What is the recommended treatment for testicular sebaceous cysts?

Management of Testicular Sebaceous Cysts

Surgical excision through a small incision is the recommended treatment for testicular sebaceous cysts, particularly when they become symptomatic, infected, or cosmetically concerning. 1

Diagnosis and Evaluation

• Scrotal ultrasound with Doppler is the gold standard initial imaging test for any testicular or scrotal mass

  • High-frequency (>10 MHz) ultrasound helps determine if the mass is intratesticular or extratesticular 2
  • Sebaceous cysts typically appear as hypoechoic, oval-shaped lesions (91.5% of cases) 3
  • About half (50.8%) show a homogeneous appearance described as "pseudotestis" 3
  • The presence of an "epidermal punctum" (visible skin pore) is characteristic of sebaceous cysts 3

• Clinical features of sebaceous cysts:

  • Benign encapsulated, subepidermal nodules filled with keratin material 1
  • Commonly occur in hair-bearing areas including the scrotum 1
  • Histologically lined by stratified squamous epithelium containing keratin debris and cholesterol 1

Treatment Options

1. Surgical Excision (Primary Recommendation)

• Complete surgical excision is indicated when cysts are:

  • Symptomatic (painful)
  • Infected
  • Cosmetically concerning
  • Large or multiple 1

• Surgical techniques:

  • Mini-incision technique using 5% phenol is recommended for selected cases where minimal scarring is important 4
  • For multiple or extensive cysts, complete removal of affected scrotal skin may be necessary 1

2. Percutaneous Sclerotherapy (Alternative Approach)

• Can be considered for epididymal cysts (though not specifically sebaceous cysts)
• Performed on an outpatient basis under ultrasound guidance
• Studies show 84% of patients become symptom-free after treatment 5
• Advantages include:
  • Safety and effectiveness
  • Lower cost than surgery
  • No reported complications
  • Avoidance of surgical risks 5

Important Considerations

• Differentiation from testicular cancer is crucial:

  • Unlike testicular cancer, sebaceous cysts are extratesticular
  • Ultrasound can reliably distinguish between intratesticular and extratesticular masses with 98-100% accuracy 2

• Malignant transformation:

  • Though rare, malignant transformation has been reported in long-standing sebaceous cysts in other body locations 6
  • This supports the case for removal of large or long-standing cysts

• Follow-up:

  • After removal, histopathological examination should be performed to confirm the benign nature of the cyst 1, 6
  • No specific follow-up regimen is required after complete excision of confirmed benign sebaceous cysts

Clinical Pitfalls to Avoid

• Misdiagnosis: Don't confuse sebaceous cysts with testicular tumors; proper imaging is essential
• Scrotal violation: When surgical intervention is needed, avoid direct scrotal incision if there's any concern for testicular cancer 7
• Delayed treatment: Infected sebaceous cysts can cause significant morbidity and should be treated promptly
• Incomplete excision: Failure to remove the entire cyst wall can lead to recurrence

Remember that while testicular cancer guidelines emphasize radical orchiectomy for intratesticular masses 7, sebaceous cysts are extratesticular and therefore managed differently with local excision being the standard approach.