Varicocele, Hydrocele, and Spermatocele

Benign or nonacute scrotal masses are represented by hydroceles, varicoceles, and spermatoceles. Key components to evaluation are physical exam and scrotal ultrasound. Hydroceles represent extra fluid in the tunica vaginalis, leading to a swollen scrotum. Varicoceles have a dilatation of the pampiniform venous plexus, giving the “bag of worms” appearance on exam. Spermatoceles present as an epididymal cyst, commonly arising from the head of the epididymis. Hydroceles, varicoceles, and spermatoceles are usually asymptomatic and do not require treatment unless they are causing pain or other complications.

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Varicocele

Definition

Varicocele is the dilatation of the pampiniform venous plexus, which is connected to the internal spermatic or gonadal vein.

Varicocele: image showing left-sided dilated pampiniform venous plexus in the scrotum

Image: “Varicocele” by Samuel La’mert. License: CC BY 4.0

Epidemiology

  • Affects about 15%–20% of postpubertal males 
  • Mostly unilateral and left sided 
  • Bilateral presentation in 33% of males

Pathophysiology

  • Increased intravascular venous pressure via compression:
    • The left gonadal vein drains into the renal vein (at a right angle).
    • “Nutcracker effect”: 
      • ↑ Left renal venous pressure due to the anatomic position of the left renal vein (the vein is compressed between the aorta and superior mesenteric artery) 
      • Elevated renal vein pressure → ↑ left gonadal vein pressure → retrograde blood flow toward the testis 
      • Effect: dilatation of the vein and pampiniform venous complex 
  • Secondarily, tumors/masses (right side) can produce the same effect.

Clinical presentation

  • Usually painless
  • Acute onset of dull aching pain may indicate a thrombotic event.
  • Testicular atrophy from slightly increased scrotal temperatures 
  • Can present with infertility

Diagnosis

Examination:

  • Physical exam:
    • General genitourinary inspection 
    • Assess for testicular atrophy bilaterally.
  • Exam maneuvers:
    • Valsalva maneuver: “bag of worms” on palpation
    • Standing position: most prominent representation of varicocele 
    • Supine position: usually see decompression and disappearance of low-grade varicoceles 
  • Grades I to III: 
    • I: palpable only with Valsalva maneuver 
    • II: not visible on inspection, but palpable upon standing
    • III: visible on gross inspection 

Imaging (scrotal ultrasound):

  • Transillumination: negative
  • Doppler: several anechoic tubes
  • Delineating dilated venous complex with retrograde blood flow

Management

Treatment approach:

  • For older men (completed a family): conservative management (routine follow-up exams, scrotal support, antiinflammatory drugs)
  • For young men:
    • Normal semen analysis: Monitor every 1 to 2 years. 
    • Testicular atrophy or abnormal semen: surgery (microsurgical gonadal vein ligation vs. percutaneous venous embolization) 

Clinical considerations:

  • Infertility: a couple’s inability to conceive for a period of 1 year after actively trying to become pregnant:
    • Workup consists of physical exam, semen analysis, and sometimes scrotal ultrasound to rule out subclinical varicocele
    • Varicoceles increase the temperature in the testis, decreasing spermatogenesis. 
  • Renal cell carcinoma (RCC): 
    • Usually asymptomatic, but may present with flank pain or hematuria
    • Suspect if the patient has a right-sided varicocele.
    • Right varicocele forms from the compressive effect of the renal mass (on the blood vessels) or from an associated thrombus: 
      • Diagnosis: renal mass on imaging (via contrast-enhanced cross-sectional imaging)
      • Treatment is primary tumor resection.

Hydrocele

Definition

Hydrocele is a collection of peritoneal fluid in the tunica vaginalis surrounding the testes. If bloody, the condition is referred to as hematocele.

Epidemiology and etiology

  • Overall approximately 5% incidence
  • Causes:
    • Congenital: patent processus vaginalis (outpouching of parietal peritoneum)
    • Acquired: secondary to infection (e.g., filariasis) or trauma

Pathophysiology

Multifactorial, consisting of anatomic and fluid factors:

  • Patent processus vaginalis leading to fluid transport to scrotum 
  • Impaired peritoneal fluid absorption 
  • Excessive fluid production from iatrogenic causes such as: 
    • Epididymo-orchitis 
    • Trauma 
    • Testicular torsion

Clinical presentation

  • Increasing scrotal mass and painless (most common presentation)
  • Difficulty walking
  • Progressive heaviness and a dull ache in the scrotum

Hydrocele: enlarged scrotal mass filled with fluid

Image: “Hydrocele” by Dan Mischianu et al. License: CC BY 2.0

Diagnosis

  • Physical exam:
    • General genitourinary inspection 
    • Difficult to palpate testicles due to surrounding fluid sac 
    • Tense scrotal skin 
  • Exam maneuvers:
    • Shine pen light to scrotum and see transillumination signifying fluid. 
    • Absent reducibility of swelling   
  • Scrotal ultrasound:
    • Transillumination: positive 
    • Visualize hypoechoic (darker) fluid surrounding the testicle

Transverse view of scrotal ultrasound showing hydrocele:
A: large left hydrocele as noted by the dark border delineating fluid surrounding the normal testicle in grey color
B: a smaller amount of fluid as a small hydrocele of the right testicle

Image: “Scrotal ultrasonography” by Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea. License: CC BY 3.0

Management

  • Conservative: scrotal support underwear and optimize medical fluid management 
  • Surgical: excision of the hydrocele sac (if symptomatic)

Spermatocele

Overview

  • Spermatocele is a paratesticular epididymal cyst with sperm-containing fluid.
  • Commonly arises from the head (caput) of the epididymis

Pathophysiology

  • Occlusion by agglutinated germ cells
  • Gestational diethylstilbestrol (DES) exposure
  • Inflammation and epididymal scarring leading to adhesions with formation of loculated collections containing spermatozoa

Clinical presentation

  • Incidental scrotal mass on exam 
  • Usually painless 
  • Aching, discomfort, and heaviness of the affected testicle in larger variants

Diagnosis

  • Physical exam: Often, mass is located at the head of the epididymis. 
  • Imaging:
    • Scrotal ultrasound: cystic lesions from the epididymis
    • Color Doppler: characteristic “falling snow” appearance/sign (movement of internal echoes away from transducer, indicating solid particles)

Transverse view of a scrotal ultrasound: Testicle is grey structure to the right and spermatocele is fluid-filled sac on the left (darker).

Image: “Spermatocele” by Iwak. License: Public Domain

Management

  • Conservative: serial scrotal exams, scrotal support underwear 
  • Medical: oral analgesics with NSAIDs for patients with scrotal pain
  • Surgical: spermatocelectomy

Differential Diagnosis

Scrotal swelling or mass has the following differential diagnoses:

  • Testicular cancer: the most common solid tumor affecting men between ages 15–35 years. Testicular cancer frequently presents as a painless testicular mass. Examination shows a firm mass, with negative transillumination on ultrasound. Initial management for a primary tumor is radical orchiectomy.
  • Inguinal canal and hernias: bulge in the inguinal area or scrotum due to herniation of the bowel or omentum through the canal. Indirect inguinal hernias are the most common type of hernia and most are congenital. Diagnosis is by physical examination with patient straining, and on ultrasound, negative transillumination is noted. Management is surgical repair when indicated.
  • Generalized edema (liver cirrhosis): Scrotal swelling also occurs in conditions associated with hypoproteinemia and increased hydrostatic pressure such as liver cirrhosis. Swelling is not just localized in the scrotum but is systemic, often in the abdomen (ascites) and the lower extremities. Management involves addressing the underlying condition.

References

  1. Eyre, R.C. (2020). Nonacute scrotal conditions in adults. UpToDate. Retrieved January 21,2021, from https://www.uptodate.com/contents/nonacute-scrotal-conditions-in-adults
  2. Pais, V. (2019) What causes spermatocele? Medscape. Retrieved 22 Jan 2021 from https://www.medscape.com/answers/443432-159405/what-causes-spermatocele
  3. Pais, V. (2019) Spermatocele. Medscape. Retrieved Jan 22 2021 from https://emedicine.medscape.com/article/443432-overview
  4. Parke, J., Jafre, S. (2020) Hydrocele. Medscape. Retrieved 22 Jan 2021 from https://emedicine.medscape.com/article/443432-overview
  5. White, W., Kim, E. (2019) Varicocele. Medscape. Retrieved 22 Jan 2021 from https://emedicine.medscape.com/article/438591-overview

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