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Sperm Granuloma of the Inguinal Vas Deferens Mimicking Recurrent Incarcerated Inguinal Hernia
Case Report Sperm Granuloma of the Inguinal Vas Deferens Mimicking Recurrent Incarcerated Inguinal Hernia Leslie A. Deane, Paul Nash Suding, Michael E. Lekawa, Navneet Narula, and Elspeth M. McDougall Masses of the spermatic cord are rare and can be neoplastic or inflammatory lesions. We present a case of a sperm granuloma of the inguinal vas deferens presenting as a recurrent incarcerated inguinal hernia in a 42-year-old man. UROLOGY 69: 1209.e1–1209.e3, 2007. © 2007 Elsevier Inc.
V
asitis nodosa and sperm granulomas are classically located adjacent to the scrotal vas and on the epididymal side of prior vasectomy. Spontaneously occurring granulomas and those in atypical locations are unusual, and without an antecedent history of prior vasectomy, sexually transmitted disease, or other obstructive lesions of the vas deferens the diagnosis may be elusive.
CASE REPORT A 42-year-old man presented to the emergency department with right groin pain that had started 8 months before but was worse in the 2 months leading up to his presentation. The past medical history was not significant. Specifically, there was no history of past urologic disease, sexually transmitted disease, orchitis, epididymitis, trauma, inguinal or scrotal surgery, and no history of vasectomy or previous herniorrhaphy. He was examined and diagnosed with an incarcerated right inguinal hernia, which was reduced after analgesic administration, with resolution of the pain. Results from genital examination were normal. The patient was then scheduled for an elective right inguinal hernia repair. A few weeks later he returned to the hospital with the same symptoms and was found to have a recurrent incarceration, which was again reduced under analgesia with resolution of the pain. At the time of hernia repair an inflamed and thickened spermatic cord was noted to contain a discrete mass in the inguinal portion of the cord. An intraoperative consultation from the urology department was requested. The spermatic cord was fully mobilized, and From the Departments of Urology, Surgery, and Pathology, University of California, Irvine, Orange, CA Address for correspondence: Leslie A. Deane, M.B.B.S., F.R.C.S.C., Department of Urology, University of California, Irvine, UCI Medical Center, 101 The City Drive South, Building 55, Route 81, Room 360, Orange, CA 92868. E-mail: [email protected] Submitted: September 10, 2006; accepted (with revisions): March 12, 2007
© 2007 Elsevier Inc. All Rights Reserved
the right testis was delivered. Results of palpation and gross examination of the testis and epididymis were normal. There was a firm and discrete mass in the inguinal cord, with normal vas deferens palpable both proximally and distally. A small excisional biopsy of the mass was submitted for frozen section and revealed fibromuscular tissue with mild chronic inflammation. Because of the dense fibrosis and adherence of the mass to the vessels and vas, the concern of a possible tumor of the spermatic cord, and the unknown etiology of the intraoperative findings, a radical orchiectomy was performed, with high ligation of the spermatic cord. Attempting to separate the mass from the cord would have devascularized the testis, and because the suspicion of tumor was high, extirpative management was chosen to avoid compromise of the margins or the risk of potential tumor spillage. A mesh hernia repair was then performed owing to a weakness in the floor of the inguinal canal. No obvious direct or indirect hernia was noted; however, because of the adherence of the cord to the floor of the inguinal canal, reinforcement was necessary. The final pathologic evaluation revealed a mass in the paratesticular region and one mass in the midportion of the spermatic cord, each measuring 1 cm. The mass in the paratesticular region had the histologic features of vasitis nodosa, consisting of proliferating ductules lined by tall columnar cells and separated by smooth muscle (Fig. 1A). A sperm granuloma was also seen. The mass in the midportion of the spermatic cord consisted of a sperm granuloma with hemorrhage and fibrosis (Fig. 1B–D). The patient has been seen in follow-up, and the incision is well healed. He is now pain free.
COMMENT Sperm granulomas present as masses adjacent to the vas deferens or epididymis. They are usually less than 1 cm in 0090-4295/07/$32.00 1209.e1 doi:10.1016/j.urology.2007.03.046
Figure 1. (A) Sample from the mass in the paratesticular region with histologic features of vasitis nodosa, consisting of proliferating ductules (open arrows) that are separated by smooth muscle. The ductules are lined by tall columnar cells. There is a sperm granuloma (solid arrow) surrounding the muscle coat. (B, C) Sample from the mass in the midportion of the spermatic cord. This mass consists of extravasated sperms (arrow in B) surrounded by hemorrhage, chronic inflammatory cells, and organizing fibrosis (C). (D) Higher magnification of the sperm granuloma showing the extravasated sperms (arrow) and histiocytes (open arrow). Hematoxylin and eosin stain; original magnification, ⫻2 in A, ⫻10 in B, ⫻20 in C, and ⫻40 in D.
size, and many are symptomatic. They occur after infection (sexually transmitted disease), trauma, or surgery (vasectomy) and are a result of the inflammatory reaction produced by sperm extravasating into the interstitium. They commonly occur after vasectomy (3%) and are mainly found in proximity to the scrotal vas. The usual treatment is conservative, with analgesics being the mainstay. If they become large or pain is persistent then excision is recommended. Vasitis nodosa typically occurs in the paratesticular region and is also relatively common after vasectomy. It is characterized by proliferation of small ducts and gland-like structures in the wall of the vas when a high-pressure obstruction permits extravasation of spermatic fluid into the vasal interstitium.1 We have found one prior report of a sperm granuloma and vasitis nodosa identified at inguinal exploration for hernia, but to our knowledge this is the first report of a sperm granuloma of the inguinal vas deferens mimicking a 1209.e2
recurrent incarcerated hernia.2 We speculate that the granuloma in our patient arose spontaneously and may be related to undisclosed inguinal trauma or to a past history of sexually transmitted disease with obstruction of the inguinal or pelvic vas. The differential diagnosis of a spermatic cord mass includes rhabdomyosarcoma, which occurs predominantly in the pediatric population, leiomyosarcoma, liposarcoma, lipoma, sperm granuloma, and vasitis nodosa in patients with a history of vasectomy. Because the possibility of a tumor is a definite concern, unless the antecedent history points toward an inflammatory or infectious etiology, we recommend radical orchiectomy as the most judicious management in this specific scenario.
CONCLUSIONS Masses of the spermatic cord are rare. When an intraoperative consult is sought for a cord mass, the safest UROLOGY 69 (6), 2007
approach is to perform a radical orchiectomy unless the mass is clearly noted to arise from the vas and dissection without compromise of the testicular vasculature and potential tumor margin is deemed safe and feasible. Even though some of these masses will be benign, as in this case, the concern of malignancy is higher, especially when there is dense adherence and
UROLOGY 69 (6), 2007
conservative excision may risk tumor spillage and incomplete resection. References 1. Easley S, and MacLennan GT: Vasitis and epididymitis nodosa. J Urol 175: 1502, 2006. 2. Onishi N, Honjoh M, Takeyama M, et al: Vasitis nodosa suspected of the spermatic cord tumor: a case report. Hinyokika Kiyo 38: 595–597, 1992.
1209.e3
V
asitis nodosa and sperm granulomas are classically located adjacent to the scrotal vas and on the epididymal side of prior vasectomy. Spontaneously occurring granulomas and those in atypical locations are unusual, and without an antecedent history of prior vasectomy, sexually transmitted disease, or other obstructive lesions of the vas deferens the diagnosis may be elusive.
CASE REPORT A 42-year-old man presented to the emergency department with right groin pain that had started 8 months before but was worse in the 2 months leading up to his presentation. The past medical history was not significant. Specifically, there was no history of past urologic disease, sexually transmitted disease, orchitis, epididymitis, trauma, inguinal or scrotal surgery, and no history of vasectomy or previous herniorrhaphy. He was examined and diagnosed with an incarcerated right inguinal hernia, which was reduced after analgesic administration, with resolution of the pain. Results from genital examination were normal. The patient was then scheduled for an elective right inguinal hernia repair. A few weeks later he returned to the hospital with the same symptoms and was found to have a recurrent incarceration, which was again reduced under analgesia with resolution of the pain. At the time of hernia repair an inflamed and thickened spermatic cord was noted to contain a discrete mass in the inguinal portion of the cord. An intraoperative consultation from the urology department was requested. The spermatic cord was fully mobilized, and From the Departments of Urology, Surgery, and Pathology, University of California, Irvine, Orange, CA Address for correspondence: Leslie A. Deane, M.B.B.S., F.R.C.S.C., Department of Urology, University of California, Irvine, UCI Medical Center, 101 The City Drive South, Building 55, Route 81, Room 360, Orange, CA 92868. E-mail: [email protected] Submitted: September 10, 2006; accepted (with revisions): March 12, 2007
© 2007 Elsevier Inc. All Rights Reserved
the right testis was delivered. Results of palpation and gross examination of the testis and epididymis were normal. There was a firm and discrete mass in the inguinal cord, with normal vas deferens palpable both proximally and distally. A small excisional biopsy of the mass was submitted for frozen section and revealed fibromuscular tissue with mild chronic inflammation. Because of the dense fibrosis and adherence of the mass to the vessels and vas, the concern of a possible tumor of the spermatic cord, and the unknown etiology of the intraoperative findings, a radical orchiectomy was performed, with high ligation of the spermatic cord. Attempting to separate the mass from the cord would have devascularized the testis, and because the suspicion of tumor was high, extirpative management was chosen to avoid compromise of the margins or the risk of potential tumor spillage. A mesh hernia repair was then performed owing to a weakness in the floor of the inguinal canal. No obvious direct or indirect hernia was noted; however, because of the adherence of the cord to the floor of the inguinal canal, reinforcement was necessary. The final pathologic evaluation revealed a mass in the paratesticular region and one mass in the midportion of the spermatic cord, each measuring 1 cm. The mass in the paratesticular region had the histologic features of vasitis nodosa, consisting of proliferating ductules lined by tall columnar cells and separated by smooth muscle (Fig. 1A). A sperm granuloma was also seen. The mass in the midportion of the spermatic cord consisted of a sperm granuloma with hemorrhage and fibrosis (Fig. 1B–D). The patient has been seen in follow-up, and the incision is well healed. He is now pain free.
COMMENT Sperm granulomas present as masses adjacent to the vas deferens or epididymis. They are usually less than 1 cm in 0090-4295/07/$32.00 1209.e1 doi:10.1016/j.urology.2007.03.046
Figure 1. (A) Sample from the mass in the paratesticular region with histologic features of vasitis nodosa, consisting of proliferating ductules (open arrows) that are separated by smooth muscle. The ductules are lined by tall columnar cells. There is a sperm granuloma (solid arrow) surrounding the muscle coat. (B, C) Sample from the mass in the midportion of the spermatic cord. This mass consists of extravasated sperms (arrow in B) surrounded by hemorrhage, chronic inflammatory cells, and organizing fibrosis (C). (D) Higher magnification of the sperm granuloma showing the extravasated sperms (arrow) and histiocytes (open arrow). Hematoxylin and eosin stain; original magnification, ⫻2 in A, ⫻10 in B, ⫻20 in C, and ⫻40 in D.
size, and many are symptomatic. They occur after infection (sexually transmitted disease), trauma, or surgery (vasectomy) and are a result of the inflammatory reaction produced by sperm extravasating into the interstitium. They commonly occur after vasectomy (3%) and are mainly found in proximity to the scrotal vas. The usual treatment is conservative, with analgesics being the mainstay. If they become large or pain is persistent then excision is recommended. Vasitis nodosa typically occurs in the paratesticular region and is also relatively common after vasectomy. It is characterized by proliferation of small ducts and gland-like structures in the wall of the vas when a high-pressure obstruction permits extravasation of spermatic fluid into the vasal interstitium.1 We have found one prior report of a sperm granuloma and vasitis nodosa identified at inguinal exploration for hernia, but to our knowledge this is the first report of a sperm granuloma of the inguinal vas deferens mimicking a 1209.e2
recurrent incarcerated hernia.2 We speculate that the granuloma in our patient arose spontaneously and may be related to undisclosed inguinal trauma or to a past history of sexually transmitted disease with obstruction of the inguinal or pelvic vas. The differential diagnosis of a spermatic cord mass includes rhabdomyosarcoma, which occurs predominantly in the pediatric population, leiomyosarcoma, liposarcoma, lipoma, sperm granuloma, and vasitis nodosa in patients with a history of vasectomy. Because the possibility of a tumor is a definite concern, unless the antecedent history points toward an inflammatory or infectious etiology, we recommend radical orchiectomy as the most judicious management in this specific scenario.
CONCLUSIONS Masses of the spermatic cord are rare. When an intraoperative consult is sought for a cord mass, the safest UROLOGY 69 (6), 2007
approach is to perform a radical orchiectomy unless the mass is clearly noted to arise from the vas and dissection without compromise of the testicular vasculature and potential tumor margin is deemed safe and feasible. Even though some of these masses will be benign, as in this case, the concern of malignancy is higher, especially when there is dense adherence and
UROLOGY 69 (6), 2007
conservative excision may risk tumor spillage and incomplete resection. References 1. Easley S, and MacLennan GT: Vasitis and epididymitis nodosa. J Urol 175: 1502, 2006. 2. Onishi N, Honjoh M, Takeyama M, et al: Vasitis nodosa suspected of the spermatic cord tumor: a case report. Hinyokika Kiyo 38: 595–597, 1992.
1209.e3