Treatment of Epididymal Cysts
Asymptomatic epididymal cysts require no treatment and can be managed with reassurance alone. 1
Initial Diagnostic Confirmation
- Scrotal ultrasound is the primary imaging modality to confirm the cystic nature of the lesion and distinguish it from solid masses that would require more aggressive management 1
- No additional imaging studies are needed for uncomplicated epididymal cysts without suspicious features 1
- The key distinction is whether the cyst is symptomatic (causing pain, discomfort, or functional impairment) versus incidentally discovered 2, 3
Management Algorithm Based on Symptoms and Size
Asymptomatic Cysts <1 cm
- Conservative management with observation is recommended 2
- Approximately 50% of epididymal cysts involute spontaneously within an average of 17 months 2
- Patient education on testicular self-examination to monitor for changes 1
Asymptomatic Cysts >1 cm
- Conservative management with follow-up at 24-48 months 2
- If the cyst does not regress after this observation period, surgical excision should be considered 2
Symptomatic Cysts (Any Size)
Symptomatic epididymal cysts warrant active treatment, with two primary options:
Option 1: Percutaneous Sclerotherapy (Preferred for Cysts >5 cm)
- Percutaneous sclerotherapy with 3% Polidocanol under ultrasound guidance is a safe, effective first-line treatment for symptomatic cysts >5 cm in diameter 3
- Performed on an outpatient basis with 100% technical success rate 3
- 84% of patients remain symptom-free after treatment (68% after single session, with improvement to 84% after repeat procedure if needed) 3
- No complications reported, significantly lower cost than surgery 3
- Follow-up at 3,6, and 12 months; repeat procedure offered if symptoms persist or cyst remains >5 cm 3
Option 2: Surgical Excision
Microscopic cyst resection is the preferred surgical approach when surgery is indicated, offering superior outcomes compared to traditional non-microscopic techniques 4
Indications for surgical excision:
- Persistent symptoms despite conservative management 2
- Large asymptomatic cysts (>1 cm) that fail to regress after 24-48 months of observation 2
- Acute scrotal symptoms due to inflammation, intracystic bleeding, or secondary torsion of the epididymis 2
- Patient preference after failed sclerotherapy 3
Surgical technique considerations:
- Microscopic epididymal exploration and cystectomy significantly reduces complications compared to non-microscopic approaches 4
- Microscopic visualization allows complete intact cyst removal with minimal bleeding (2-3 mL) and no need for wound drainage 4
- Surgery should ideally be performed before the cyst reaches 0.8 cm in diameter to prevent complete destruction of ipsilateral epididymal tubules, which can occur with cysts >0.9 cm 4
- Microscopic technique significantly reduces postoperative scrotal hematoma, edema, and long-term pain while better preserving epididymal patency 4
Critical Pitfalls and Caveats
Distinguish from Testicular Pathology
- Ensure proper ultrasound technique by an experienced ultrasonographer to accurately characterize the extratesticular location and cystic nature 1
- Epididymal cysts are extratesticular and benign; intratesticular cystic lesions require different management algorithms 1
Acute Scrotal Presentation
- Torsion of epididymal cysts is extremely rare but presents as acute scrotum 5, 6
- Diagnosis is typically made intraoperatively during scrotal exploration 5, 6
- If acute scrotal symptoms occur, surgical exploration may be necessary to rule out testicular torsion or other emergencies 2, 5
Postoperative Complications
- Traditional non-microscopic surgery carries high risk of complications including scrotal edema, hematoma, sustained pain, and seminal tract obstruction 4
- Microscopic technique dramatically reduces these complications and is recommended for patients with future fertility concerns 4
- Acute epididymitis can occur postoperatively (reported in approximately 9% of cases) and responds to antibiotic therapy 2