Spermatocele Treatment & Management

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.

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. Epididymal injury, which may lead to infertility, was documented in 17.12% of patients undergoing spermatocelectomy in one study. ^[18]

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:

• Tetracycline
• Fibrin glue
• Phenol
• Sodium tetradecyl sulfate (STS)
• Quinine
• Talc powder
• Polidocanol ^[5]
• Ethanolamine oleate
• Alcohol

With polidocanol instillation, success rates of 34-59% were noted after a single instillation. With repeated treatments, up to 89% were ultimately considered successful.

Low et al reported that sclerotherapy with 100% alcohol produced resolution of spermatoceles/epididymal cysts after a single procedure in 25 of 34 patients (73.5%). A second procedure was offered if fluid collection persisted, and was successful in all cases. ^[19]

Comparative trials have not established any one agent as a superior spermatocele sclerosing agent. ^[6] Similarly, no standard dosing for maximal benefit is currently available.

 

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. ^[10] With large spermatococeles, devascularization of the blood supply to the testis may result in testis atrophy or loss.

Sclerotherapy

Sclerotherapy is performed on an outpatient basis after the potential complications are discussed. Local anesthesia is used, 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 been performed.

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)

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. Treatment with anti-inflammatory medication can reduce the incidence of subclinical epididymitis/swelling and increase the cure rate. ^[20]

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. 

A transversus abdominis plane (TAP) block, in which local anesthetic is injected into the plane between the internal oblique and transversus abdominis muscle, can be used to reduce the need for opioids. In a randomized, controlled study that included patients undergoing spermatocelectomy, Wegner et al reported that adding dexamethasone 8 mg to ropivacaine 0.2% in a TAP block did not significantly prolong analgesia, but was associated with a 1-point reduction in pain score at 12 hours post block. ^[21]  

Discharge instructions for patients include the following:

• Keep the dressing in place
• Allow the wound to dry for 48 hours
• 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.

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 patient education information, see the Men's Health Center, as well as The Male Anatomy.

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

Potential complications of sclerotherapy include the following:

• Epididymal injury
• Infertility
• Bleeding
• Infection
• Chemical epididymitis
• Spermatocele recurrence

Postprocedure, minor pain was noted in 10%, moderate pain in 4%, and severe pain in approximately 3% of patients. ^[7] 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.

The expected outcome and prognosis of spermatocelectomy are excellent. In one study 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.

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. ^[11]