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Spermatocele Treatment & Management

  • Author: Vernon M Pais, Jr, MD; Chief Editor: Edward David Kim, MD, FACS  more...
 
Updated: Oct 15, 2015
 

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.

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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, because of the risk that 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.

Sclerosant materials that have been used, all with degrees of success varying from 30%-100%, have included the following:

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.

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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.

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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 (Open Table in a new window)

Fluid Aspirated from Spermatocele



(Volume in mL)



Sclerosant Solution Injected



(Volume in mL)



< 20 2
20-50 3
51-100 5
101-200 10
201-300 15
301-400 20
401-800 25
>800 30

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.

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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.

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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.

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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.

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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.

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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.

Although surgical specimens are often sent for pathology analysis after spermatocelectomy, it may be of little clinical benefit. In a retrospective study of 57 spermatocelectomy cases and 102 hydrocelectomy cases, none of the pathology specimens showed any indication of malignancy, and the estimated direct cost of these analyses totaled $49,449. in order to demonstrate whether one agent or dosing regimen is superior to others.[6]

 

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Contributor Information and Disclosures
Author

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

Vernon M Pais, Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Urological Association, Endourological Society, Sigma Xi, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

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

Shaun E Wason, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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

Shlomo Raz, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, California Medical Association

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

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

Additional Contributors

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

Allen Donald Seftel, MD is a member of the following medical societies: American Urological Association

Disclosure: Received consulting fee from lilly for consulting; Received consulting fee from abbott for consulting; Received consulting fee from auxilium for consulting; Received consulting fee from actient for consulting; Received honoraria from journal of urology for board membership; Received consulting fee from endo for consulting.

References
  1. Sista AK, Filly RA. Color Doppler sonography in evaluation of spermatoceles: the "falling snow" sign. J Ultrasound Med. 2008 Jan. 27(1):141-3. [Medline].

  2. Jahnson S, Sandblom D, Holmäng S. A randomized trial comparing 2 doses of polidocanol sclerotherapy for hydrocele or spermatocele. J Urol. 2011 Oct. 186(4):1319-23. [Medline].

  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. 2007 Dec. 56(6):520-5. [Medline].

  4. Kauffman 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. [Medline].

  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. 2011 May-Jun. 37(3):307-12; discussion 312-33. [Medline].

  6. Shah VS, Nepple KG, Lee DK. Routine pathology evaluation of hydrocele and spermatocele specimens is associated with significant costs and no identifiable benefit. J Urol. 2014 Oct. 192 (4):1179-82. [Medline].

  7. Davis RS. Intratesticular spermatocele. Urology. 1998 May. 51(5A Suppl):167-9. [Medline].

  8. Gray CL, Powell CR, Amling CL. Outcomes for surgical management of orchalgia in patients with identifiable intrascrotal lesions. Eur Urol. 2001 Apr. 39(4):455-9. [Medline].

  9. Gutman H, Golimbu M, Subramanyam BR. Diagnostic ultrasound of scrotum. Urology. 1986 Jan. 27(1):72-5. [Medline].

  10. Itoh M, Li XQ, Miyamoto K. Degeneration of the seminiferous epithelium with ageing is a cause of spermatoceles?. Int J Androl. 1999 Apr. 22(2):91-6. [Medline].

  11. Moloney GE. Comparison of results of treatment of hydrocele and epididymal cysts by surgery and injection. Br Med J. 1975 Aug 23. 3(5981):478-9. [Medline].

  12. Nash JR. Sclerotherapy for hydrocele and epididymal cysts: a five-year study. Br Med J (Clin Res Ed). 1984 Jun 2. 288(6431):1652. [Medline].

  13. Nashan D, Behre HM, Grunert JH. Diagnostic value of scrotal sonography in infertile men: report on 658 cases. Andrologia. 1990 Sep-Oct. 22(5):387-95. [Medline].

  14. Rubenstein RA, Dogra VS, Seftel AD, Resnick MI. Benign intrascrotal lesions. J Urol. 2004 May. 171(5):1765-72. [Medline].

  15. Tammela TL, Hellstrom PA, Mattila SI. Ethanolamine oleate sclerotherapy for hydroceles and spermatoceles: a survey of 158 patients with ultrasound followup. J Urol. 1992 Jun. 147(6):1551-3. [Medline].

  16. Walsh TJ, Seeger KT, Turek PJ. Spermatoceles in adults: when does size matter?. Arch Androl. 2007 Nov-Dec. 53(6):345-8. [Medline].

  17. 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. [Medline].

 
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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.
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.
Table 1. Volume of Sclerosant Solution Used for Sclerotherapy
Fluid Aspirated from Spermatocele



(Volume in mL)



Sclerosant Solution Injected



(Volume in mL)



< 20 2
20-50 3
51-100 5
101-200 10
201-300 15
301-400 20
401-800 25
>800 30
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