How are epididymal cysts treated in relation to infertility?

Treatment of Epididymal Cysts in Relation to Infertility

Epididymal cysts do not require treatment for fertility purposes as they are not associated with impaired semen parameters or infertility. 1

Understanding Epididymal Cysts and Fertility

Epididymal cysts are benign fluid-filled structures commonly found during urological examinations or scrotal ultrasound. Recent evidence shows they are more prevalent than previously thought, with studies reporting their presence in up to 71% of men (73% of infertile men and 67% of fertile men) 2.

Key points about epididymal cysts and fertility:

• Epididymal cysts have no statistically significant association with:

  • Semen volume
  • Sperm concentration
  • Sperm motility
  • Sperm morphology
  • Total motile sperm count
  • Serum hormonal values 1

• Neither the size nor laterality (unilateral or bilateral) of epididymal cysts correlates with any semen parameter 1

Treatment Algorithm for Epididymal Cysts

1. Asymptomatic Epididymal Cysts

• Recommendation: No treatment required
• Patients should be counseled toward conservative management with observation for asymptomatic epididymal cysts during fertility evaluation 1
• This is particularly important as the 2024 AUA/ASRM guidelines emphasize focusing on conditions that affect fertility outcomes 3

2. Symptomatic Epididymal Cysts

For symptomatic cysts (pain, discomfort, or cosmetic concerns), treatment options include:

A. Percutaneous Sclerotherapy

• Indication: Symptomatic cysts >5 cm in diameter 4
• Procedure: Outpatient-based with ultrasound guidance using 3% Polidocanol as sclerosing agent
• Efficacy: 84% of patients become symptom-free after treatment (may require second session)
• Advantages: Safe, effective, no complications, lower cost than surgery 4

B. Microscopic Cyst Resection

• Indication: Symptomatic cysts requiring surgical intervention
• Recommendation: Consider surgery before cyst reaches 0.8 cm in diameter
• Caution: Larger cysts (>0.9 cm) may cause destruction of epididymal tubules
• Advantages: Reduced bleeding (2-3 mL), no wound drainage required, lower incidence of scrotal hematoma, edema, and long-term pain 5

Important Considerations for Fertility Evaluation

When evaluating males with epididymal cysts who are concerned about fertility:

1. Focus on established causes of infertility:

   • The 2024 AUA/ASRM guidelines recommend evaluating for potentially correctable conditions affecting fertility 3
   • Varicoceles, hormonal imbalances, and genetic factors should be prioritized over epididymal cysts 3

2. Avoid unnecessary interventions:

   • Epididymal sperm retrieval should be avoided if future microsurgical reconstruction might be pursued due to the risk of epididymal scarring and obstruction 3
   • For men with abnormal semen parameters, focus on other potential causes rather than the epididymal cysts 3

3. Consider assisted reproductive technologies when appropriate:

   • For couples with infertility not related to epididymal cysts, consider IVF or other assisted reproductive technologies as recommended by the AUA/ASRM guidelines 3

Pitfalls to Avoid

1. Unnecessary surgical intervention: Avoid surgical treatment of asymptomatic epididymal cysts in the setting of fertility evaluation, as this will not improve fertility outcomes 1

2. Misattribution of infertility causes: Do not attribute fertility issues to epididymal cysts when other factors like varicoceles, testicular size, or hormonal issues may be the actual cause 2

3. Confusing epididymal cysts with other conditions: Ensure proper differentiation between epididymal cysts and spermatoceles through ultrasound imaging 6

By following these evidence-based recommendations, clinicians can provide appropriate management for patients with epididymal cysts while properly addressing fertility concerns.