Case Report

206 Urology Journal    Vol 5    No 3    Summer 2008

Spermatocele Presenting as Acute Scrotum
Atsuya Hikosaka, Yutaka Iwase

Urol J. 2008;5:206-8. 
www.uj.unrc.ir

Keywords: spermatocele, 
epididymis, acute scrotum, torsion 

abnormality

Department of Urology, Toyota 
Kosei Hospital, Toyota, Japan

Corresponding Author:
Atsuya Hikosaka, MD

Department of Urology, Toyota 
Kosei Hospital, 500-1, Ibobara, 

Josui-cho, Toyota, Aichi 470-0396, 
Japan

Tel: +81 565 43 5000
Fax: +81 565 43 5100

E-mail: uropatho@ybb.ne.jp

INTRODUCTION
Spermatocele, a retention cyst 
of the scrotum which is or has 
been in communication with 
the semen-carrying system,(1) is a 
relatively common clinical entity. It 
presents typically as an intrascrotal 
paratesticular mass, but it usually 
has few subjective symptoms. Here, 
we report a case of spermatocele 
manifested with acute scrotum due 
to its unique feature.

CASE REPORT
A 25-year-old man presented 
to our hospital complaining of 
persistent left scrotal pain with a 
sudden onset 12 hours earlier. He 
had no history of scrotal injury or 
vasectomy. Physical examination 
noticed a thumb-head-sized soft 
subcutaneous ovoid mass with 
severe tenderness above the left 

testicle, but bilateral testes were 
normally palpable. Laboratory 
findings were unremarkable. 
Doppler ultrasonography showed 
a simple cystic mass adjacent to 
the upper pole of the left testis and 
normal appearance of the both 
testes. However, slight decrease 
of blood flow in the left testis 
was suggested (Figure 1). Due 
to these confusing findings and 
perpetual pain, immediate surgical 
exploration was performed, which 
revealed a cystic lesion with a short 
stalk arising from the head of the 
left epididymis (Figure 2). The cyst 
was filled with yellowish turbid 
fluid and was twisted about 180 
degrees. Histologically, the inner 
surface of the cyst wall was lined 
with columnar epithelial cells with 
cilia (Figure 3, Left). On cytological 
examination, the fluid in the cyst 
included spermatozoa (Figure 3, 

Figure 1. Left, Scrotal ultrasonography demonstrates a cystic lesion adjacent to the left testicle. Right, Doppler ultrasonography 
suggests slight decrease in the blood flow of the left testis compared with the right one.



Spermatocele Presenting as Acute Scrotum—Hikosaka and Iwase

Urology Journal    Vol 5    No 3    Summer 2008 207

Right). These findings led to the pathological 
diagnosis of spermatocele. The convalescence 
period was uneventful with cease of scrotal 
pain, and the patient was discharged 5 days 
postoperatively.

DISCUSSION
The first 2 cases of spermatocele presenting as 
acute scrotum were reported in 1985,(2) followed 

only by 3 other cases.(3-5) Therefore, the present 
case is the 6th in the literature to our knowledge. 
They have occurred mostly in young patients 
(age range, 13 to 44 years; mean, 24.5 years) who 
may suffer from other common causes of acute 
scrotum such as torsion of the spermatic cord or 
the appendix. Hence, its diagnosis may be difficult 
even though normal blood flow would be proved 
by Doppler ultrasonography. 

Figure 3. Left, Histological findings of the resected cystic mass. The cyst wall consists of connective tissue lined inside with cuboid or 
columnar epithelial cells with microvilli (hematoxylin-eosin, × 200). Right, Cytological appearance of the fluid in the cyst. A number of 
spermatozoa are evident among many erythrocytes and some histiocytes (Papanicolaou, × 400).

Figure 2. Macroscopic findings on the surgical exploration. An ovoid cystic tumor (asterisk) arising from the head of the epididymis is 
shown. The testis appears normal. The tumor is connected with the epididymis by a distinct stalk. The photos were taken after release 
of torsion (Left, medial side and Right, lateral side). T indicates testis and E, epididymis.



Spermatocele Presenting as Acute Scrotum—Hikosaka and Iwase

208 Urology Journal    Vol 5    No 3    Summer 2008

Interestingly, all spermatoceles with torsion 
had arisen from the head of the epididymis, 
while some anatomical evaluations suggest the 
spermatocele originates most frequently from the 
ductuli efferentes testis, and less commonly from 
the superior vas afferens, canal of the epididymis, 
and the appendix testis.(1) In addition, they all had 
distinct pedicles with torsion, resulting in acute 
scrotum. The pedunculated hydatid (appendix 
of the epididymis) has vesicular structure lined 
inside with epithelial cells similar to those of 
the spermatic tract, attachment to the head 
of the epididymis by a stalk, and connection 
with the canal of the epididymis.(1) Considering 
these findings, it is suggested that the origin of 
spermatocele which can be the cause of acute 
scrotum is the appendix of the epididymis in 
connection with the canal of the epididymis. This 
kind of spermatocele may arise secondarily as a 
result of cystic transformation of the hydatid, 
contrary to a primary spermatocele which arises 
from the ductuli efferentes.

Although rare, urologists should keep in 
mind that the torsion of spermatocele can be a 
differential diagnosis of acute scrotum.

CONFLICT OF INTEREST
None declared.

REFERENCES
1. Crossan ET. Spermatocele. Ann Surg. 1920;72:500-7.

2. Jassie MP, Mahmood P. Torsion of spermatocele: a 
newly described entity with 2 case reports. J Urol. 
1985;133:683-4.

3. Kaye RI, Cromie WJ. Torsion of a spermatocele: 
a case report and review of the literature. J Urol. 
1990;143:786.

4. Odabas O, Aydin S, Yilmaz Y. Torsion of a 
spermatocele. J Urol. 1995;154:2143.

5. Takimoto K, Okamoto K, Wakabayashi Y, Okada Y. 
Torsion of spermatocele: a rare manifestation. Urol Int. 
2002;69:164-5.