Treatment for Scrotal Pearls (Epidermoid or Sebaceous Cysts)
The definitive treatment for scrotal pearls (epidermoid or sebaceous cysts) is surgical excision, which is indicated when the cysts become infected, cause discomfort, or for cosmetic concerns. 1
Diagnosis and Evaluation
- Ultrasound (US) or US duplex Doppler of the scrotum is the recommended initial imaging modality to confirm the diagnosis and rule out other scrotal pathologies 1
- Scrotal pearls typically appear as well-defined, hypoechoic or anechoic lesions with smooth borders on ultrasound 1
- These cysts are benign and contain keratinous material enclosed within a stratified squamous epithelial lining 2
- Multiple cysts can occur simultaneously on the scrotum, though this presentation is relatively uncommon 2, 3
Treatment Options
Surgical Management
Incision and drainage is the recommended treatment for inflamed epidermoid cysts 1
- This involves making a small incision, evacuating the cyst contents, and removing the cyst wall
- For small, uncomplicated cysts, minimal excision technique can be used, involving a 2-3 mm incision with expression of contents and extraction of the cyst wall 4
Complete surgical excision is preferred for:
For extensive involvement with multiple cysts, subtotal excision of the scrotal wall may be necessary, followed by scrotoplasty for reconstruction 5, 3
Medical Management
Systemic antibiotics are generally unnecessary unless there is:
- Extensive surrounding cellulitis
- Systemic signs of infection (fever, SIRS)
- Multiple lesions
- Severely impaired host defenses 1
Inflamed cysts are difficult to excise completely, and it is often preferable to:
- Treat the acute inflammation first with warm compresses and possibly antibiotics
- Postpone definitive excision until inflammation has subsided 4
Special Considerations
Histopathological examination is not routinely necessary for typical epidermoid cysts but should be performed if there are:
- Unusual clinical features
- Rapid growth
- Suspicion of malignancy 4
The risk of malignant transformation of scrotal epidermoid cysts is extremely low 2, 5
Cosmetic results after proper surgical excision are generally excellent with low recurrence rates 3
Follow-up
- Follow-up is typically not required after successful removal of scrotal pearls unless there are complications or recurrence 3
- Patients should be advised to seek medical attention if they develop new cysts or signs of infection at the surgical site 1
Common Pitfalls
- Attempting to excise inflamed cysts can lead to incomplete removal and recurrence; it's better to wait until inflammation subsides 4
- Failure to completely remove the cyst wall is the most common cause of recurrence 4, 3
- Scrotal pearls should not be confused with testicular microlithiasis or scrotal calculi (scrotal lithiasis), which have different management approaches 6