Case Report

Extra scrotal spermatocele causing lower abdominal pain: a first case report^?

Abstract

Lower quadrant abdominal pain is a common complaint evaluated in emergency departments (EDs).The number of differential diagnoses is lowered when the pain in a male patient is associated with a palpable tender mass. These diagnoses include inguinal hernia, inflamed inguinal lymph node, rectus sheath hematoma, cryptorchidism, mass derived from the spermatic cord, and polyorchidism. We report a case of extra scrotal spermatocele causing lower quadrant abdominal pain that was misdiagnosed as an inguinal hernia on several ED visits. Lower quadrant mass and pain caused by a spermatocele are unusual conditions. Upon the patient’s third (ED) visit, the painful mass remained located in his right lower quadrant. The lower quadrant mass was movable on palpation and with pressure could be delivered into the superior aspect of the scrotum. The patient had an abdominal and pelvic computed tomo- graphy scan and lower quadrant ultrasound. The imaging studies revealed the mass to be a cystic structure. Surgical excision confirmed that the mass was a spermatocele. Differential diagnoses, Diagnostic approaches, and treat- ment are discussed.

A lower quadrant spermatocele resulting in a mass and causing pain is an unusual condition. A review of the literature revealed no findings for extra scrotal or abdominal spermatocele or epididymal cyst.

We report an extra scrotal spermatocele causing a lower quadrant painful mass. Differential diagnoses, diagnostic approaches, and treatment are discussed.

A 45-year-old man presented to the emergency depart- ment (ED) with a chief complaint of right groin pain. The patient noted that he had a mass in his right lower quad- rant for the previous 10 months. He noted that the pain was gradual in onset, precipitated by movement, improved with nonsteroidal anti-inflammatory drugs, achy, nonra- diating, and constant. His vital signs were normal. He had 2 Previous ED visits for right groin pain, 7 months and

^? There was no grant support.

2 months before his third ED visit, and had been diagnosed with a reducible direct right inguinal hernia on both visits. He complained of 6/10 right lower quad- rant pain and Chronic low back pain. His past surgical history was remarkable for appendectomy 16 years ago. Physical examination revealed normal genitalia with 2 normal, nontender descended testicles. Abdominal exami- nation revealed a 2 x 3-cm well-circumscribed mass in the right lower quadrant that was movable and with pressure could be delivered into the superior aspect of the right hemiscrotum. He had no lymphocytosis, and his renal function test results were normal. Computed tomo- graphic (CT) scan with contrast revealed no bulky lympha- denopathy within the abdomen or pelvis and a cystic structure in the superior aspect of the right hemiscrotum measuring 25 x 19 mm.

Figs. 1 and 2 are CT images that reveal the sperma- tocele in the axial and coronal planes. Fig. 3 is an ultra- sound (US) image that reveals a cystic lesion in the superior aspect of the right hemiscrotum, measuring 21 x

26 x 35 mm, consistent with a large spermatocele far removed from the epididymis.

Three weeks after his third ED visit, the patient underwent an exploration with excision of the mass loca- ted in his right lower quadrant in the inguinal canal. The Surgical pathology examination revealed the mass to be a spermatocele.

Fig. 1 Axial plane CT scan section showing spermatocele in the superior aspect of the right hemiscrotum (arrow).

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358.e8 Case Report

Fig. 2 Coronal plane CT scan section showing spermatocele in the superior aspect of the right hemiscrotum (arrow).

Lower quadrant abdominal pain is a common complaint evaluated in EDs [1]. The number of differential diagnoses is lowered when the pain in a male patient is associated with a palpable tender mass. These diagnoses include inguinal hernia, inflamed inguinal lymph node, rectus sheath hematoma, cryptorchidism, mass derived from the spermat- ic cord, and polyorchidism. In this case, the patients’ physical examination revealed no signs of infection or bruising, a normal scrotum examination result, and a tender palpable mass that could be moved on examination from the abdomen into the superior aspect of the scrotum. The diagnoses of polyorchidism, which is extremely rare, and mass derived from the spermatic cord rose to the top of the differential [2].

A CT scan was used to help delineate the etiology of the mass based on the patient’s working differential of polyorchidism vs mass derived from spermatic cord. The patient’s worsening low back pain in conjunction with a possible third testicle raised the concern for cancer

Fig. 3 Ultrasound image revealing the cystic structure of the spermatocele.

and potential retroperitoneal spread. The CT scan revealed the mass to be a cystic structure. A US revealed the mass to be consistent with a spermatocele far removed from the epididymis.

A spermatocele is a cyst-like mass that usually forms within the epididymis [3,4]. The difference between an epididymal cyst and spermatocele has to do with size. Epididymal cystic masses larger than 2 cm are usually called spermatoceles [4]. Spermatoceles usually form in the caput of the epididymis and are located superior and posterior to the testis [5]. A lower abdominal quadrant location of an extra scrotal spermatocele is an unusual finding.

The treatment of spermatocele depends on the size, location, and level of discomfort [4,5]. If the spermatocele does not cause pain or concern to the patient, then observation is appropriate. If the spermatocele causes pain or the location or size causes the patient concern, then the spermatocele can be surgically excised.

In conclusion, we report the first case of an extra scrotal spermatocele causing a lower quadrant mass and pain. The PubMed, Cochrane Databases, NLM Gateway, FirstSearch, and CINAHL databases were searched using key words spermatocele and epididymal cyst with abdominal, abdo- men, lower quadrant, non-scrotal, and extra scrotal; and no case reports were found. In our case, the patient presented with a lower quadrant Abdominal mass causing discomfort for 10 months. The CT scan and US revealed a cystic structure consistent with a spermatocele. The mass was surgically removed, and pathologic examination found the mass to be a spermatocele.

Ms Zglinicki performed the literature search for authors. Ann Marie Zglinicki, MS, AHIP; Manager-Library Ser- vices, Mercy Philadelphia Hospital, Philadelphia, Pennsyl- vania 19143.

Denis J. Dollard MD Department of Emergency Medicine Mercy Philadelphia Hospital Philadelphia, PA 19143, USA

E-mail address: [email protected]

John B. Fobia MD Department of Surgery Mercy Philadelphia Hospital

Philadelphia, PA 19143, USA

doi:10.1016/j.ajem.2010.04.013

References

1. National Hospital Ambulatory Medical Care Survey: 2006 Emer- gency Department summary; number 7; August 6, 2008; Pitts S., Niska R., J.Xu, and Burt C., Ed.D., Division of Health Care Statistics.

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1. Kundu AK, Deb D, Pradhan P, Ghosh G, Chakrabarty S. Triorchidism: an incidental finding and review of literature. J Anat Soc India 2001;50(1):37-9.
2. Clarke BG, Bamford SB, Gherardi GJ. Spermatocele: pathologic and surgical anatomy. Arch Surg 1963;86:351.
3. Author: Robert C. Eyer, M.D.; Section Editor: Michael P. O’Leary, M.D.; Deputy Editor: David M. Rind, M.D.; Evaluation of nonacute

scrotal pathology in adult men; UpToDate.Incorporated; URL: http://utdol.com/online/content/topic.do?topicKey=primneph/7784& selectedTitle=1~95&source=search_result. Last date viewed: October 2, 2009.

1. McAninch JW. Disorders of the testis, scrotum, and spermatic cord. In: Tanagho EA, McAninch JW, editors. Smith’s general urology. New York: McGraw Hill; 2000. p. 688-9.