Management of Scrotal Wall Cysts
For a scrotal wall cyst not communicating with the testicle, conservative observation is the appropriate initial management, with surgical excision reserved for symptomatic cases (persistent pain, infection, or cosmetic concerns).
Initial Diagnostic Approach
Ultrasound confirmation is essential to definitively establish that the cyst is within the scrotal wall and does not communicate with the testicular parenchyma 1. High-resolution scrotal ultrasound (7.5 MHz transducer) should demonstrate:
- An anechoic or hypoechoic mass separate from the testis 1
- Well-defined walls with posterior acoustic enhancement 2
- No internal vascularity on Doppler evaluation 1, 3
This imaging is critical to exclude intratesticular pathology, which would require entirely different management including potential orchiectomy 3.
Conservative Management Strategy
Observation is the preferred initial approach for asymptomatic scrotal wall cysts 4, 2. The evidence supporting this includes:
- Spontaneous resolution occurs in a significant proportion of cases: Complete involution was documented in 33% of epididymal cysts (14/42 patients) with an average time of 11.2 months, and size reduction occurred in an additional 48% 4
- Benign natural history: Scrotal wall cysts (epidermoid cysts, sebaceous cysts, trichilemmal cysts) follow a benign course with malignant transformation being extremely rare 5, 6
Follow-up protocol during observation:
- Serial physical examinations every 3-6 months 4
- Repeat ultrasound if clinical change occurs 1
- Patient education about warning signs (rapid growth, pain, infection) 4
Indications for Surgical Excision
Surgery should be performed when:
- Persistent or intractable scrotal pain that impacts quality of life 4
- Infection or inflammation of the cyst 5, 6
- No involution observed during extended follow-up (typically >12-18 months) 4
- Cosmetic concerns causing significant patient distress 5, 6, 7
- Diagnostic uncertainty despite imaging, particularly if solid components are present 1, 3
Surgical Technique
For solitary or few cysts, simple excision with primary closure is appropriate 4, 6.
For multiple cysts or extensive involvement, subtotal excision of the scrotal wall using tumescent anesthesia provides excellent outcomes 6:
- This approach has demonstrated excellent cosmetic results with minimal complications 6
- Low morbidity and early discharge 5
- Rare recurrence during follow-up 6
For massive scrotal wall involvement, complete scrotal wall resection followed by scrotoplasty with thigh fasciocutaneous flap coverage may be necessary 5, 7.
Critical Pitfalls to Avoid
Never perform scrotal violation (scrotal incision) for suspected testicular pathology 1. If there is any uncertainty about whether the mass communicates with the testis:
- Inguinal approach is mandatory if testicular involvement cannot be excluded 1
- Scrotal violation can lead to altered lymphatic drainage and potential tumor spread if malignancy is present 8
Do not assume all scrotal masses are benign cysts 3. Any solid component, complex features, or associated hydrocele requires exclusion of testicular tumor with tumor markers (AFP, β-HCG, LDH) and potential urology referral 1, 3.
Special Considerations
Histopathological examination is essential after excision to confirm the diagnosis 6:
- Most scrotal wall nodules are non-calcified epidermoid cysts 6
- Some may show dystrophic calcification (scrotal calcinosis) 6
- Rare cases may be trichilemmal cysts or sebaceous cysts 5, 7
Screening for metabolic abnormalities (calcium, phosphate) is generally negative and not routinely indicated unless multiple calcified lesions are present 6.