What are the treatment options for testicular cysts?

Treatment Options for Testicular Cysts

The optimal treatment for testicular cysts depends on symptoms, size, and characteristics, with observation being the first-line approach for asymptomatic simple cysts, while symptomatic or large cysts may require surgical intervention through organ-sparing techniques when possible.

Diagnostic Approach

Before determining treatment, proper diagnosis is essential:

• High-resolution ultrasound is the diagnostic modality of choice, revealing:

  • Anechoic mass with well-defined walls
  • Enhanced posterior through transmission
  • Edge shadowing characteristic of simple cysts 1

• Differentiation from malignancy is critical:

  • Simple cysts appear as fluid-filled structures without solid components
  • Frozen section may be recommended in doubtful cases before definitive surgery 2

Treatment Algorithm

1. Asymptomatic Simple Cysts

• Observation/surveillance is the recommended first-line approach 1
• Regular ultrasound follow-up to monitor for changes in size or characteristics
• No intervention needed if stable and asymptomatic

2. Symptomatic Cysts

Treatment options depend on size, symptoms, and patient factors:

For Small to Moderate Symptomatic Cysts (<5 cm):

• Organ-preserving surgery (partial orchiectomy/enucleation) is preferred 1, 3
  • Preserves testicular tissue and function
  • Should be performed only in experienced centers 2
  • Requires careful surgical technique through inguinal approach

For Large Symptomatic Cysts (>5-6 cm):

• Percutaneous sclerotherapy may be considered for epididymal cysts 4

  • 84% success rate for symptom resolution
  • Lower complication risk than surgery
  • Outpatient procedure under ultrasound guidance

• Radical orchiectomy may be necessary in select cases 5

  • Considered for very large cysts (>6 cm)
  • When malignancy cannot be excluded
  • In older patients with significant symptoms
  • Should be performed through inguinal incision 2

3. Special Considerations

• Testicular Intraepithelial Neoplasia (TIN) may be found in preserved testicular tissue after partial orchiectomy

  • Adjuvant radiotherapy (16-20 Gy) may be required 2
  • Can be delayed in patients wishing to father children

• Fertility concerns:

  • Sperm banking should be offered before any surgical intervention
  • If fertility is a priority, organ-preserving approaches should be attempted when possible

Clinical Pearls and Pitfalls

• Avoid scrotal violation for biopsy or surgery - always use inguinal approach 2
• Consider contralateral testicular biopsy in high-risk patients (testicular atrophy, age <40) to rule out TIN 2
• Frozen section is recommended in doubtful cases before definitive surgery 2
• Simple testicular cysts are more common than previously thought (9.8% prevalence in one ultrasound study) 6
• Careful follow-up is essential after conservative management to monitor for changes

The treatment approach should prioritize testicular preservation when possible while ensuring complete resolution of symptoms and ruling out malignancy, as this strategy optimizes both quality of life and long-term outcomes.