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Pelvis » Scrotum And Testicles
Bilateral spermatoceles
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Presentation A 60 year old man presents with bilateral palpable scrotal masses. He had a vasectomy performed 25 years ago. A scrotal ultrasound was performed.
Caption: Transverse image of the right scrotum.
Description: The right epididymal head appears enlarged and mildly lobular.
Caption: Right oblique image of the scrotum.
Description: Numerous dilated fluid-filled spaces are seen in the region of the epididymal body and tail. The visualized right testis appears normal.
Caption: Transverse image of the right epididymal body.
Description: The rounded fluid filled structures appear to be arising from the epididymus, seen anteriorly in the center on this image. Note the enhanced through transmission beneath the largest cyst.
Caption: Transverse image of the right epididymal tail.
Description: More fluid filled structures are seen in the epididymal tail.
Caption: Color Doppler image of the right epididymis.
Description: No abnormal area of increased vascularity are seen in either the epididymis or testis.
Caption: Transverse left epididymal scan.
Description: The left epididymus also exhibits multiple cystic structures in the epididymal head and body.
Caption: Transverse scan in the upper part of scrotal sac.
Description: The left epididymal body is thickened and has adjacent fluid filled areas. Some of these areas show internal septations.
Caption: Color Doppler of the left epididymal cystic area.
Description: Sparse vascularity is noted around the periphery of the cystic area in the epididymal tail.
Caption: Midline transverse scan of the scrotum.
Description: This image shows the large cystic lesions associated with the epididymi bilaterally.
Differential Diagnosis Bilateral spermatoceles

Final Diagnosis Bilateral spermatoceles.

This case is presented to show the ultrasound appearance of a spermatocele.

A spermatocele is a benign clear fluid-filled cyst that may arise in any part of the epididymis and contains non-viable sperm. A spermatocele is usually asymptomatic but sometimes produces palpable masses that may cause discomfort to the patient. It is more common in older men. 

No definitive casuative factor for spermatocele has been established. The sperm passes through the epididymis where it undergoes maturation. One theory that has been postulated in the pathogenesis of a spermatocele is that with advancing age, the seminiferous epithelium degenerates and the germ cells that are shed accumulate and block the efferent ducts, resulting in sterile cystic collections within the epididymis.

Ultrasound appearance:
1. Spermatoceles may be single or multiple, unilateral or bilateral.
2. Commonly located in the epididymal head, however they can also be seen in the body and tail. 
3. They appear as well-defined hypoechoic or cystic structures that show significant posterior enhancement.
4. Internal septations may be present in the cysts.

Role of ultrasound:
1. To establish a diagnosis and distinguish from other intrascrotal lesions such as a varicocele, hydrocele or a simple epididymal cyst.
2. Ultrasound guided therapeutic aspiration of a multilocular spermatocele may be performed to obtain relief of symptoms.

Case References
  1. Yagi H, Igawa M, Shiina H, Shigeno K, Yoneda T, Wada Y. Multilocular spermatocele: a case report. Int Urol Nephrol. 2001;32(3):413-6.
  2. Nejd F Alsikafi. Spermatocele.
  3. Itoh M, Li XQ, Miyamoto K, Takeuchi Y. Degeneration of the seminiferous epithelium with ageing is a cause of spermatoceles? Int J Androl. 1999 Apr;22(2):91-6.
Follow Up

This patient refused any form of treatment and follow up scrotal ultrasound revealed no change in the spermatoceles.

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