Epididymal Cyst Management
For asymptomatic epididymal cysts, observation with clinical follow-up is the recommended approach, while symptomatic cysts larger than 5 cm should be treated with either surgical excision or percutaneous sclerotherapy, with sclerotherapy offering an 84% success rate and fewer complications than surgery.
Initial Evaluation and Diagnosis
Ultrasound is essential to confirm the diagnosis and differentiate epididymal cysts from other scrotal pathology, showing characteristic echo-free cystic structures in the epididymis 1, 2.
Rule out testicular torsion immediately in any patient presenting with acute scrotal pain, especially in adolescents, as this is a surgical emergency that can compromise testicular viability 3, 4.
Physical examination typically reveals a painless testicular enlargement on palpation, though symptomatic cysts may cause discomfort 5.
Treatment Algorithm Based on Symptoms and Size
Asymptomatic Cysts
Conservative management with clinical follow-up is the treatment of choice for asymptomatic epididymal cysts regardless of size 1, 2.
Document stability of the mass over time with periodic clinical examination 2.
No intervention is required unless symptoms develop 1.
Symptomatic Cysts
For cysts >5 cm with symptoms:
Percutaneous sclerotherapy with 3% Polidocanol is a highly effective first-line option, achieving symptom resolution in 84% of cases after one or two sessions 5.
The procedure is performed on an outpatient basis with ultrasound guidance, has 100% technical success, no complications, and lower costs than surgery 5.
Surgical excision remains the traditional standard treatment but carries higher risk of complications including damage to the epididymis, vas deferens, and potential fertility issues 5, 2.
For cysts <5 cm with symptoms:
Consider conservative management first, as many will resolve spontaneously 1.
If symptoms persist or worsen, proceed with sclerotherapy or surgical excision 2.
Special Considerations in Children and Adolescents
Epididymal cysts in prepubertal children are more common than previously recognized and are usually congenital abnormalities related to embryonic hormonal disorders 1, 2.
Symptomatic cysts in children require surgical excision rather than sclerotherapy, as this is the established treatment approach in pediatric populations 2.
Asymptomatic cysts diagnosed by ultrasound in children warrant clinical follow-up to document stability rather than immediate intervention 2.
Emergency Complications Requiring Immediate Surgery
Torsion of an epididymal cyst is rare but presents with acute scrotal pain mimicking testicular torsion 6, 4.
Ultrasound may show a large epididymal cyst with internal echoes and dependent debris, suggesting torsion 4.
Emergency surgical exploration is required, with excision of the torted cyst providing immediate symptomatic relief 6, 4.
Large cysts (>5 cm) are more prone to torsion complications 6.
Common Pitfalls to Avoid
Do not assume all acute scrotal pain is testicular torsion—consider epididymal cyst torsion in patients with known cysts presenting with acute pain 4.
Do not perform surgery on asymptomatic cysts discovered incidentally on ultrasound, as this exposes patients to unnecessary surgical risks 1, 2.
Do not confuse epididymal cysts with spermatoceles—while similar, spermatoceles contain sperm and occur post-puberty, whereas epididymal cysts can occur in prepubertal children 1.
Ultrasound is mandatory before any intervention, as some solid epididymal tumors can mimic cystic lesions sonographically 2.