History

Fact Explanation
Scrotal swelling The swelling usually lies in the head of the epididymis superior and posterior to the pole of the testis.[1] Usually a small swelling that is found incidentally. It may rarely be large enough for the patient to complain that he has grown a third testis.[2] Spermatocele is often bilateral but causes asymmetrical swellings; therefore the patient may not notice the swelling of the contralateral scrotum. [2,3,4,5]
Pain This is a rare complaint, most spermatoceles are painless but patients between 30-40 years may present with pain. [2] This may even be due to constant palpation of the swelling out of anxiety. [4]
Age usually greater than 40 years Commonly seen in this age group though it may rarely be encountered in children or adolescents. [2] The cause for a spermatocele remains unknown. It is speculated that it may be a relic of a past inflammatory process or blockage of the epididymal ducts that causes proximal dilatation. [4]
References
  1. RUSSELL RCG, WILLIAM N S, BULSTRODE C J K. Bailey and Love's Short Practice of Surgery. 23rd edition. Hodder Arnold. 2000.
  2. BROWSE N L, BLACK J, BURNAND K G, THOMAS W E G. Browse's Introduction to the Symptoms and Signs of Surgical Disease. 4th edition. Hodder Arnold. 2005.
  3. MIZUO T, TANIZAWA A, ANDO M. A case of bilateral spermatocele. Hinyokika Kiyo. 1988 Jul vol-34(7):1253-5 [viewed 15 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3051952
  4. ENSIGN C, BRANT W O. Infections, tumors and lumps affecting the scrotal content. The Clinical Advisor. 14 August 2012. [viewed 15 March 2014]. Available from: http://www.clinicaladvisor.com/infections-tumors-and-lumps-affecting-the-scrotal-content/article/253191/1/
  5. CLAIN A. Hamilton Bailey's Demonstrations of Physical Signs in Clinical Surgery. 16th edition. John Wright and Sons Ltd. 1984.

Examination

Fact Explanation
Scrotal swelling Felt as a smooth, freely mobile, cystic swelling that is confined to the scrotum. Size can vary from 1-2 cm to a large swelling with a diameter of 15cm. [1,2,3,4] Can palpated on the postero-superior aspect of the testis distinctly separate from the testis. The spermatic cord can be palpated and feels normal.[1]
Multilocularity Is felt as a lobular swelling and does not form a perfect sphere.[1] This is due to the multiple and multilocular nature of epididymal cysts and spermatoceles. In some instances individual loculi may be felt and can be described as elongated, bosselated swellings. [2,4]
Transillumination Illuminates very effectively as the fluid collected within the epididymis is clear. [2]
Swelling of the contralateral scrotum Spermatoceles are often bilateral but usaully asymmetrical. Therefore examination of the contralateral hemi-scrotum may reveal a small, freely mobile, cystic mass with a smooth bosselated surface that can be palpated separately from the testis. The swelling is transilluminant and consistent with the diagnosis of a spermatocele. [2]
References
  1. BROWSE N L, BLACK J, BURNAND K G, THOMAS W E G. Browse's Introduction to the Symptoms and Signs of Surgical Disease. 4th edition. Hodder Arnold. 2005.
  2. CLAIN Alan. Hamilton Bailey's Demonstrations of Physical Signs in Clinical Surgery. 16th edition. John Wright and Sons Ltd. 1984.
  3. ENSIGN C, BRANT W O. Infections, tumors and lumps affecting the scrotal content. The Clinical Advisor. 14 August 2012. [viewed 15 March 2014]. Available from: http://www.clinicaladvisor.com/infections-tumors-and-lumps-affecting-the-scrotal-content/article/253191/1/
  4. JUNNILA J, LASSEN P, MAJ. Testicular Masses. American Family Physician. February 1998. vol- 15;57(4):685-692. [viewed 15 March 2014]. Available from: http://www.aafp.org/afp/1998/0215/p685.html

Differential Diagnoses

Fact Explanation
Epididymal cyst Presents with identical clinical findings. Can only be differentiated with aspiration and examination of the cyst fluid.Fluid from a spermatocele appears like "barley water"as it contains dead spermatozoa while fluid from a epididymal cyst is crystal clear.[1] But usually not performed as it is distressing and painful to the patient. [2]
Testicular torsion Occurs most often in young men, with sudden onset severe, unilateral scrotal pain that is often associated with nausea and vomiting.[3] On examination the testis on the affected side will appear to be in a higher position within the scrotum. [4]
Epididymoorchitis Presents with gradual development of scrotal pain, with fever, urethral discharge and urinary symptoms. On examination, the epididymis is exquisitely tender, the scrotum is erythematous and warm while elevation of the scrotum may provide relief of pain. [3]
Inguino-scrotal hernia The swelling is not confined to the scrotum and extends upwards in to the inguinal region. There will be a visible and palpable cough impulse and percussion will yield a tympanic note.[1]
Testicular malignancy Presents with a painless swelling of the scrotum in 75 percent of cases. [1] It is usually a hard immobile scrotal lump. [4] Enlarged para-aortic lymph nodes may present as an abdominal mass in advanced cases. About 95 percent of all testicular malignancies occur in the 20-45 year age group.
Hydrocele Appears as a painless scrotal swelling that can be transilluminated. [3] However the testis can not be palpated separately within the scrotum and the swelling has smooth, uniform surface in contrast to the bosselated surface of the multilocular spermatocele. [4]
Varicocele Commonly appears on the left side. [1,3] The enlarged veins of the pampiniform plexus are usually obvious on examination.On light palpation the scrotum will feel like a 'bag of worms.' When the patient lies down the veins will empty and the swelling disappears. [1]
References
  1. CLAIN Alan. Hamilton Bailey's Demonstrations of Physical Signs in Clinical Surgery. 16th edition. John Wright and Sons Ltd. 1984.
  2. ORLANDO MS, SCHLECKER BA, WEIN, AJ. Benign diseases of the testicle and paratesticular tissues. American Urological Association Update 1986;5:1-7.

  3. JUNNILA Jennifer, LASSEN Patrick, MAJ. Testicular Masses. American Family Physician. February 1998. vol- 15;57(4):685-692. [viewed 15 March 2014]. Available from: http://www.aafp.org/afp/1998/0215/p685.html
  4. BROWSE Norman L, BLACK John, BURNAND Kevin G, THOMAS William EG. Browse's Introduction to the Symptoms and Signs of Surgical Disease. 4th edition. Hodder Arnold. 2005.

Investigations - for Diagnosis

Fact Explanation
Aspiration of fluid from the cyst [1] A spermatocele contains dead spermatozoa.[2] This gives it a 'barley water' appearance. This investigation is not usually carried out as it is painful and distressing to the patient. [3] In addition the distinction between a spermatocele and epididymal cyst is only of academic interest as management options are identical.
Ultra sound scan [4] This investigation is not essential as the diagnosis of a spermatocele is based on clinical findings.[4] However sonography is highly sensitive in the detection of spermatoceles and is primarily used rule out the possibility of a testicular tumor. [5]
Color doppler sonography [5] This investigation is used in research studies to enhance the presumptive diagnosis of spermatocele. [5]
References
  1. KUNNAMO Ilkka. Evidence based medicine guidelines.1st edition. John Wiley and Sons. March 4, 2005.
  2. CLAIN Alan. Hamilton Bailey's Demonstrations of Physical Signs in Clinical Surgery. 16th edition. John Wright and Sons Ltd. 1984.
  3. ORLANDO MS, SCHLECKER BA, WEIN, AJ. Benign diseases of the testicle and paratesticular tissues. American Urological Association Update 1986;5:1-7.

  4. ENSIGN Craig, BRANT William O. Infections, tumors and lumps affecting the scrotal content. The Clinical Advisor. 14 August 2012. [viewed 15 March 2014]. Available from: http://www.clinicaladvisor.com/infections-tumors-and-lumps-affecting-the-scrotal-content/article/253191/1/
  5. SISTA Akhilesh K, FILLY Roy A. Color Doppler Sonography in Evaluation of Spermatoceles The “Falling Snow” Sign. Journal of Ultrasound Medicine. 2008; vol- 27:141–143. [viewed 15 March 2014] Available from: http://www.jultrasoundmed.org/content/27/1/141.full.pdf

Investigations - Followup

Fact Explanation
Seminal Fluid Analysis (SFA) [1] There is a significant risk of epididymal injury following spermatocelectomy. This necessitates that patient counseling be performed pre-procedurally since epididymal injury may lead to infertility.[1] Follow-up after 6 weeks with an SFA in a patient an epididymal injury is suspected is recommended.
References
  1. ZAHALSKY MP, BERMAN AJ, NAGLER HM. Evaluating the risk of epididymal injury during hydrocelectomy and spermatocelectomy. J Urol. 2004 Jun;171(6 Pt 1):2291-2. [viewed on 15 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15126805

Management - General Measures

Fact Explanation
Conservative management [1] Reassure the patient of the benign nature of the cyst and advise to ignore the swelling. [1] Surgical management is only indicated if their is intractable scrotal pain or if large cysts become troublesome or cosmetically unacceptable. [2]
References
  1. RUSSELL RCG, WILLIAM Norman S, BULSTRODE Christopher JK. Bailey and Love's Short Practice of Surgery. 23rd edition. Hodder Arnold. 2000.
  2. ERICKI, HOSGOR M, AKSOYN, OKUR Ö, YILDIZ M, DURSUNA, DEMIRCAN Y, ÖRNEK Y, GENISOLl İ. Management of epididymal cysts in childhood. J Pediatr Surg. 2013 Oct;48(10):2153-6.[viewed 15 March 2014] doi: 10.1016/j.jpedsurg.2013.01.058.

Management - Specific Treatments

Fact Explanation
Percutaneous sclerotherapy [1] Percutaneous sclerotherapy using Polidocanol is the ideal sclerosing agent for superficial and delicate structures, such as epididymal cysts due to its local anesthetic properties. [1] Other agents include talc, sodium tetradecyl sulfate, tetracycline, fibrin glue, phenol, quinine, and ethanolamine oleate.
Spermatocelectomy [2] Indicated only is the cyst is large, obtrusive and cosmetically unacceptable to the patient. [2] There is a significant risk of epididymal injury that may lead to infertility.
Microsurgical spermatocelectomy [3] A microsurgical approach minimizes injury to the epididymis and testicular blood supply. Which reduces post operative complications such as infertility. [3]
References
  1. PIERI S, AGRESTI P, MORUCCI M, CARNABUCI A, De MEDICI L. A therapeutic alternative in the treatment of epididymal cysts: percutaneous sclerotherapy. Radiol Med. 2003 May-Jun;105(5-6):462-70. [viewed 15 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12949457
  2. RUSSELL RCG, WILLIAM Norman S, BULSTRODE Christopher JK. Bailey and Love's Short Practice of Surgery. 23rd edition. Hodder Arnold. 2000.
  3. KAUFMANN EC, KIM HH, TANRIKUT C, GOLDSTEIN M. Microsurgical spermatocelectomy: technique and outcomes of a novel surgical approach. J Urol. 2011 Jan;185(1):238-42. [VIEWED 15 March 2014] doi: 10.1016/j.juro.2010.09.017.