Unusual presentation of paratesticular leiomyoma with prominent vascular features: clinical, surgical, and histological insights.

Paratesticular leiomyomas are rare benign mesenchymal tumors arising from smooth muscle of paratesticular tissues, including vascular walls, dartos muscle, and spermatic cord. Angioleiomyoma represents a vascular-rich subtype. They usually present as slow-growing, painless extratesticular masses in middle-aged men. Imaging helps localization but is not diagnostic while histopathology with immunohistochemistry confirms diagnosis. A 49-year-old motocross athlete presented with progressive scrotal enlargement causing discomfort. Examination showed a large encapsulated mass displacing normal testes. Computed tomography revealed a large heterogeneous paratesticular lesion with neoangiogenesis. The mass was excised and scrotoplasty was performed. Histology showed benign spindle cells, low Ki-67 (~3%), and positivity for desmin and CD34. This case emphasizes recognition and testis-sparing management of paratesticular leiomyoma, ensuring excellent outcomes without need for long-term surveillance.