Recurrent Arteriovenous Malformation of the Spermatic Cord

Georgetown University Hospital, Department of Urology, 3800 Reservoir Road NW, Washington, DC 20007

A 30 year old Hispanic male with no past medical history presented with a painful midline scrotal mass.  He reported a history of a similar mass which had been resected 5 years previously. Histologic analysis at that time showed a benign vascular lesion representing an arteriovenous malformation.  Physical examination at this latest presentation demonstrated a 3 cm tender, firm mass superiomedial to the right testis but attached to the spermatic cord.  Ultrasound showed a discrete 3.4×2.1×3.6cm cystic mass with thin, hypervascular internal septations (Figure 1).

The mass was adjacent to but separate from the right testis. Due to his persistent discomfort,  the patient elected to undergo surgical excision of the mass.

A midline scrotal incision was made and the testis was delivered.  Upon further dissection; a 3cm, dark, cystic mass with multiple septations was seen. The mass appeared to be attached to the spermatic cord (Figure 2).

The mass was carefully resected from the cord, and did not obviously invade or arise from any particular cord structure.  Pathologic examination showed a benign vascular lesion consistent with an arteriovenous malformation.  At follow up several weeks later, the patient had complete resolution of his symptoms.

AVM of the genital area is rare, and there is only a few documented cases of AVM of the spermatic cord (1-6).  To our knowledge this is the first report of a recurrent AVM of the spermatic cord.

AVM of the spermatic cord is typically found incidentally as a painless mass or on imaging during infertility workup.  There is one case in which the patient presented (as in our case) with a painful mass in the scrotum (6).  Scrotal AVM, on the other hand, frequently presents with bleeding, ulcerated lesions or a large, painful mass (7,8).  Differential diagnosis should include lipoma of the cord, adenomatoid tumor, leiomyoma, malignancy (sarcoma), or other vascular lesions, such as varicocele, hemangioma, lymphangioma or hamartoma (5,8).

Patients are usually young men in their second, third or fourth decade of life with little past medical history (1-6).  Several patients with genital AVM report a prior history of trauma to the area (5).  Physical examination may reveal palpable, dilated tortuous veins, skin discoloration, and possibly a bruit or thrill on auscultation (8).  Workup of the suspected AVM may include ultrasound evaluation or arterial angiography.  Doppler images will show increased vascularity in the cystic septations (5,6,8,9).  Arterial angiography is preferred for cases of larger masses or when the diagnosis is uncertain (6,10).  This modality offers the advantage of possible embolization at the time of diagnosis.  Magnetic resonance imaging has also been employed for imaging of these lesions (9).

Management options include observation (9), angiographic embolization (10), and surgical excision (5).  Surgical excision is the definitive therapy if less invasive therapies fail, and may involve orchiectomy or cord resection (6).  While AVM of the spermatic cord is a rare lesion, it should be considered in the workup of a scrotal mass.  This is the first documented case of a recurrent AVM of the spermatic cord.  While prior trauma (5) or scrotal surgery (1) are well established risk factors, history of scrotal AVM should also be considered when evaluating a patient with a mass of the spermatic cord.

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