Encysted Spermatic Cord Hydroceles: A Report of Three Cases in Adults and a Review of the Literature

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1 Acta Radiologica ISSN: (Print) (Online) Journal homepage: Encysted Spermatic Cord Hydroceles: A Report of Three Cases in Adults and a Review of the Literature J. P. Busigó & F. Eftekhari To cite this article: J. P. Busigó & F. Eftekhari (2007) Encysted Spermatic Cord Hydroceles: A Report of Three Cases in Adults and a Review of the Literature, Acta Radiologica, 48:10, To link to this article: Published online: 09 Jul Submit your article to this journal Article views: 741 Full Terms & Conditions of access and use can be found at

2 CASE REPORT ACTA RADIOLOGICA Encysted Spermatic Cord Hydroceles: A Report of Three Cases in Adults and a Review of the Literature J. P. BUSIGÓ &F.EFTEKHARI Department of Diagnostic Radiology, Division of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, Texas, USA Busigó JP, Eftekhari F. Encysted spermatic cord hydroceles: a report of three cases in adults and a review of the literature. Acta Radiol 2007;48: A hydrocele of the spermatic cord, which results from aberrant closure of the processus vaginalis, is an asymptomatic entity detected incidentally on computed tomography (CT) scans performed for other clinical indications. There are two variations of a spermatic cord hydrocele: the encysted variety that does not communicate with the peritoneal cavity, and the funicular variety that does communicate with the peritoneal cavity. The encysted type can be confused with an inguinal mass (lymphadenopathy, hernias), and also primary tumors of the cord. We reviewed CT scans for all three adults and ultrasound images for one patient. Confirmation of spermatic cord hydrocele was made by surgery in one case, and CT and follow-up CT in two cases. Our findings indicate that a mass of the spermatic cord, showing fluid attenuation by CT and an avascular, anechoic appearance with sound transmission by ultrasound in an otherwise asymptomatic patient or even in those with an underlying malignancy, should prompt the radiologist to consider the diagnosis of spermatic cord hydrocele. This may eliminate the need for unnecessary, highly invasive procedures such as biopsy or surgical exploration. Key words: Computed tomography; cord hydrocele; hydrocele; spermatic cord; ultrasound Farzin Eftekhari, Department of Diagnostic Radiology, Division of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Unit #0368, 1515 Holcombe Boulevard, Houston, TX, 77030, USA (tel , . feftekhari@mdanderson.org) Hydrocele is accumulation of fluid between the two layers of the processus vaginalis, an extension of the peritoneal cavity into the scrotum. Spermatic cord hydrocele results from failure of the processus vaginalis to close as the testicles descend into the scrotum during fetal development. There are two variations of spermatic cord hydrocele. The encysted variety is closed at both proximal and distal ends of the processus vaginalis, and the funicular variety is patent proximally at the inguinal ring, thus communicating with the peritoneal cavity, and closed distally (1, 2, 4, 5, 7). The encysted type can be confused with inguinal lymphadenopathy, hernias containing bladder or intestine, and also primary tumors of the cord. Most reports of this entity in the literature are in pediatric patients (2, 6), and there is a paucity of information on spermatic cord hydrocele in adults. In this report, we describe the clinical, computed tomographic (CT), and ultrasonographic (US) features in three adult cases of spermatic cord hydrocele and briefly discuss the relevant embryology. Case reports A retrospective study on three adult patients was conducted after obtaining approval from the institutional review board. The three adult patients all had a history of malignancy and had been treated at our institution. CT scans were available for all three patients and were reviewed to assess the location of the hydrocele in relation to the spermatic cord, peritoneal cavity, and the processus vaginalis. One patient was also evaluated by US. Additionally, coronal reformatted images from CT scans were obtained in the second patient, and both coronal and sagittal reformatted images in the third patient. Follow-up CT scans were available for 48 months in the first patient, 24 months in the second patient, and for 11 months in the third patient. DOI / # 2007 Taylor & Francis

3 Encysted Spermatic Cord Hydroceles 1139 Case 1 The first patient was 65 years old and had been diagnosed with a transitional cell carcinoma of the urinary bladder in He had undergone radical cystectomy and a urinary diversion into an ileal conduit. During a routine physical examination in early August 1990, the urologist noticed a mass herniating through the patient s inguinal canal. On examination, a fairly well-circumscribed mass that herniated into the inguinal canal upon Valsalva maneuver was noted. It was the surgeon s opinion at the time that the patient had an indirect hernia with a mass that was herniating into it. It was not suspicious for bowel, but given the prior history of bladder cancer, it was decided to investigate this further. A contrast-enhanced CT scan was requested in September This showed a rounded density in the right inguinal ring (Fig. 2A C) with radiographic differential diagnoses of either a bowel loop or a mobile testis, which was unchanged from a previous study in The surgeon requested an US examination and needle biopsy to further characterize this mass. This examination showed a cm thinwalled cystic mass within the inguinal canal that corresponded to the clinically palpable nodule. Given its proximity to surgical clips, a sonographic diagnosis of lymphocele was made. Both testicles were identified within the scrotum. No ascites was noted. On discussion with the surgeon, he preferred not to have the needle biopsy done, so that he could identify the mass at the time of exploration. In September 1990, a surgical exploration was performed under local anesthesia to allow the patient to perform the Valsalva maneuver and to keep the mass within the canal. A cystic mass was detected within the spermatic cord structures, but not within a hernia sac. The internal ring was somewhat patulous, but there was no evidence of an indirect or direct hernia. The cystic mass was completely excised. The surgical diagnosis was a spermatic cord hydrocele. Histological examination revealed a cm cystic structure that was lined by endothelial cells and contained tan, partly gelatinous fluid consistent with hydrocele. The patient was last seen in October 1993 and was free of disease (follow-up period 48 months). Case 2 A 69-year-old patient had been diagnosed with three metachronous melanomas of the upper extremities and trunk in 1962, 1968, and He developed pulmonary and axillary node metastases in 2002, and peritoneal and splenic metastases in The patient came to our institution in 2003 to receive chemotherapy. During staging workup, a CT scan (Fig. 3) incidentally showed a cystic structure in the right groin. In view of our experience in the first case (described above), this mass was confidently diagnosed as a cord hydrocele. The stability of the lesion on serial CT scans performed over the ensuing 24 months was considered confirmation of this diagnosis. Case 3 A 56-year-old patient had undergone radiation therapy for stage II squamous cell carcinoma of Fig. 1. Schematic diagram showing variations in closure of the processus vaginalis. A. Expected closure at both ends. B. Communicating hydrocele as a result of patent processus vaginalis. C. Funicular spermatic cord hydrocele resulting from closure of the processus vaginalis distally and communicating with the peritoneal cavity proximally. D. Encysted spermatic cord hydrocele resulting from closure of the proximal and distal ends of the processus vaginalis. Acta Radiol 2007 (10)

4 1140 J. P. Busigó & F. Eftekhari Fig. 2. Cord hydrocele in a 65-year-old man with transitional cell carcinoma of the bladder. A C. Contrast-enhanced CT of the pelvis shows a cystic nodule anterior to the right spermatic cord (arrow). D. Longitudinal and transverse ultrasound views of the right inguinal region in the same patient show an ellipsoid cystic structure in the right spermatic cord (arrow). the anus and had no other abnormalities. The initial CT scan performed at our institution (Fig. 4) revealed bilateral inguinal cystic nodules. The patient denied any symptoms from either groin. On the basis of our experience with the first patient, the diagnosis of cord hydrocele was proposed. In view of low clinical suspicion for metastatic disease, this lesion was monitored during follow-up CT examinations, the most recent being in April 2007 (11-month follow-up). Discussion Fig. 3. Encysted hydrocele of the spermatic cord in a 68-year-old man with melanoma. Contrast-enhanced CT of the pelvis shows a cystic structure anterior to the right spermatic cord (arrow). Hydrocele is accumulation of fluid between the two layers of the tunica vaginalis, a remnant of the peritoneal cavity within the scrotum. As the testis descends from its retroperitoneal position into its final destination in the scrotum between 28 and 32 weeks of gestation, it carries with it two layers of the peritoneum, so-called processus vaginalis. Embryologically, a hydrocele of the spermatic cord results from aberrant closure along the course of the processus vaginalis. The testicles descend Acta Radiol 2007 (10)

5 Encysted Spermatic Cord Hydroceles 1141 Fig. 4. Bilateral encysted spermatic cord hydroceles in a 56-year-old man with squamous cell carcinoma of the anus. A C. Contrastenhanced CT of the pelvis shows bilateral cystic structures at the spermatic cords (arrow). D, E. Sagittal and coronal reformatted images show bilateral hydroceles anterior to the spermatic cords (arrows). into the scrotum between 28 and 32 weeks of gestation (1), and are enveloped by the processus vaginalis. The processus vaginalis normally closes at two points: proximally at the internal inguinal ring and distally above the epididymis. The distal end becomes the tunica vaginalis of the testis (1, 4, 5, 7). The intervening segment undergoes involution (Fig. 1A). If both proximal and distal points fail to close, then a communicating hydrocele will result, allowing the peritoneal fluid to extend into the scrotal sac (Fig. 1B). If only the distal point closes, a funicular hydrocele will result (Fig. 1C). If closure occurs at both ends, but the intervening segment fails to atrophy, then an encysted hydrocele will result (4) (Fig. 1D). It is estimated that, in 20% of cases, the processus vaginalis may remain patent throughout life and that the majority of the time the patient will experience no symptoms (5). The few reports of cord hydrocele in the English literature have occurred primarily in pediatric patients, and there is a paucity of information in adults. Hydrocele of the spermatic cord can be confused with an inguinal mass (i.e., inguinal lymphadenopathy, inguinal hernias (bladder or intestines), Richter hernias (3)) or primary tumors of the spermatic cord. Sonographic findings of a wellcircumscribed cystic structure separate from the epididymis and testis enable the radiologist to correctly diagnose spermatic cord hydrocele (2). It should be noted that a hydrocele may occasionally contain fine septations (2). Because our three patients all had underlying neoplastic disease, it was imperative to determine whether their inguinal masses represented metastatic disease or an unrelated benign condition. CT findings were identical in all three patients and consisted of a well-defined, nonenhancing structure of fluid attenuation located in the middle third of the inguinal canal. This fluid collection did not extend into the scrotal sac or peritoneal cavity. US performed in the first patient demonstrated an avascular and anechoic structure that could not be repositioned into the peritoneal cavity. No bowel loops or connection with the bladder were identified to suggest either an inguinal or a Richter hernia (3). This finding is consistent with previously reported sonographic features of spermatic cord hydroceles (2, 6). In conclusion, the presence of unilateral or bilateral cystic structure(s) within the inguinal canals on CT or US in an otherwise asymptomatic male, or even in patients with an underlying malignancy, should prompt the radiologist to consider the diagnosis of spermatic cord hydrocele. This may help eliminate the need for unnecessary invasive procedures. It is anticipated that this abnormality will be diagnosed on CT examinations of adults with increasing frequency. Acknowledgments The authors wish to thank Mary Carr for secretarial assistance, David Bier for graphic design, and Vickie J. Williams for editorial comments. Acta Radiol 2007 (10)

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