List of Abbreviations
EC – epididymal cysts
US – ultrasound examination
LCE – level of confidence of evidence
GRS – grade of recommendation strength
РКИ – randomized controlled trial
MRI – magnetic resonance imaging
ATC – Anatomical Therapeutic Chemical Classification System
GRLS – State Register of Medicines
INN – International Nonproprietary Name
STI – sexually transmitted infections.
Terms and Definitions
Epididymal cysts are cystic lesions containing serous fluid. An epididymal cyst is filled with fluid composition similar to transudate.
Spermatocele is a connective tissue cavity associated with the epididymis, lined internally with columnar epithelium. The content of a spermatocele is seminal fluid with a neutral or alkaline reaction, containing fat bodies, isolated leukocytes, and epithelial cells.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
N43.4 (D29.3) – Epididymal cysts (EC), or cysts of the epididymis, are benign lesions most commonly located in the head of the epididymis. Seminal cysts of the epididymis are quite common, accounting for up to 7% of all detected scrotal masses. ECs are cystic lesions containing serous fluid [17]. Spermatocele is a connective tissue cavity associated with the epididymis, lined internally with columnar epithelium. A distinguishing feature of spermatocele and epididymal cyst is the nature of the internal contents of these lesions.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
It is believed that epididymal cysts form as a result of embryogenesis disorders responsible for the formation of the tubular apparatus of the gonads, as well as scrotal trauma, acute and chronic epididymitis leading to obliteration of the seminiferous tubules. The pool of spermatozoa, encountering an obstruction in the form of an abortive ending tubule, accumulates, which promotes tubule dilation and cyst cavity formation [17, 19]. ECs can be single or multiple, with unilateral or bilateral localization.
1.3 Epidemiology of the Disease or Condition
There are no reliable epidemiological data at the time of writing these guidelines.
1.4 Features of Coding the Disease or Condition
N43.4 Spermatocele
D29.3 Benign neoplasm of epididymis
1.5 Classification of the disease or condition
No classification exists for this disease
1.6 Clinical presentation of the disease or condition
Clinical manifestations of spermatocele are variable and directly depend on the size and localization of the epididymal cysts. In most cases, the disease is asymptomatic and is an incidental finding, for example, during self-examination. As the cyst increases in size and compresses the epididymal tissue, pain syndrome of varying intensity appears, and enlargement of the hemiscrotum on the affected side is possible. Alterations/changes in spermiogram analysis (oligo/azoospermia) are also possible if the cyst is localized in the tail of the epididymis with compression of the epididymal duct.
2. Diagnostics, medical indications and contraindications for diagnostic methods
Diagnosis of epididymal cysts is straightforward. In most cases, it is limited to 1–2 diagnostic steps.
Criteria for establishing the diagnosis are based on 3 main methods:
1) Anamnesis data
2) Physical examination data
3) Instrumental examination data
Comprehensive ultrasound examination (US) of the scrotum remains the primary diagnostic and most reliable method for detecting ECs. The use of ultrasound in this category of patients allows timely detection of the nature of pathological changes in the epididymis and determination of indications for surgical treatment.
The presence of an anechoic lesion in the epididymis, around which no areas of hypervascularity are detected, indicates an epididymal cyst. This method is particularly significant when examining patients with clinically symptomatic epididymal cysts (pain syndrome, enlarged scrotum) [21, 22].
2.1 Complaints and Anamnesis
It is recommended to collect complaints and anamnesis in all patients with suspected spermatocele to determine the examination strategy by inquiring about the presence of:
✓ a palpable scrotal mass;
✓ pain in the area of the mass;
✓ the duration of these symptoms [2].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comment: Patients with an epididymal cyst are usually asymptomatic, and the condition is frequently discovered during an examination for other scrotal pathologies. In rare cases of epididymal cyst torsion, symptoms will be characteristic of acute scrotum syndrome [2].
2.2 Physical Examination
It is recommended to perform a physical examination of male genital organs (palpation for male genital pathology), including in the standing position, in patients with suspected spermatocele for differential diagnosis with other scrotal diseases [2, 35].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comment: Physical examination consists of inspection and palpation of the scrotal contents. Inspection is performed with the patient standing. It reveals a round mass of elastic consistency, painless upon palpation and not adherent to surrounding tissues (the localization within the organ may vary, but in most cases it is the head of the epididymis)
2.3 Laboratory Diagnostics
It is recommended that all men complaining of infertility, changes in ejaculate, or with a cyst localized in the tail of the epididymis (risk of obstruction) undergo a basic ejaculate analysis (spermogram), including determination of ejaculate volume, sperm concentration, total sperm count, percentage of motile spermatozoa (including percentages of spermatozoa with slow and rapid progressive motility), percentage of morphologically normal forms, and round cell concentration; if the percentage of motile spermatozoa is less than 40%, the percentage of live spermatozoa should be determined to assess fertility parameters [9, 19, 24, 31, 32, 33, 34].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
It is recommended for patients with a spermatocele, if clinical and anamnestic signs of STIs are present, to perform a molecular biological test of urethral discharge for sexually transmitted infections (Neisseria gonorrhoeae, Trichomonas vaginalis, Chlamydia trachomatis, Mycoplasma genitalium), to identify urogenital pathogens [22, 27, 28, 29, 30].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
2.4 Instrumental Diagnostics
It is recommended to perform a scrotal ultrasound examination in all patients with suspected spermatocele (with color Doppler imaging if possible) to establish the diagnosis and rule out concomitant pathology (tumor, varicocele, orchiepididymitis) [1, 7, 21, 26].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comment: Comprehensive ultrasound examination (US) of the scrotum remains the primary diagnostic and most reliable method for detecting epididymal cysts. The use of ultrasound in this category of patients allows for the timely identification of the nature of pathological changes in the epididymis and determination of indications for surgical treatment. The presence of an anechoic lesion in the epididymis without surrounding areas of hypervascularization is considered a sign of an epididymal cyst. This method is especially significant when examining patients with clinically manifested epididymal cysts (pain syndrome, enlarged scrotum).
It is recommended in case of diagnostic difficulties or insufficient diagnostic value of scrotal ultrasound to perform magnetic resonance imaging of the scrotum (with contrast enhancement if necessary) to clarify the diagnosis [25].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: In cases where scrotal ultrasound does not help to establish a diagnosis with sufficient reliability, it makes sense to perform a contrast-enhanced MRI of the scrotum. The MRI technique allows for a highly accurate diagnosis.
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
Treatment of epididymal cysts consists exclusively of surgical correction methods.
3.1 Surgical Treatment:
It is recommended to perform surgical treatment for an epididymal cyst in the presence of:
✓ pain syndrome;
✓ cyst size greater than 10 mm and its continued growth;
✓ torsion of the epididymal cyst;
✓ infection of the cyst;
✓ tense cyst;
✓ suspicion of obstructive oligo-/azoospermia [11, 19].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended when indications are present to perform excision of the epididymal cyst using precision techniques and avoiding trauma to surrounding tissues [11, 12, 19].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comment: Enucleation/excision of the cyst is considered the traditional surgical method for treating epididymal cysts. The technique involves layered dissection of the epididymal cyst from the affected side while maintaining its integrity, followed by layered wound closure.
Diet therapy
Dietary therapy is not provided.
Pain management
Performed as part of the relevant surgical procedures
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Rehabilitation measures are not provided for this group of patients.
5. Prevention and Dispensary Observation
Specialized preventive measures are not provided for this group of patients. Dispensary follow-up is not required.
6. Organization of Medical Care
Indications for elective hospitalization: surgical intervention to eliminate the spermatocele.
Indications for emergency hospitalization: development of complications, pain syndrome.
Indications for patient discharge from the hospital: completion of the surgical intervention.
7. Additional Information
No data.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Performance assessment (yes/no) |
|---|---|---|
1 | Anamnesis was collected in patients with suspected spermatocele | Yes/no |
2 | Physical examination (palpation for male genital pathology) was performed in patients with suspected spermatocele | Yes/no |
3 | Ultrasound examination of the scrotum was performed in patients with suspected spermatocele | Yes/no |
4 | Surgical treatment of spermatocele was performed in the presence of indications and absence of contraindications | Yes/no |
References
Show references
Anisimov A. V. Differential ultrasound diagnosis of liquid space-occupying lesions of the scrotum. Sonoace international. 2001; 9: 40-49.
Apolikhin O. I., Sivkov A. V., Efremov E. A. et al. Clinical and statistical classification of andrological diseases. Experimental and Clinical Urology. 2011; 1: 17-25.
Atayeva S. Kh., Akhmedov Ya. A. High-resolution ultrasound for pediatric scrotal pathology. Uzbek Journal of Case Reports. 2022; 2(1): 18-22.
Bondarenko S. V., Tarusin D. I. Lesions of the spermatic tracts in children and adolescents. Andrology and Genital Surgery. 2005; 6(1): 6-16.
Gareev V. D., Ermakova L. A. Clinical and anatomical characteristics of spermatocele in children. FORCIPE. 2020; 3(S): 236.
Grigorenko A. V., Pisklakov A. V., Ponomarev V. I. et al. Use of scrotoscopy for the diagnosis and treatment of scrotal diseases in children. Vyatka Medical Bulletin. 2023; 80(4): 8-12.
Delyagin V. M., Gerberg A. M., Demina E. S., Senyakovich N. B. The role of ultrasound in the diagnosis of scrotal organs. SonoAce-Ultrasound. 2000; 7: 74-83.
Dovzhansky I. V., Zubareva E. V. Local anesthesia with articaine in the surgical treatment of patients with spermatocele. Bulletin of the Reaviz Medical Institute: Rehabilitation, Doctor and Health. 2023; 13(2S): 236.
Zhiborev B. N. Spermatocele as a cause of infertility. Andrology and Genital Surgery. 2011; 12(2): 123-124.
Zubarev V. A., Arkhangelsky A. I., Dolzhansky I. V. et al. Comparative evaluation of the efficacy and safety of local anesthesia with articaine and lidocaine in the surgical treatment of spermatocele. Kazan Medical School Diary. 2023; 2(40): 14-17.
Zubarev V. A., Arkhangelsky A. I., Topuzov M. E. et al. Surgical tactics for treating patients with spermatoceles of various sizes. Kazan Medical School Diary. 2021; 1(31): 36-39.
Ismailov K. A., Volodko E. A., Chanakanov Z. I. et al. Outcomes of surgical treatment of congenital inguinal-scrotal diseases in children. Avicenna Bulletin. 2012; 3(52): 62-67.
Korshunov M. N., Kramareva K. I., Kindarova L. B., Darenkov S. P. Optimization of interaction between pediatric and adult urologist-andrologist as a tool for reproductive loss prevention. Urological Notices. 2019; 9(1S): 52-53.
Lobkarev O. A., Lutfullin N. I., Lobkarev A. O. A case of atypical hydrocele and epididymal cyst. Kazan Medical Journal. 2010; 91(5): 712.
Malysheva T. F., Balashov A. T., Malyshev V. A. Sclerotherapy of fluid lesions of the scrotum under ultrasound guidance. Andrology and Genital Surgery. 2005; 2: 50-54.
Pereverzev A. S. Chronic pelvic pain syndrome in men. International Medical Journal. 2005; 2: 109-114.
Ryskulbekov N. R., Abaraliev A. K., Suranov D. A. Fertility of men who underwent surgery on the reproductive system. Healthcare of Kyrgyzstan. 2022; 3: 72-76.
Sargsyan D. V., Vinogradov I. V. Long-term results of sclerotherapy in the treatment of epididymal cysts. Experimental and Clinical Urology. 2021; 1: 62-67.
Sargsyan D. V., Vinogradov I. V. Modern view on the treatment of epididymal cysts as a factor of obstructive azoospermia. Bulletin of Urology. 2019; 3: 47-54.
Sargsyan D. V., Vinogradov I. V., Vinogradova E. V. Study of the clinical efficacy and safety of sclerotherapy in the treatment of epididymal cysts. Experimental and Clinical Urology. 2020; 2: 118-123.
Stratienko S. V., Aristarkhov V. G., Zhiborev B. N., Khobocheva E. A. Significance and features of ultrasound examination of epididymal cysts. I.P. Pavlov Russian Medical Biological Herald. 2006; 14(1): 84-87.
USupbaev A. Ch., Kutbolsun U. U. Urogenital infections in patients with cystic diseases of the epididymis. Science, New Technologies and Innovations of Kyrgyzstan. 2020; 3: 91-94.
Usupbaev A. Ch., Kutbolsun U. U. Epidemiology of cystic diseases of the epididymis. Science, New Technologies and Innovations of Kyrgyzstan. 2019; 3: 136-139.
Usupbaev A. Ch., Kutbolsun Uulu U., Rysbaev B. A. [The relationship of male infertility with cystic changes of the epididymis]. // Meditsina Kyrgyzstana. 2018;4:80-82. (In Russ.)
Churayants V. V., Kovalev V. A., Koroleva S. V. [Magnetic resonance imaging in the diagnosis of scrotal diseases]. // Meditsinskaya vizualizatsiya. 2006;1:90-97. (In Russ.)
Patil, V., Shetty, S. M., & Das, S. (2015). Common and Uncommon Presentation of Fluid within the Scrotal Spaces. Ultrasound international open, 1(2), E34–E40. https://doi.org/10.1055/s-0035-1555919
Pellati D, Mylonakis I, Bertoloni G, Fiore C, Andrisani A, Ambrosini G, Armanini D. Genital tract infections and infertility. Eur J Obstet Gynecol Reprod Biol. 2008;140(1):3-11. doi: 10.1016/j.ejogrb.2008.03.009.
Huang C, Zhu HL, Xu KR, Wang SY, Fan LQ, Zhu WB. Mycoplasma and ureaplasma infection and male infertility: a systematic review and meta-analysis. Andrology. 2015;3(5):809-816. doi: 10.1111/andr.12078.
Lin HP, Lu HX. Analysis of detection and antimicrobial resistance of pathogens in prostatic secretion from 1186 infertile men with chronic prostatitis.Zhonghua Nan Ke Xue. 2007;13(7):628-631.
Zhang Z, Li Y, Lu H, Li D, Zhang R, Xie X, Guo L, Hao L, Tian X, Yang Z, Wang S, Mei X. A systematic review of the correlation between Trichomonas vaginalis infection and infertility. Acta Trop. 2022 Dec;236:106693. doi: 10.1016/j.actatropica.2022.106693. Epub 2022 Sep 15. PMID: 36116548.
WHO laboratory manual for the examination and processing of human semen, sixth edition. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO2021.
Kamischke A, Cordes T, Nieschlag E. The diagnostic of male infertility-an important part of reproductive medicine. Ther Umsch. 2009;66(12):789-795. doi: 10.1024/0040-5930.66.12.789.
Schlegel PN, Sigman M, Collura B, De Jonge CJ, Eisenberg ML, Lamb DJ, et al. Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline Part I. J Urol. 2021;205(1):36-43. doi: 10.1097/JU.0000000000001521.
WHO, WHO Manual for the Standardized Investigation and Diagnosis of the Infertile Couple. Cambridge: Cambridge University Press, 2000.
Kliesch S. Hydrozele, Spermatozele und Vasektomie: Komplikationsmanagement [Hydrocele, spermatocele, and vasectomy: management of complications]. Urologe A. 2014 May;53(5):671-5. German. doi: 10.1007/s00120-014-3486-4. PMID: 24806800.
Appendix A1. Working Group Composition
Alexander I. Neymark, MD, PhD, Professor, Head of the Department of Urology and Andrology with DPO Course, Altai State Medical University of the Russian Ministry of Health; Chief freelance urologist of Altai Krai and the Siberian Federal District; Chairman of the regional branch of the Russian Society of Urology (RSU)
Andrey V. Yakovlev, PhD, Assistant Professor at the Department of Urology and Andrology with DPO Course, Altai State Medical University of the Russian Ministry of Health; member of the RSU.
Revaz R. Kharchilava, PhD, Director of the Praxi Medica Training Center for Medical Practice, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow.
Conflict of interest: The authors declare no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience of these clinical guidelines:
Urologist
Surgeon
Medical students, residents, postgraduate students
In these clinical guidelines, all data are ranked by level of reliability (evidence) depending on the quantity and quality of studies on the issue.
Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for grading levels of evidence certainty (LEC) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
No reference materials available
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Epididymal cysts (ECs) are benign lesions most commonly located in the head of the epididymis. Epididymal spermatoceles are quite common, accounting for up to 7% of all detected scrotal mass lesions. ECs are cystic lesions containing serous fluid [17]. A spermatocele is a connective tissue cavity connected to the epididymis and lined on the inside with columnar epithelium. The distinguishing feature between a spermatocele and an epididymal cyst is the nature of the internal contents of these formations.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Rating scales and other questionnaires are not used.