What is the treatment for an epididymal cyst?

Treatment of Epididymal Cysts

Epididymal cysts should be managed conservatively with observation and regular follow-up ultrasound unless they are symptomatic or have concerning features, in which case surgical excision is recommended. 1

Diagnosis and Assessment

• High-frequency (>10 MHz) scrotal ultrasound with Doppler is the gold standard for diagnosis of epididymal cysts 1
• Ultrasound helps determine:
  • Size of the cyst
  • Location within the epididymis
  • Single vs. multiple cysts
  • Presence of any concerning features
  • Contralateral involvement

Management Algorithm

1. Asymptomatic Epididymal Cysts

• Small cysts (<1 cm): Conservative management with observation 2

  • Follow-up ultrasound at 6-8 weeks to ensure stability 1
  • Approximately 50% of epididymal cysts involute within an average of 17 months 2, 3

• Large asymptomatic cysts (>1 cm):

  • Initial conservative management
  • If no regression after 24-48 months of follow-up, consider surgical excision 2

2. Symptomatic Epididymal Cysts

• Symptoms may include:

  • Scrotal pain
  • Scrotal mass/swelling
  • Discomfort during physical activity
  • Psychological distress

• Treatment options:

  1. Surgical excision: Standard approach for persistent symptomatic cysts 2, 4

     • Indicated for:
       • Persistent scrotal pain
       • No involution during follow-up
       • Cysts >5 cm in diameter
       • Complications (torsion, hemorrhage)

  2. Percutaneous sclerotherapy: Alternative to surgery 5

     • Uses 3% Polidocanol as sclerosing agent
     • Performed on outpatient basis under ultrasound guidance
     • Success rate: 84% of symptomatic patients become symptom-free
     • Advantages: less invasive, lower cost, fewer complications than surgery

3. Emergency Situations

• Immediate surgical exploration is indicated for:
  • Acute scrotal pain with suspected torsion of epididymal cyst 6
  • Intracystic hemorrhage
  • Secondary torsion of the epididymis 2

Follow-up Protocol

• For conservatively managed cysts:
  • Ultrasound at 3,6, and 12 months
  • Continue follow-up until complete involution or for at least 24 months
  • Average time to complete regression: 17 months 3

Special Considerations

• In children, conservative management is preferred as most epididymal cysts (approximately 50%) involute with time 3
• In patients with a single testicle, preservation of testicular function should be prioritized 1
• Consider fertility preservation counseling before any surgical intervention if there is significant testicular involvement 1

Complications of Treatment

• Surgical excision carries risks of:

  • Infection
  • Hematoma
  • Damage to surrounding structures
  • Post-operative epididymitis (reported in some cases) 2

• Percutaneous sclerotherapy has shown no significant complications in available studies 5

The management of epididymal cysts should focus on symptom relief and prevention of complications while using the least invasive approach possible. Most asymptomatic cysts can be safely observed, while symptomatic cysts may require intervention based on size, symptoms, and patient preference.