A Paratesticular Mass
A Paratesticular Mass
40-year-old man complained of an intermittently painful nodule in the right hemiscrotum since the time of his vasectomy 2 years ago. No information concerning the specific technique employed for his vasectomy could be found. The pain was particularly severe during sexual intercourse and strenuous physical activity. It was becoming increasingly difficult to perform his job as a fireman. The pain was refractory to antibiotics, anti-inflammatory drugs, scrotal support, and prolonged periods of inactivity. An atrophic left cryptorchid testicle had been removed when he was 5 years old. He had no other significant medical history.
The patient's physical examination was normal except for a surgically absent left testicle and a firm, mobile, smooth, painful nodule located on the end of the testicular side of the right vasectomy site. The CBC, BUN, serum creatinine, and urinalysis were normal. A serum HIV antibody was negative.
Scrotal ultrasound showed a dilated vas deferens with internal debris. A 17.8 x 6.1-mm nodule was observed at the end of the dilated vas. A color Doppler ultrasound revealed increased flow in the nodule, which suggests inflammation (Fig. 1). The solitary right testicle was normal.
(Enlarge Image)
Color Doppler ultrasound of right hemiscrotum shows inflamed, vascular, 1-cm, solid lesion adjacent to testicular cut end of vas deferens. Internal debris seen in proximally dilated segment.
Local anesthetic and steroid injections into the spermatic cord were offered for diagnostic and therapeutic purposes. The patient declined injections and requested surgical excision of the lesion. The right vas deferens was mobilized through a transverse scrotal incision. An inflammatory nodular mass was entangled at the testicular cut end of the vas deferens. No sutures or clips were observed. The lesion was excised with an additional 4cm of the attached vas deferens since it also appeared to be involved. The remaining portion of the vas deferens was ligated with a 2-0 silk suture. Representative sections of the resected specimen at different levels are shown in Figures 2A, 2B, 3A, and 3B.
(Enlarge Image)
Histopathology of resected specimen. (A) Demonstrates spermatozoa within lumen of vas deferens (arrow). Outer portion of vas demonstrates several noncaseating granulomas containing admixture of histiocytes, lymphocytes, and degenerative sperm (arrowheads) (10x magnification). (B) Shown at 100x magnification.
(Enlarge Image)
Histopathology of resected specimen. (A) Demonstrates spermatozoa within lumen of vas deferens (arrow). Outer portion of vas demonstrates several noncaseating granulomas containing admixture of histiocytes, lymphocytes, and degenerative sperm (arrowheads) (10x magnification). (B) Shown at 100x magnification.
(Enlarge Image)
Histopathology of resected specimen (at level adjacent to region seen in Fig. 2) demonstrates vasitis nodosa. (A) Irregular proliferation of ductules originating from vasal lumen (white arrow) into smooth muscular wall of vas deferens and adjacent soft tissues (open arrows; 20x magnification). (B) Shown at 40x magnification. Cytologic atypia, vesicular nuclei, mitotic figures, and prominent nucleoli resemble adenocarcinoma (curved arrow).
(Enlarge Image)
Histopathology of resected specimen (at level adjacent to region seen in Fig. 2) demonstrates vasitis nodosa. (A) Irregular proliferation of ductules originating from vasal lumen (white arrow) into smooth muscular wall of vas deferens and adjacent soft tissues (open arrows; 20x magnification). (B) Shown at 40x magnification. Cytologic atypia, vesicular nuclei, mitotic figures, and prominent nucleoli resemble adenocarcinoma (curved arrow).
What do you recommend as the next step?
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<p>Observation</p>
40-year-old man complained of an intermittently painful nodule in the right hemiscrotum since the time of his vasectomy 2 years ago. No information concerning the specific technique employed for his vasectomy could be found. The pain was particularly severe during sexual intercourse and strenuous physical activity. It was becoming increasingly difficult to perform his job as a fireman. The pain was refractory to antibiotics, anti-inflammatory drugs, scrotal support, and prolonged periods of inactivity. An atrophic left cryptorchid testicle had been removed when he was 5 years old. He had no other significant medical history.
The patient's physical examination was normal except for a surgically absent left testicle and a firm, mobile, smooth, painful nodule located on the end of the testicular side of the right vasectomy site. The CBC, BUN, serum creatinine, and urinalysis were normal. A serum HIV antibody was negative.
Scrotal ultrasound showed a dilated vas deferens with internal debris. A 17.8 x 6.1-mm nodule was observed at the end of the dilated vas. A color Doppler ultrasound revealed increased flow in the nodule, which suggests inflammation (Fig. 1). The solitary right testicle was normal.
(Enlarge Image)
Color Doppler ultrasound of right hemiscrotum shows inflamed, vascular, 1-cm, solid lesion adjacent to testicular cut end of vas deferens. Internal debris seen in proximally dilated segment.
Local anesthetic and steroid injections into the spermatic cord were offered for diagnostic and therapeutic purposes. The patient declined injections and requested surgical excision of the lesion. The right vas deferens was mobilized through a transverse scrotal incision. An inflammatory nodular mass was entangled at the testicular cut end of the vas deferens. No sutures or clips were observed. The lesion was excised with an additional 4cm of the attached vas deferens since it also appeared to be involved. The remaining portion of the vas deferens was ligated with a 2-0 silk suture. Representative sections of the resected specimen at different levels are shown in Figures 2A, 2B, 3A, and 3B.
(Enlarge Image)
Histopathology of resected specimen. (A) Demonstrates spermatozoa within lumen of vas deferens (arrow). Outer portion of vas demonstrates several noncaseating granulomas containing admixture of histiocytes, lymphocytes, and degenerative sperm (arrowheads) (10x magnification). (B) Shown at 100x magnification.
(Enlarge Image)
Histopathology of resected specimen. (A) Demonstrates spermatozoa within lumen of vas deferens (arrow). Outer portion of vas demonstrates several noncaseating granulomas containing admixture of histiocytes, lymphocytes, and degenerative sperm (arrowheads) (10x magnification). (B) Shown at 100x magnification.
(Enlarge Image)
Histopathology of resected specimen (at level adjacent to region seen in Fig. 2) demonstrates vasitis nodosa. (A) Irregular proliferation of ductules originating from vasal lumen (white arrow) into smooth muscular wall of vas deferens and adjacent soft tissues (open arrows; 20x magnification). (B) Shown at 40x magnification. Cytologic atypia, vesicular nuclei, mitotic figures, and prominent nucleoli resemble adenocarcinoma (curved arrow).
(Enlarge Image)
Histopathology of resected specimen (at level adjacent to region seen in Fig. 2) demonstrates vasitis nodosa. (A) Irregular proliferation of ductules originating from vasal lumen (white arrow) into smooth muscular wall of vas deferens and adjacent soft tissues (open arrows; 20x magnification). (B) Shown at 40x magnification. Cytologic atypia, vesicular nuclei, mitotic figures, and prominent nucleoli resemble adenocarcinoma (curved arrow).
What do you recommend as the next step?
Right radical orchiectomy
Barium enema
Observation
CT scan of the abdomen and the pelvis
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<p>Observation</p>