Most spermatoceles are asymptomatic. When the cysts have dilated enough to become large and noticeable, they may present as:

• Small to large sized lumps in the scrotum
• Cysts are usually less than 1 cm wide
• They are typically found superior to the testicle (at the location of the head of the epididymis)
• Smooth, spherical, well circumscribed masses
• They may be painful

• Scrotal Mass

  Located at the superior pole of the testis and caput epididymis, the spermatocele is soft and fluctuant and can be transilluminated (a flashlight can be seen if shined through the scrotal mass). [healthcentral.com]

  Left scrotal mass Lack of recurrence after 4 years of follow-up Tunuguntla et al. [ 2 ] 17 Radical orchidectomy Left scrotal mass Our case 42 Vimentin (+), SMA (+), CD68 (+), ALK (−) Local excision Left scrotal mass Lack of recurrence after a year of [ncbi.nlm.nih.gov]

  Abnormalities within the male reproductive tract may appear as scrotal masses. Masses may be of little significance or may represent life-threatening illnesses. [uropartners.com]

• Swelling of the Scrotum

  The heat from the water relaxes your scrotum, making it easier for you to detect anything unusual. Then follow these steps: Stand in front of a mirror. Look for any swelling on the skin of the scrotum. Examine each testicle with both hands. [mayoclinic.org]

  On examination, the epididymis is exquisitely tender, the scrotum is erythematous and warm while elevation of the scrotum may provide relief of pain. [3] Inguino-scrotal hernia The swelling is not confined to the scrotum and extends upwards in to the [explainmedicine.com]

  These are too similar conditions of fluid swelling in the scrotum. [metrovanurology.com]

• Testicular Pain

  Rarely, severe groin pain can stem from a serious medical condition, such as cancer or testicular torsion. [my.clevelandclinic.org]

  A number of conditions can cause testicular pain, and some require immediate treatment. Causes The cause of spermatoceles is unknown. [mayoclinic.org]

  A number of conditions can cause testicular pain, and some require immediate treatment. The cause of spermatoceles is unknown. [fortishealthcare.com]

• Testicular Mass

  Testicular cysts: US findings. Radiology. 1987;163:537-538. Brown DL, Benson CB, Doherty FJ, et al. Cystic testicular mass caused by dilated rete testis: Sonographic findings in 31 cases. AJR Am J Roentgenol. 1992;158:1257-1259. [appliedradiology.com]

  Family physicians often must evaluate patients with testicular pain or masses. The incidental finding of a scrotal mass may also require evaluation. Patients may seek evaluation of a scrotal mass as an incidental finding. [aafp.org]

  However, if a "must not miss" diagnoses related to testicular masses such as testicular torsion, epididymitis, acute orchitis, strangulated hernia and testicular cancer is suspected, the family physician must refer to a urologist.[18] Finding a painless [en.wikipedia.org]

• Epididymal Swelling

  Treatment with anti-inflammatory medication can reduce the incidence of subclinical epididymitis/swelling and increase the cure rate. [19] Postoperative Details Spermatocelectomy Postoperatively, patients are encouraged to continue scrotal support, using [emedicine.medscape.com]

Work up consists of a detailed history and physical examination.

Laboratory tests

Laboratory test are rarely performed. Usually a physical examination and imaging studies are sufficient to form a diagnosis. If the patient also complains of pain during urinating and/or in the scrotum, urinalysis may be done to check for epididymitis.

Imaging 

Ultrasound: Scrotal ultrasound will assist diagnosis if there is uncertainty [6].

Color Doppler Sonography: Color Doppler may reveal a 'falling snow' sign, resulting from internal echoes moving away from the transducer [7].

Transillumination: Spermatoceles are transilluminate on examination as they contain fluid.

Test results

On the basis of imaging studies and physical examination, spermatoceles can be diagnosed and treatment, if needed, can be started.

Spermatocelectomy

This procedure is only performed when the spermatocele is large and poses some discomfort to the patient. It is conducted via a transscrotal approach and is the primary surgical treatment for this condition. The patient must be counselled regarding the risks of infertility, as well as the more common complications of hematoma, infection, swelling, recurrence and pain [8].

Scleropathy

This procedure is less effective than spermatocelectomy. Coaptation of the walls of the cyst, by the help of a sclerosing agent or sclerosant, is done after aspirating the cyst to prevent recurrence. Sclerosants used include tetracycline, phenol and sodium tetradecyl sulphate [9]. Comparative trials have not established any one agent as a superior spermatocele sclerosing agent [10]. It should be noted that this procedure carries more risks and complications than a spermatocelectomy.

Medications

Medications are given only to relieve symptoms. Analgesics may be given if the patient suffers from scrotal pain. Antibiotics may be started if the patient tests positive for epididymisitis.

Spermatoceles have an excellent prognosis. As they are benign masses, they may not require treatment at all if asymptomatic. If, however, they are symptomatic and/or large in size, they can be successfully treated with surgery.

Complications

Complications of spermatoceles are rare. Some of them may include:

• Torsion of the cyst can occur but is extremely rare with only a handful of cases reported [4]. 
• Infection secondary to cyst formation [5].
• Large sized cysts leading to painful sores 
• Scrotal distortion
• Burning pain during urinating (rare)
• Infertility (rare)

Spermatoceles are mainly idiopathic. Several factors have been proposed to be the underlying cause of development of a spermatocele. It is generally accepted, however, that any condition, that blocks one or more of the ducts in the scrotum may result in formation of a spermatocele.

Scarring of any part of the ducts may result in this condition and so can vasectomy. Trauma and inflammation may also cause spermatoceles [3]. Aneurysmal dilatations of the epididymis may also cause the formation of a spermatocele.

Incidence

Cysts are found in as many as 30% of asymptomatic patients having scrotal ultrasound for other reasons, but most of these are spermatoceles [2].

Age

Spermatoceles have no known predisposition to age. 

Spermatoceles are typically smooth, well circumscribed scrotal masses that may occur anywhere along the vas deferens or somewhere in the ducts of the testis itself.
They most commonly occur from the head, known as the caput, of the epididymis. They contain fluid and varying content of spermatozoa.

Spermatoceles are benign and may go unnoticed unless large in size or painful. They may be of a few millimetres or grow up to be many centimetres wide.

Although the exact etiology is heretofore unknown, it is clear that any factor that results in blockage of one or more of the testicular ducts will eventually predispose to the formation of a spermatocele. Such factors include inflammation, such as epididymisitis, scarring due to vasectomy, trauma to the scrotum, etc.

Spermatoceles can not be prevented from forming unless they are due to an underlying treatable cause such as inflammation.

Spermatocele refers to a small cystic accumulation of semen in dilated efferent ducts or ducts of the rete testis [1]. It usually occurs as a sac like dilatation of a region of the narrow epididymis. The dilated cyst contains clear to cloudy fluid, mostly containing sperms.

Definition

A spermatocele is a cyst like dilatation of the ducts inside the scrotum. The cysts can be solitary or many. They contain clear fluid and typically some amount of sperms.

Cause

They are caused by blockage of the ducts carrying the sperms. The blockage may be due to trauma, scarring, a complication of vasectomy, infection and inflammation, etc.

Symptoms

Spermatoceles typically present as small swellings in the scrotum. They may or may not be painful.

Diagnosis

Diagnosis is made on the basis of physical examination and ultrasound.

Treatment

If asymptomatic, spermatoceles do not require treatment. If, however, they are large and painful, surgical intervention is recommended.

1. Robbins and Cotran, Pathologic Basis of Disease. 8th ed. Ch21, pg 993
2. Pais VM, et al. Spermatocele. eMedicine. June 2009.
3. Wampler SM. Common scrotal and testicular problems. Primary Care Clinic Office Practice. 2010;37:613.
4. Yilmaz E, Batislam E, Bozdogan O, et al. Torsion of an epididymal cyst. Int J Urol. 2004 March;11(3):182-3.
5. Gunaydin G, Ozyurt C, Kocak I, et al. Anti bacterial activity of the fluid contents of spermatocele and epididymal cysts. Br J Urol. 1995 Jan;75(1):68-70.
6. Muttarak M, Chaiwun B; Painless Scrotal Swelling: ultrasonographical features with pathological correlation. Singapore Med J. 2005 April;46(4):196-201; quiz 202.
7. Sista AK, Filly RA. Color Doppler sonography for evaluation of spermatoceles: the 'falling snow' sign. J Ultrasound Med. Jan 2008;27(1):141-3
8. Kauffman EC, Kim HH, Tanrikut C, Goldstein M. Microsurgical spermatocelectomy: techniques and outcomes of a novel surgical approach. J Urol. Jan 2011; 185(1):238-42.
9. Freedman D. 'A lovely bunch of coconuts'. Scand J Urol Nephrol Suppl. 1991;138:227-8.
10. East JM, DuQuesnay D. Sclerotherapy of idiopathic hydroceles and epididymal cysts: a historical comparison trial of 5% phenol versus tetracycline. West Indian Med J. Dec 2007;56(6):520-5