Treatment of Epididymal Head Cysts
Conservative management is the treatment of choice for asymptomatic epididymal cysts, while surgical excision is recommended for symptomatic cysts or those larger than 1 cm that do not regress after 24-48 months of observation.
Diagnostic Approach
Before determining treatment, proper evaluation should include:
- Ultrasound examination to confirm diagnosis and determine size
- Assessment for symptoms (pain, discomfort, swelling)
- Evaluation for complications (torsion, infection)
Treatment Algorithm
Asymptomatic Epididymal Cysts
- Cysts < 1 cm: Conservative management with observation 1, 2
- Cysts > 1 cm:
- Initial observation for 24-48 months
- If no regression occurs after this period, consider surgical excision 1
Symptomatic Epididymal Cysts
- Surgical excision is indicated regardless of size when 1:
- Persistent pain or discomfort is present
- Acute scrotal symptoms develop (inflammation, bleeding)
- Torsion occurs (rare but serious complication)
Complications Requiring Immediate Intervention
- Torsion of epididymal cyst: Immediate surgical exploration and excision 3, 4
- Infection: May require antibiotics and possibly drainage or excision
Alternative Treatment Options
For patients who refuse surgery or are poor surgical candidates, percutaneous sclerotherapy may be considered:
- Performed on an outpatient basis under ultrasound guidance
- Uses sclerosing agents such as 3% Polidocanol
- Success rate of approximately 84% for symptomatic relief
- Lower complication rate compared to surgery 5
Post-Treatment Follow-up
- For conservatively managed cysts: Ultrasound follow-up at 6-12 month intervals
- For surgically treated cases: Follow-up examination at 3 months to ensure proper healing
- Monitor for recurrence or development of new cysts
Pitfalls and Caveats
Misdiagnosis: Epididymal cysts must be differentiated from other scrotal pathologies including:
- Hydrocele
- Varicocele
- Testicular tumors
- Spermatocele (contains sperm, unlike true epididymal cysts)
Unnecessary surgery: Many epididymal cysts (approximately 50%) involute spontaneously within 17 months 1
Delayed diagnosis of complications: Torsion of epididymal cysts can present as acute scrotum and requires immediate surgical intervention 3, 4
Post-surgical complications: Though rare, these may include infection, hematoma, or recurrence
By following this structured approach to treatment, most epididymal head cysts can be managed effectively with minimal morbidity and excellent outcomes.