What is the treatment for epididymal cyst and hydrocele?

Treatment of Epididymal Cysts and Hydroceles

Critical Distinction: These Are NOT Infectious Conditions

The provided guidelines address epididymitis (infection/inflammation), NOT epididymal cysts or hydroceles, which are benign fluid collections requiring completely different management. The question asks about cyst and hydrocele treatment, not infectious epididymitis.

Management Algorithm for Epididymal Cysts and Hydroceles

Asymptomatic Lesions

• Observation only is appropriate for asymptomatic epididymal cysts and hydroceles 1, 2, 3
• No intervention is required unless symptoms develop 4

Symptomatic Lesions: Treatment Options

First-Line: Percutaneous Sclerotherapy

For symptomatic epididymal cysts and hydroceles in patients over 40 years, sclerotherapy should be the primary treatment approach 3, 4

Sclerotherapy technique and outcomes:

• Performed as outpatient procedure with ultrasound guidance 4
• Aspiration of fluid followed by injection of sclerosing agent 1, 2, 3

Agent selection:

• Polidocanol (3%): Preferred for its local anesthetic properties, particularly suitable for delicate scrotal structures 3, 4

  • Hydroceles: 67% cure rate after single treatment, 87% overall cure rate 3
  • Epididymal cysts: 46% cure rate after single treatment, 64% overall cure rate, improving to 84% with repeat treatment 3, 4

• Tetracycline: Alternative sclerosing agent 1, 2

  • Hydroceles: 77% long-term cure rate (24-39 months follow-up) 1
  • Epididymal cysts: Nearly 100% success rate at 9 months 2
  • Pain after instillation can be prevented with prophylactic spermatic cord block 2

• Sodium tetradecyl sulphate (STD): Another effective option 5

  • Initial success rate 76%, improving to 94% with multiple treatments 5

Key advantages of sclerotherapy:

• Quick, safe, and cost-effective 1, 4
• Allows palpation of testis and cytological examination of aspirated fluid 1
• Low complication rate 3, 4
• 94% patient satisfaction 3

Important Timing Consideration

• Do not operate on early recurrences (within 3 months) as they often result from chemical inflammation and resolve spontaneously 1
• Reassess at 3 months before considering surgical intervention 1

Second-Line: Surgical Excision

• Reserved for sclerotherapy failures after multiple attempts 3, 5
• Consider for patients who decline sclerotherapy 4
• Important caveat: Surgery carries higher risk of complications compared to sclerotherapy 4

Treatment Criteria

• Size threshold: Treat symptomatic cysts >5 cm in diameter 4
• Symptoms warranting treatment include pain, discomfort, or bothersome enlargement 4

Follow-Up Protocol

• Assess at 3,6, and 12 months post-sclerotherapy 4
• If symptoms persist or cyst remains >5 cm, offer repeat sclerotherapy session 4
• Most recurrences occur early and may resolve without intervention 1

Common Pitfall to Avoid

Do not confuse epididymal cysts/hydroceles with acute epididymitis. The guidelines provided 6 address infectious epididymitis requiring antibiotics, which is an entirely different condition from benign fluid collections that require mechanical drainage or sclerotherapy, not antimicrobial therapy.