An incidental finding of a paratesticular leiomyoma on varicocele repair

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Introduction The paratesticular region is composed of spermatic cord, epididymis, vestigial remnants, and tunica vaginalis. Although paratesticular neoplasms are rare, they are clinically significant lesions that affect patients of all ages. Epididimal tumours, both primary and secondary, whether benign or malignant are extremely rare and the incidence is at most 0.03% of all male cancers. Benign tumours accounts for 75% of epididimal tumors cases. The most common benign epididymal tumour are adenomatoid tumors, followed by leiomyoma and papillary cystadenoma. Thus, we report a case of leiomyoma in a 51-year-old male who presented with a long standing history of gradual growing scrotal swelling. Case description A 51-year-old gentleman referred to the outpatient clinic with left scrotal pain and gradual swelling for more than 7 years. There were no associated obstructive lower urinary tracts symptoms, trauma, fever or constitutional symptoms. The patient had a background surgical history of left varicocele repair 7 years ago. He has an unremarkable past medical history. On examination, no masses were felt in the abdomen. There was an old scar at the left groin from the previous surgery and a hard non tender swelling was felt in the left scrotal sac inseparable from the left testes and epididymis, which was irreducible and not transluminant. Dilated and tortuous veins above the testicle ('bag of worms') were also identified which get decompressed on lying supine. Digital rectal examination was also normal. The patient's routine laboratory investigations were all within normal limits. Testicular tumor markers of Alpha fetoprotein and beta HCG were also requested and were normal. An ultrasound was done and showed a Grade III left varicocele with surrounding soft tissue density most likely hematoma and Grade I right varicocele. In view of the suspicious hard swelling in the left scrotal sac, he underwent left testicular exploration through a left inguinal approach and delivery of the left testis revealed an ovoid paratesticular mass attached to the tail of the left epididymis, measuring 2.5x2.5x2cm. Grossly it was firm and well circumscribed with a gray-white homogeneous surface. Complete enucleation of the left paratesticular mass was done and the specimen was sent to histopathology and microscopic-assisted bilateral varicocele repair was then carried out. Histopathology reported interlacing fascicles of spindle shaped cells with eosinophilic fibrillary cytoplasm, blunt ended nuclei elongated with fine chromatin, indistinct nucleolus and variable cytoplasmic vacuole at one end, minimal atypia, few mitotic figures and no coagulative tumor necrosis those featuring paratesticular leiomyoma. Results and conclusions Despite being rare, the diagnosis of leiomyoma of epididymis should be considered in the differential diagnosis of solid epididymal masses.