Primary intramedullary spinal cord germinoma (PISCG) is very rare, and its preoperative diagnosis is therefore difficult. In addition, its treatment protocols and long-term outcomes are not yet established. Here, we report the case of a patient with a primary conus medullaris germinoma who initially presented with ejaculatory disturbance and coccygeal hypoesthesia. After the total excision of the germinoma and radiotherapy, no tumor recurrence was noted for 22 years. We have also reviewed the distribution of PISCG in spinal segments and its treatment modalities.