What is the diagnosis and recommended treatment for a patient with a lump on their left testicle and ultrasound findings showing multiple cysts within the left epididymis?

Diagnosis and Management of Left Epididymal Cysts

The diagnosis is benign epididymal cysts of the left epididymis, and the recommended treatment is conservative management with reassurance and observation, as these are benign lesions that do not require intervention unless symptomatic. 1, 2

Diagnosis

The ultrasound findings confirm multiple cysts within the left epididymis (up to 2.1 cm) with normal bilateral testes and normal testicular blood flow, which is diagnostic of benign epididymal cysts. 3

Key diagnostic points from the imaging:

• No intratesticular masses present - this is the critical finding that rules out testicular cancer, as ultrasound is nearly 100% sensitive for detecting intratesticular masses and 98-100% accurate for distinguishing intratesticular from extratesticular processes. 3
• Normal testicular size and echogenicity bilaterally - excludes testicular atrophy or other parenchymal abnormalities. 3
• Normal vascular flow on Doppler - excludes torsion or vascular compromise. 3
• Extratesticular location of cysts - most extratesticular masses are benign, unlike intratesticular masses which require aggressive evaluation. 4

Recommended Management

Conservative Approach (Primary Recommendation)

Observation with reassurance is the treatment of choice for asymptomatic or minimally symptomatic epididymal cysts. 2, 5

• No surgical intervention is needed unless the patient develops persistent, bothersome symptoms (pain, discomfort) or the cyst significantly enlarges. 6, 2
• Approximately 50-60% of epididymal cysts involute spontaneously within an average of 17 months (range 4-50 months), particularly in younger patients. 6, 5
• Patient education on testicular self-examination should be provided to monitor for any changes. 1

Indications for Intervention (If Needed)

Surgery or sclerotherapy should only be considered if:

• Persistent symptoms (pain, discomfort) that significantly affect quality of life. 7, 6
• Large cysts (>5 cm) that do not regress after 24-48 months of observation. 7, 6
• Acute scrotal symptoms due to cyst complications (inflammation, intracystic bleeding, or secondary torsion). 6

Intervention Options (If Conservative Management Fails)

1. Percutaneous sclerotherapy (preferred minimally invasive option):

   • 84% success rate for symptomatic relief with low complication rates. 7
   • Performed with ultrasound guidance using 3% Polidocanol as sclerosing agent. 7
   • Safer, less costly, and fewer complications than surgery. 7

2. Surgical excision:

   • Reserved for failed sclerotherapy or patient preference. 6, 5
   • Can be performed via scrotal approach for confirmed benign extratesticular lesions. 5

Critical Reassurance Points

The patient can be definitively reassured that:

• This is NOT testicular cancer - the ultrasound clearly shows normal testicular parenchyma with no intratesticular masses. 3
• Epididymal cysts are benign and extremely common, particularly in adolescents and young adults. 2, 4
• No urgent treatment is required - this is a self-limiting condition in the majority of cases. 2, 5
• Fertility is not affected by simple epididymal cysts. 2

Common Pitfalls to Avoid

• Do not perform testicular biopsy or orchiectomy - the ultrasound definitively shows extratesticular pathology with normal testes. 3
• Do not order tumor markers (AFP, β-HCG, LDH) - these are only indicated when an intratesticular mass is present. 3
• Avoid premature surgical intervention - most cases resolve spontaneously, and surgery carries risks including epididymitis (reported in up to 10% post-operatively). 6, 5
• Do not confuse with intratesticular pathology - the distinction between intra- and extratesticular location is critical for management, as intratesticular masses require aggressive evaluation for malignancy. 3, 4