What is the next best step in managing a patient with epididymal thickening, bilateral hydrocele, and a simple cyst in the left testicle, who has persistent pain and nausea despite recent doxycycline treatment?

Management of Persistent Epididymal Thickening with Bilateral Hydrocele and Testicular Cyst

Urological referral for surgical intervention is the next best step for this patient with persistent symptoms despite appropriate antibiotic therapy.

Clinical Assessment of Current Presentation

The patient presents with:

• Right epididymal thickening in the distal portion at the inferior pole
• Bilateral hydrocele (right greater than left)
• 3 mm simple cyst in the left testicle (new finding)
• Persistent pain and nausea despite completing doxycycline 100 mg BID for 10 days

This clinical picture suggests:

1. Failed medical management of presumed epididymitis
2. Possible underlying pathology requiring surgical evaluation
3. Need for definitive treatment of the hydrocele and evaluation of the testicular cyst

Management Algorithm

Step 1: Evaluate Treatment Failure

• The patient has completed appropriate first-line antibiotic therapy for epididymitis (doxycycline 100 mg BID for 10 days) 1
• Persistent symptoms after 2 weeks of appropriate antibiotics indicate treatment failure
• Nausea with scrotal pain raises concern for possible underlying pathology

Step 2: Next Best Management Option

Given the treatment failure and ultrasound findings, the options include:

1. Surgical intervention (recommended):

   • Scrotal exploration with possible epididymectomy
   • Hydrocelectomy
   • Evaluation of the testicular cyst

2. Alternative antibiotic regimen:

   • Not recommended as first-line therapy has already failed
   • No evidence supports switching antibiotics after appropriate initial therapy

3. Sclerotherapy for hydrocele:

   • Could be considered but not as first-line given the epididymal pathology
   • Success rates of 77-100% reported with various sclerosants 2, 3, 4
   • Not appropriate until infectious/inflammatory process is resolved

Rationale for Surgical Approach

1. Persistent epididymal thickening:

   • Suggests ongoing inflammatory process or underlying pathology
   • May require direct visualization and possible epididymectomy

2. Bilateral hydrocele:

   • Contributes to discomfort and may not resolve spontaneously
   • Surgical correction has high success rates

3. Simple testicular cyst:

   • New finding requiring evaluation
   • Simple enucleation with testicular preservation is the standard approach 5

4. Persistent symptoms:

   • Pain and nausea despite appropriate antibiotics suggest need for definitive intervention
   • Chronic epididymitis (symptoms >3 months) requires specialized management 1

Surgical Considerations

• Scrotal exploration allows direct visualization of all pathology
• Hydrocelectomy can be performed concurrently
• The simple cyst can be enucleated with testicular preservation 5
• Epididymal pathology can be directly addressed

Important Caveats and Considerations

1. Pre-surgical evaluation:

   • Serum tumor markers (β-HCG, AFP, LDH) should be obtained to rule out testicular malignancy 6
   • Urinalysis and culture to identify any persistent infection

2. Fertility considerations:

   • Discuss sperm banking before surgical intervention if fertility is a concern 6
   • Surgical intervention on the epididymis may affect fertility

3. Follow-up care:

   • Regular monitoring for recurrence is essential
   • Potential complications include testicular atrophy (9.1-47.5%) 1

4. Alternative for hydrocele if surgery is declined:

   • Aspiration and sclerotherapy with tetracycline or polidocanol could be considered as a second-line option 2, 3, 4
   • Success rates of 77-97% with re-treatment

Conclusion

The persistence of symptoms despite appropriate antibiotic therapy, combined with the ultrasound findings of epididymal thickening, bilateral hydrocele, and a testicular cyst, indicates the need for surgical intervention. This approach allows for direct visualization and definitive treatment of all pathologies while ruling out more serious conditions.