Cases

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Sperm granuloma: The sonogram images suggest a sperm granuloma or epididymitis nodosa (see Images 1-2). Note the combination of a solid and cystic structure on the posterior aspect of the left epididymis with no doppler flow in the solid component of the structure. A sperm granuloma is a subtype of chronic epididymitis (defined as inflammation lasting >6 wk) that occurs when sperm leaks into the interstitium because of inflammation, trauma, surgery, or multiple or severe acute epididymal infections due to urinary tract infections, sexually transmitted diseases, viral infections, or tuberculosis. Often, extravasated sperm leads to a granulomatous reaction, which appears as a round mass. In postoperative cases, the cause is usually a slipped ligature, as observed in as many as 40% of men after vasectomy. This condition is usually asymptomatic and resolves with time. However, approximately 3% of men with postvasectomy sperm granulomas present with chronic scrotal pain. In this case, the diagnosis was made by obtaining a thorough history and physical examination, including an assessment of risk factors, such as sexually transmitted disease and previous trauma or surgery. Absence of transillumination of the scrotal mass was an important physical finding. The scrotal sonograms showed a well-defined, hypoechoic intraepididymal lesion (note that the lesion may have various characteristics: with or without epididymal enlargement, cystic changes, or a heterogeneous echo pattern). Sonographic findings are not specific in all cases and may be similar in both benign and malignant testicular and paratesticular tumors. In fact, the differential diagnosis of a solid paratesticular mass includes benign entities, such as a sperm granuloma, fibrous pseudotumor, adenomatoid tumor of the epididymis or tunica albuginea, lipoma, leiomyoma, and inflammatory nodule. About 3-16% of solid paratesticular masses are malignant, and, among these, rhabdomyosarcoma is the most common. Testicular tumors are usually asymptomatic, but 10% of patients present with pain secondary to acute hemorrhage in the tumor. A more definitive diagnosis can be made with biopsy of the lesion. A sample histopathologic slide is provided for reference (see Image 3). Other common causes of testicular pain are testicular torsion, torsion of the testicular appendage, acute epididymitis, orchitis, and scrotal abscess. Of these diagnostic possibilities, testicular torsion must be a primary consideration because of the threat of testicular infarction, which can lead to infertility. Evidence of torsion includes a firm, tender testis that is high in the scrotum and that often lies horizontally when the patient is standing. The cremasteric muscle reflex may be absent, and elevating the testis may relieve the patient's pain (Phren sign). Torsion of the testicular appendage or epididymis is suspected when intense pain is present near the head of the epididymis or testis, when an isolated tender nodule is palpable, and when a small dark blue spot is visible on transillumination (blue-dot sign). Acute epididymitis and orchitis typically have an insidious onset of pain because of the infectious cause. Treatment for symptomatic sperm granulomas include the application of warm compresses or bathing twice daily and the use of nonsteroidal anti-inflammatory drugs. If symptoms persist, referral to a specialist should be considered for possible steroid injections and prescription of neuromodulating agents. Surgery may be attempted. A urologist may elect to drain the granuloma or resect the epididymis if the pain is intractable, though only about 25% of patients achieve symptomatic relief.