatic Cord
• Paratesticular Tumors
• Scrotum and Testicle, Mass
• Spermatic Cord Mass and Tumors Images 
• Varicocele, Adult
• Varicocele, Pediatric
CODES
ICD9
• 171.6 Malignant neoplasm of connective and other soft tissue of pelvis
• 222.8 Benign neoplasm of other specified sites of male genital organs
• 608.9 Unspecified disorder of male genital organs
ICD10
• C49.5 Malignant neoplasm of connective and soft tissue of pelvis
• D29.8 Benign neoplasm of other specified male genital organs
• N50.9 Disorder of male genital organs, unspecified
CLINICAL/SURGICAL PEARLS
• Pain may be attributed to emergencies such as torsion.
• Ultrasound is a valuable diagnostic tool.