What is the assessment and management plan for a patient with small bilateral simple hydroceles, a 2 mm epididymal head cyst versus spermatocele in the right epididymis, and a small left-sided varicocele?

Assessment and Management of Small Bilateral Hydroceles, Epididymal Cyst/Spermatocele, and Small Left Varicocele

These findings are benign and require no intervention—observation is the appropriate management strategy for all three conditions in this asymptomatic patient.

Assessment

Bilateral Simple Hydroceles

• Small, simple hydroceles represent benign fluid collections between the parietal and visceral layers of the tunica vaginalis, resulting from an imbalance between fluid secretion and reabsorption 1
• Asymptomatic hydroceles do not require correction—treatment is only indicated when hydroceles cause patient impairment or discomfort 2
• The diagnosis is confirmed by ultrasound, which has already been performed in this case 3

Epididymal Cyst vs. Spermatocele (2 mm, Right)

• A 2 mm lesion is extremely small and clinically insignificant 4
• Both epididymal cysts and spermatoceles are benign masses that are easily characterized by ultrasound imaging 4
• Conservative management is the treatment of choice—surgery is recommended only in selected cases where the lesion causes symptoms or significant size-related concerns 4
• In younger men, fertility preservation must be considered before any intervention, as spermatocele resection may lead to epididymal obstruction and infertility 2

Small Left-Sided Varicocele

• Do not treat this varicocele if the patient has normal semen analysis or if this is a subclinical (non-palpable) varicocele 5
• Treatment is only indicated for infertile men with clinical (palpable) varicoceles, abnormal semen parameters, and otherwise unexplained infertility when the female partner has good ovarian reserve 5, 6
• In adolescents, surgery is indicated only for varicoceles associated with persistent testicular size difference (>2 ml or 20%) confirmed on two visits 6 months apart 5, 6
• Routine ultrasonography to identify non-palpable varicoceles is discouraged, as treatment of subclinical varicoceles does not improve semen parameters or fertility rates 7, 6

Management Plan

Immediate Actions

• No intervention required for any of these findings 5, 2, 4
• Document that all three conditions are small and asymptomatic

Follow-Up Strategy

• Hydroceles: No routine follow-up needed unless symptoms develop (pain, discomfort, cosmetic concerns) 2, 1
• Epididymal cyst/spermatocele: No follow-up required for a 2 mm lesion—this is a self-limiting condition in the majority of cases 4
• Varicocele: Follow-up only if the patient develops infertility concerns or if this is an adolescent with concern for testicular growth asymmetry 5, 6

When to Reconsider Treatment

For the varicocele specifically:

• If the patient presents with infertility AND has abnormal semen parameters AND the varicocele is clinically palpable (not just ultrasound-detected) 5, 6
• If this is an adolescent with documented testicular size difference >2 ml or 20% confirmed on two visits 6 months apart 5
• Consider in cases of elevated sperm DNA fragmentation with unexplained infertility or recurrent ART failure 5

For the hydroceles:

• If they enlarge and cause patient discomfort, pain, or cosmetic concerns 2, 3
• If fertility preservation is desired before any surgical intervention, discuss sperm cryopreservation 2

For the epididymal cyst:

• Only if it significantly enlarges or becomes symptomatic 4

Critical Pitfalls to Avoid

• Do not operate on subclinical (non-palpable) varicoceles—this does not improve fertility outcomes 5, 7, 6
• Do not treat asymptomatic hydroceles or small epididymal cysts—unnecessary surgery risks complications including infertility 2, 4
• If the patient is young and desires future fertility, any consideration of surgery for the epididymal cyst must include detailed counseling about potential epididymal obstruction 2
• Ensure the varicocele is truly clinical (palpable on examination) before considering treatment, as ultrasound-only findings do not warrant intervention 7, 6