What is the treatment for a scrotal cyst?

Treatment of Scrotal Cysts

For scrotal cysts, initial management depends on whether the cyst is symptomatic and its location: asymptomatic simple cysts can be observed, while symptomatic cysts should be treated with parenchyma-sparing surgical excision or percutaneous sclerotherapy for epididymal cysts. 1, 2

Diagnostic Confirmation First

Before any treatment decision, scrotal ultrasound with Doppler is mandatory to definitively characterize the lesion and exclude malignancy. 3, 4 The American College of Radiology emphasizes that ultrasound is 98-100% accurate in differentiating intratesticular from extratesticular processes, which is critical since intratesticular lesions carry higher malignancy risk. 3, 4

Key ultrasound findings for simple cysts include:

• Anechoic mass with well-defined walls 1
• Enhanced posterior through-transmission 1
• Edge shadowing 1
• No internal vascularity on Doppler 3

Treatment Algorithm by Location and Symptoms

Intratesticular Simple Cysts

Asymptomatic intratesticular cysts:

• Observation alone is appropriate 1
• No intervention required if ultrasound confirms benign characteristics 1

Symptomatic intratesticular cysts:

• Local parenchyma-sparing excision is the ideal treatment 1
• This preserves testicular function while removing the symptomatic lesion 1

Epididymal Cysts

Conservative management:

• Up to 60% of epididymal cysts in pediatric patients regress spontaneously over 4-50 months 5
• Observation is recommended for asymptomatic or minimally symptomatic cysts 5, 2

Active treatment indications:

• Cysts >5 cm in diameter causing symptoms 2
• Persistent testicular pain 5
• Patient anxiety about increasing paratesticular mass 5

Treatment options for symptomatic epididymal cysts:

1. Percutaneous sclerotherapy (preferred minimally invasive option):

   • 84% success rate in achieving symptom resolution 2
   • Performed with ultrasound guidance using 3% Polidocanol 2
   • Outpatient procedure with no reported complications 2
   • Significantly lower cost than surgery 2
   • May require repeat session in some cases (performed in 4/25 patients in one series) 2

2. Surgical excision:

   • Standard treatment but carries higher complication risk than sclerotherapy 2
   • Reserved for sclerotherapy failures or patient preference 2
   • Complete excision via scrotal incision 5

Cutaneous Scrotal Cysts

For multiple superficial scrotal wall cysts:

• Short-pulsed 910-nm diode laser treatment provides rapid improvement with excellent aesthetic results 6
• Standard surgical removal remains an option 6

Critical Pitfalls to Avoid

Never assume a scrotal mass is benign without imaging confirmation. The American College of Radiology states that duplex ultrasound cannot definitively differentiate malignancies from benign conditions like dermoid cysts, granulomas, or focal fibrosis. 3 Any solid or mixed cystic lesion requires additional imaging or surgical exploration. 3

Do not delay imaging for presumed inflammatory conditions without confirming the diagnosis, as this can miss testicular malignancies. 4

Avoid treating non-palpable varicoceles identified incidentally on ultrasound, as treatment is not associated with improvement in semen parameters or fertility rates. 3

Distinguish scrotoliths from testicular microlithiasis: The Journal of Urology confirms that testicular microlithiasis (an intratesticular finding) does not require treatment in the absence of solid masses or risk factors for germ cell tumors. 7