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Keywords:

  • bilateral;
  • infertility;
  • multilocular;
  • spermatocele

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References

We report the case of a bilateral, relatively huge, multilocular spermatocele diagnosed at sonography with surgical and pathological correlation. A 45-year-old man presented with bilateral, large inguinoscrotal masses. He had had the masses since his adolescence and their size gradually increased in the past 5 years. Scrotal ultrasonographic examination showed cystic fluid masses that were 65 × 45 × 50 mm in size on the right and 55 × 45 × 40 mm in size on the left side in multilocular spaces. The cystic masses were excised via bilateral inguinoscrotal incision staying near the body of the epididymis. The patient had fathered three children with no fertility problem.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References

Spermatoceles are the sperm-containing cystic dilation of the partially obstructed efferent ductules above the epididymis. They are generally unilateral, single and smaller than 1 cm in size and rarely present marked clinical problems like disturbing pain and infertility.1–3 A spermatocele may occasionally become large enough to annoy the patient and be suspected of being a tumor.4 Bilateral, huge and multilocular cases of spermatocele have rarely been reported in published work.5,6 A unilateral spermatocele may be found in 4% of men referred for assisted conception.7 However, it was not known whether bilateral spermatocele could be found in a fertile patient. To our knowledge, this report is the first case of bilateral large, multilocular spermatocele, related to no fertility problem.

Case report

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References

A 45-year-old man was admitted to our hospital due to bilateral pain in the inguinoscrotal area. He complained of stretching pain on standing and an aching type of discomfort in the sitting position. Physical examination revealed that both testes were smaller than normal. Bilateral ovoid, huge, soft masses were palpated over the spermatic cord. The patient stated that he had had those masses since his adolescence but their size had almost doubled and the discomfort had become more evident during the past 5 years. A transillumination test was positive suggesting a cystic component. There was no history of trauma, infection or inguinoscrotal operation, including vasectomy. He had three children who are 20, 14 and 9 years-old and his wife had been using oral contraception for the past 8 years. Biochemical, hematological and hormonal examinations were normal including urinalysis and spermiogram: seminal volume 3.5 mL, sperm density 22 million/mL, motility greater than 60%, forward progression 2.0 and normal morphological sperm forms greater than 70%.

Ultrasound examination revealed bilateral multiloculated, well-defined hypoechoic cystic masses, measuring 65 × 45 × 50 mm on the right side and 55 × 45 × 40 mm on the left side (Fig. 1). These masses contained hyperechoic internal free floating particles by probe compression. There was no dilation of the rete testis to suggest its tubular ectasia. Both testes were smaller than normal, while kidneys, epididymides and seminal vesicles were normal.

image

Figure 1. Loculated, huge spermatoceles with septations on ultrasound are shown on both sides.

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Exploration was done via an inguinoscrotal incision on both sides. The cystic masses were located on the spermatic cord near the body of the epididymis. There was no connection between the spermatocele and epididymal duct. The masses were separated gently with blunt dissection from the spermatic cord bilaterally and removed (Fig. 2). The testes were replaced in the scrotum and the incision was closed with chromic catgut. The amount of the fluid was 80 cm3 on the right and 65 cm3 on the left side.

image

Figure 2. Right and left spermatocele after the excision.

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The fluid inside the spermatoceles was clear, yellowish in color and showed 20–25 mature spermatozoa per high power on microscopic examination. Biochemical analysis of the fluid revealed high levels of calcium, potassium, chloride and lactic acid dehydrogenase (LDH), while almost undetectable levels of glucose, cholesterol, lipid, albumin and bilirubin were measured. The urea, creatinine and sodium levels were comparable to plasma (Table 1). Histopathological examination of the thin, fibrotic cyst wall showed one line of cuboidal epithelium and grouped sperm within the cyst, with no connection between the spermatocele and epididymal duct.

Table 1.  Seminal fluid content *
Biochemical analysisAmount
  • Seminal fluid contained 20–25 mature spermatozoa viewed under high power microscopic examination. LDH, lactic acid dehydrogenase.

Glucose1 mg/dL
Calcium14.7 mg/dL
Urea50 mg/dL
Cholesterol1 mg/dL
Potassium6.0 mEq/L
Creatinine1.0 mg/dL
Triglyceride3 mg/dL
Chloride136 mEq/L
Sodium143 mEq/L
Albumin0 mg/dL
LDH881 IU/L
Bilirubin0 mg/dL

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References

Primary spermatocele is a well-known entity described as an accumulation of sperm in a cystic cavity probably due to an acquired or congenital partial obstruction of the spermatic ducts. Just as in tubular ectasia of the rete testis, the etiology remains obscure when there is no history of trauma, infection, vasectomy or inguinoscrotal surgery.8 Itoh et al. suggested that agglutinated immature germ cells may occlude the narrow lumen of the spermatic ducts, resulting in the formation of a spermatocele.9

In the presented case, the patient had had bilateral cystic masses since his adolescence. There had not been any prominent etiological cause to explain this very rare occurrence. Because of the high scrotal position at the body of the epididymis, macroscopically, we could not establish any communication between the rete testis and the spermatocele. Microscopic examination didn’t show such a communication. In addition, we also demonstrated mature spermatozoa in the spermatocele fluid with normal spermiogram.

Therefore, we postulated that the cause of spermatoceles in this case might be attributed to a bilateral congenital entity because of their location and long standing presence since puberty.

Spermatoceles are usually asymptomatic, single and small in size, even if they are bilateral.1–3 However, bilateral, large, multilocular spermatocele cases have rarely been reported in published work. To our knowledge, only two cases have been reported in Japan; one of these was deemed to have occurred 17 years after bilateral vasectomy.5 In another report, there was no particular reason for the development of spermatocele.6 In our search of published work we found that our case is the first case reported of a fertile patient with bilateral, multilocular, large spermatocele. We suppose that the bilateral, multilocular, large spermatocele did not affect fertility because of the partial obstruction of the efferent ductuli.

As a conclusion, this very rare condition can be found in a fertile man and can cause severe discomfort and pain. It should be excised to relieve the symptoms.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References
  • 1
    Tammela TLJ, Hellström PA, Mattila SI, Ottelin PJ, Malinen LJ, Makarainen HP. Ethanolamine oleate sclerotherapy for hydroceles and spermatoceles: a survey of 158 patients with ultrasound followup. J. Urol. 1992; 147: 15513.
  • 2
    Tartar VM, Trambert MA, Balsara ZN, Mattrey RF. Tubular ectasia of the testicle: sonographic and MR imaging appearance. Am. J. Roentgenol. 1993; 160 (3): 53942.
  • 3
    Pavlica P, Ramini R, Barozzi L. Tubular ectasia of the rete testis. The echographic aspects. Radiol. Med. (Torino) 1994; 87 (4): 4937.
  • 4
    Yagi H, Igawa M, Shiina H, Shigeno K, Yoneda T, Wada Y. Multilocular spermatocele: a case report. Int. Urol. Nephrol. 2001; 32 (3): 4136.
  • 5
    Mizoguchi H, Fukunaga Y, Kasagi Y, Ogata J. Bilateral spermatocele developed after vasectomy: a case report. Nippon Hinyokika Gakkai Zasshi 1994; 10: 156770.
  • 6
    Mizuo T, Tanizawa A, Ando M. A case of bilateral spermatocele. Acta. Urol. Jpn. 1988; 34: 12535.
  • 7
    Hirsh AV, Dean NL, Mohan PJ, Shaker AG, Bekir JS. Spermatoceles in irreversible obstructive azoospermia-reservoirs of viable spermatozoa for assisted conception. Hum. Reprod. 1996; 11 (9): 191922.
  • 8
    Rouviere O, Bouvier R, Pangaud C, Jeune C, Dawahra M, Lyonnet D. Tubular ectasia of the rete testis: a potential pitfall in scrotal imaging. Eur. Radiol. 1999; 9 (9): 18628.
  • 9
    Itoh M, Li XQ, Miyamoto K, Takeuchi Y. Degeneration of the seminiferous epithelium with ageing is a cause of spermatoceles? Int. J. Androl. 1999; 22 (2): 916.