What are the treatment options for epididymis cysts?

Treatment Options for Epididymal Cysts

Conservative management with observation is the recommended first-line approach for asymptomatic or minimally symptomatic epididymal cysts, with surgical excision reserved for persistent pain, large cysts (>5 cm), or failed sclerotherapy. 1, 2

Initial Management Strategy

Observation and Conservative Management

• Asymptomatic epididymal cysts require no intervention beyond clinical follow-up to document stability of the mass. 3, 4
• Complete spontaneous involution occurs in approximately 33% of cases (14/42 patients), with an average involution time of 11.2 months. 2
• Size reduction without complete resolution occurs in an additional 48% of cases (20/42 patients). 2
• Conservative management is particularly appropriate for cysts <5 cm in diameter without significant symptoms. 5

When to Escalate Treatment

• Persistent scrotal pain despite conservative measures warrants intervention. 2
• Cysts >5 cm in diameter that cause discomfort should be treated. 5
• Lack of involution or size reduction during follow-up may justify intervention in symptomatic patients. 2

Interventional Treatment Options

Percutaneous Sclerotherapy (Second-Line)

Sclerotherapy with 3% Polidocanol is an effective minimally invasive option for symptomatic cysts >5 cm, achieving symptom resolution in 84% of patients after one or two sessions. 5

• Technical success rate is 100% with ultrasound guidance. 5
• After initial treatment, 68% of patients are symptom-free at 3-6 months, with complete cyst disappearance in 60%. 5
• A second sclerotherapy session increases success to 84% symptom-free patients. 5
• The procedure is performed on an outpatient basis with no reported complications. 5
• Polidocanol is ideal for superficial structures due to its local anesthetic properties. 5
• This approach is significantly less costly than surgery. 5

Surgical Excision (Third-Line)

Microscopic cyst resection is the preferred surgical technique when intervention is necessary, offering superior outcomes compared to conventional nonmicroscopic approaches. 6

Indications for Surgery

• Intractable scrotal pain unresponsive to conservative management. 2
• Failed sclerotherapy. 1
• Very large cysts causing significant symptoms. 1
• Complications such as torsion. 1
• No cyst involution observed during prolonged follow-up. 2

Microscopic vs. Nonmicroscopic Technique

• Microscopic epididymal exploration and cystectomy significantly reduces postoperative complications including hematoma, edema, and chronic pain. 6
• Microscopic visualization allows complete intact cyst removal with minimal bleeding (2-3 mL). 6
• The technique better preserves epididymal patency through refined dissection of subtle tissue structures. 6
• Surgical success rates and recurrence prevention are superior with microscopic approaches. 6
• Surgery should ideally be performed before the cyst reaches 0.8 cm in diameter, as larger cysts (>0.9 cm) may cause complete destruction of ipsilateral epididymal tubules. 6

Surgical Considerations

• Conventional nonmicroscopic surgery carries higher risks of postoperative edema, hematoma, sustained pain, and seminal tract obstruction. 6
• These complications have historically made surgeons cautious about recommending surgery for patients with future childbirth plans. 6
• Wound drainage is not required with microscopic technique. 6

Critical Diagnostic Considerations

Essential Workup

• Scrotal ultrasonography is mandatory to confirm the diagnosis and characterize the cyst as an echo-free epididymal structure. 3, 4
• Physical examination alone is insufficient for diagnosis. 3
• Testicular torsion must be ruled out, as it is a surgical emergency that can present with similar symptoms. 1

Differential Diagnosis

• Spermatocele (contains sperm, typically post-pubertal). 4
• Other scrotal cystic masses. 3
• Solid epididymal tumors that may mimic cystic characteristics on ultrasound. 3

Common Pitfalls to Avoid

• Do not rush to surgery for asymptomatic or minimally symptomatic cysts, as spontaneous resolution occurs in a substantial proportion of cases. 2
• Avoid performing surgery without first attempting sclerotherapy in appropriate candidates (symptomatic cysts >5 cm). 5
• Do not use conventional nonmicroscopic surgical techniques when microscopic approaches are available, given the significantly lower complication rates. 6
• Avoid delaying surgery in patients with persistent pain or very large cysts after failed conservative management. 2