Irvin H. Hirsch, MD
Leonard G. Gomella, MD, FACS
BASICS
DESCRIPTION
• Spermatocele is a benign, fluid-filled cystic mass most often in the head (caput) of the epididymis. The spermatocele can occur in other areas of the epididymis, rete testis, or along the vas deferens.
• Sometimes referred to a “spermatic cyst” or “acquired epididymal cyst.”
• Clinically, spermatocele is differentiated from a hydrocele in that the spermatocele may contain viable or nonviable spermatozoa.
• Usually not a cause of epididymal obstruction.
• Also called an epididymal cyst or acquired epididymal cyst in the literature (1):
– Some sources state that the epididymal cyst is congenital and represents the most common epididymal mass.
– The origin of the epididymal cyst is thought to be lymphatic.
– Epididymal cyst fluid does not contain spermatozoa.
– Clinical management is similar, so the differentiation between spermatocele and epididymal cyst may not be significant.
EPIDEMIOLOGY
Incidence
• Peak incidence in 4th–5th decades
• Rare in children
• No racial or ethnic predilection
• Reported in 30–70% of postpubertal males undergoing high-resolution scrotal US
Prevalence
N/A
RISK FACTORS
• Diethylstilbesterol (DES) exposure in utero
• Inflammation
• Not clearly related to prior vasectomy, prior epididymitis, or herniorrhaphy
• Trauma
• Von-Hippel Lindau (VHL) syndrome
– Mostly epididymal cystadenomas with simple cysts less common
Genetics
• VHL syndrome:
– Mutations of the VHL suppressor gene on 3p.
– Increased incidence of epididymal cysts and papillary cystadenomas of the epididymis
PATHOPHYSIOLOGY
• Main concern is usually that of confusion with a true testicular mass.
• Precise mechanism is unknown.
– Cystic dilatations of tubules of the epididymis
– The efferent ductules in the head of the epididymis.
• The distinction between a spermatocele and an epididymal cyst is based on size; epididymal cystic masses >2 cm are spermatoceles. Spermatoceles are always located superior to the testis and are palpated as distinct from the testis, which differentiates them from hydroceles.
• Spermatoceles generally range in size from 2 to 5 cm.
• Trauma and inflammation may result in obstructed efferent ductules or epididymal tubules, resulting in a dilated spermatocele.
• No effect on fertility.
• Most are idiopathic.
• Most ≤1 cm in size.
ASSOCIATED CONDITIONS
• Epididymal obstruction may rarely be present
• Prior vasectomy
• High association with tubular ectasia of the rete testis
GENERAL PREVENTION
N/A
DIAGNOSIS
HISTORY
• Typical presentation is a painless, asymptomatic, intrascrotal mass found on testicular self-exam or on routine office exam.
• Occasionally may present with orchialgia or scrotal heaviness.
• No associated urinary symptoms
PHYSICAL EXAM
• Palpation shows a smooth, soft, spherical nontender mass at the head (caput) of the epididymis.
• Lies just superior and posterior to the testis but is distinct from testis.
• A cystic mass above the testis is usually demonstrated on scrotal transillumination.
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urine analysis
• Urine culture
• Serum AFP, hCG, LDH if there is concern over testis tumor
Imaging
• Scrotal US is diagnostic:
– Lesion is hypoechoic with posterior acoustic enhancement
– May have internal echoes
– MRI if US is indeterminate
Diagnostic Procedures/Surgery
Needle aspiration for diagnosis is not usually indicated. If indicated, a 30-gauge needle can be used to aspirate the cyst fluid.
Pathologic Findings
• Clear or opaque fluid-filled mass
• Fluid contains spermatozoa (live or dead), lymphocytes, and cellular debris
– Hydrocele, the other common cystic lesion is devoid of spermatozoa
• Fibromuscular wall lined by cuboidal epithelium
DIFFERENTIAL DIAGNOSIS
• Adenomatoid tumor of the epididymis:
– Most common solid tumor of the epididymis
• Ectopic tissues:
– Adrenal cortical rests
– Splenogonadal fusion
• Epidermoid cyst
• Epididymal calcinosis
• Epididymal cystadenoma/papillary cystadenoma;
– 2/3 associated with von Hippel–Lindau syndrome
– 1/3 of all epididymal tumors
– 2/3 associated with VHL syndrome
– On US, most common appearance is 15–20-mm solid mass with small cystic components.
• Epididymitis Epididymo-orchitis:
– Acute; very tender on exam
– Chronic; may have secondary calcification
– Common cause of epididymal pain
• Fibroma of epididymis
• Fibrous pseudotumor
• Funiculitis
• Granulomas: Sarcoidosis, TB, histoplasmosis
• Hernia
• Hydrocele
• Hydrocele of the cord
• Leiomyoma
• Malignant epididymal tumor:
– Primary (very rare): Liposarcoma, rhabdomyosarcoma (high on differential in children), leiomyosarcoma, adenocarcinoma, lymphoma
– Metastatic: Prostate, kidney, stomach most common
• Papillary cystadenoma:
• Polyorchidism
• Sarcoid
• Sperm granuloma:
– Seen in 40% post vasectomy or 2.5% idiopathic in general population
– Granulomatous lesion with few giant cells
– Consequence of extravasation of spermatozoa generally post vasectomy (of vasectomized men and of general population)
• Testis tumor
• TB of the epididymis
• Varicocele
• Vasitis and vasitis nodosa (usually associated with epididymitis)
• Young syndrome (obstructive azoospermia, sinusitis, bronchiectasis)
TREATMENT
GENERAL MEASURES
• Most do not require treatment unless symptomatic.
• Supportive care is usually sufficient:
– Scrotal supporter
– Heat
– NSAIDs
– Continued testicular self-exam
MEDICATION
First Line
Oral analgesics or NSAIDs
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Spermatocelectomy is elective and indicated for progressive enlargement or persistent pain
• Performed by magnified or microsurgical dissection of cyst from epididymal bed to preserve arterial supply and avoid injury to the epididymal tubules and resultant epididymal obstruction (2)
• Ligation of spermatocele at its stalk
• Surgery should be deferred in men seeking fertility since the spermatocelectomy can occasionally cause epididymal obstruction
ADDITIONAL TREATMENT
• Transscrotal cyst aspiration with or without sclerotherapy:
– Agents used have included tetracycline, fibrin glue, phenol, talc powder, and others
– Not usually recommended due to high recurrence rate and chemical epididymitis
– Spermatocele aspiration may provide a sperm source for azoospermic men treated by IVF or ICSI
Additional Therapies
N/A
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Most require no intervention and do not lead to epididymal obstruction.
• Recurrence rate is low postoperatively.
COMPLICATIONS
• Orchalgia
• Concern for cancer
• Postoperative spermatocelectomy:
– Regrowth of spermatocele
– Vascular injury during spermatocelectomy causing testicular atrophy
– Infection
– Epididymal obstruction: Very concerning in cases of bilateral spermatocele surgical repair. Some authors recommend sperm cryopreservation in this setting
FOLLOW-UP
Patient Monitoring
• Periodic scrotal/testicular self-exam
• Subsequent scrotal US if symptoms recur
Patient Resources
• Urology Care Foundation (AUA). http://www.urologyhealth.org/urology/index.cfm?article=117
REFERENCES
1. Walsh TJ, Seeger KT, Turek PJ. Spermatoceles in adults: When does size matter? Arch Androl. 2007;53(6):345–348.
2. Kauffman EC, Kim HH, Tanrikut C, et al. Microsurgical spermatocelectomy: Technique and outcomes of a novel surgical approach. J Urol. 2011;185(1):238–242.
ADDITIONAL READING
• Algaba F, Mikuz G, Boccon-Gibod L, et al. Pseudoneoplastic lesions of the testis and paratesticular structures. Virchows Arch. 2007;451:987–997.
• Gray CL, Powell CR, Amling CL. Outcomes for surgical management of orchalgia in patients with identifiable intrascrotal lesions. Eur Urol. 2001;39(4):455–459.
• Vohra S, Morgentaler A. Congenital anomalies of the vas deferens, epididymis and seminal vesicles. Urology. 1997;49:313–321.
• Woodward PJ, Schwab CM, Sesterhenn IA. From the archives of the AFIP: Extratesticular scrotal masses: Radiologic-pathologic correlation. RadioGraphics. 2003;23:215–240.
See Also (Topic, Algorithm, Media)
• Epididymal Cyst
• Epididymal Cystadenomas
• Epididymis, Mass (Epididymal Tumor and Cysts)
• Hydrocele
• Paratesticular Tumors, General
• Scrotum and testicle, Mass
• Sperm Granuloma
• Spermatic Cord Mass and Tumors
• Spermatocele, Images 
• Testis, Pain (Orchalgia)
CODES
ICD9
608.1 Spermatocele
ICD10
• N43.40 Spermatocele of epididymis, unspecified
• N43.41 Spermatocele of epididymis, single
• N43.42 Spermatocele of epididymis, multiple
CLINICAL/SURGICAL PEARLS
• A common pitfall is the failure to distinguish between hydrocele and spermatocele preoperatively.
• Spermatoceles are always located superior to the testis and are palpated as distinct from the testis, which differentiates them from hydroceles.
• Ideal surgical approach: Incise the tunica vaginalis over the tunica albuginea testis to maintain the spermatoceles definition throughout its excision.