What are the treatment options for epididymal cysts?

Treatment Options for Epididymal Cysts

For epididymal cysts, conservative management is recommended for asymptomatic cysts smaller than 1 cm, while surgical excision is indicated for symptomatic cysts or those larger than 1 cm that don't regress after 24-48 months of observation 1.

Diagnosis and Evaluation

• Ultrasound with Doppler is essential to:

  • Confirm the diagnosis
  • Rule out underlying pathology (especially testicular malignancy)
  • Determine size and characteristics of the cyst 1

• Pre-intervention considerations:

  • Obtain serum tumor markers (β-HCG, AFP, LDH) to rule out testicular malignancy
  • Discuss sperm banking if fertility is a concern, as procedures may affect fertility 1

Treatment Algorithm

1. Asymptomatic Epididymal Cysts

• Small cysts (<1 cm):

  • Conservative management with observation
  • Follow-up with ultrasound every 6-12 months
  • Approximately 50% involute within 17 months 2

• Large asymptomatic cysts (>1 cm):

  • Observe for 24-48 months
  • If no regression occurs after this period, consider surgical excision 1, 2

2. Symptomatic Epididymal Cysts

• First-line approach:

  • Surgical excision regardless of size 1, 2
  • Microscopic cyst resection is preferred for better outcomes and preservation of epididymal function 3

• Alternative approach:

  • Percutaneous sclerotherapy for cysts >5 cm in patients who refuse surgery
  • Uses ultrasound guidance and 3% Polidocanol as sclerosing agent
  • Success rate of 84% after one or two sessions 4

Surgical Techniques

Microscopic Cyst Resection

• Advantages:

  • Improved visualization of subtle tissue structures
  • Complete intact removal of cyst
  • Reduced bleeding (2-3 mL)
  • No wound drainage required
  • Lower incidence of postoperative complications 3

• Timing recommendation:

  • Perform surgery before cyst reaches 0.8 cm in diameter
  • Larger cysts (>0.9 cm) may cause complete destruction of ipsilateral epididymal tubules 3

Conventional Surgical Excision

• Used for larger symptomatic cysts
• Higher risk of complications compared to microscopic technique 4

Post-Treatment Care and Follow-Up

• Post-surgical monitoring:

  • Regular follow-up at 3-6 months and 12 months
  • Assess for symptom resolution and recurrence 4

• Potential complications:

  • Scrotal hematoma
  • Edema
  • Long-term postoperative pain
  • Potential impact on fertility
  • Acute epididymitis (rare) 2, 3

Special Considerations

• Adolescents:

  • Epididymal cysts are more common after age 14-15
  • Conservative approach preferred unless symptomatic
  • Association with varicocele has been reported in 46% of cases 5

• Fertility concerns:

  • Microscopic techniques should be considered for men with future fertility plans 3
  • Discuss sperm banking before any intervention 1

Clinical Pearls

• Epididymal cysts are often diagnosed incidentally during physical examination or ultrasound
• The etiology may involve obstruction in epididymal efferent ductules or dysgenesis due to hormonal disorders
• Percutaneous sclerotherapy offers a less invasive alternative with good success rates and minimal complications for patients who refuse surgery 4