What is the appropriate management for a patient presenting with a scrotal pearl, potentially an epidermoid cyst?

Management of Scrotal Pearls (Epidermoid Cysts)

For scrotal pearls (epidermoid or sebaceous cysts), confirm diagnosis with scrotal ultrasound, then manage conservatively if asymptomatic or perform surgical excision if inflamed, symptomatic, or concerning for malignancy. 1

Diagnostic Confirmation

Initial imaging is essential to differentiate scrotal pearls from other pathology:

• Obtain scrotal ultrasound with Doppler as the first-line imaging modality to confirm the diagnosis and exclude testicular masses, spermatoceles, or other scrotal pathology 2, 1
• Scrotal pearls appear as well-defined, hypoechoic or anechoic lesions with smooth borders on ultrasound 1
• Ultrasound has high sensitivity and specificity for differentiating solid from cystic masses and can characterize the relationship to the testis 3

Treatment Algorithm

For Asymptomatic Scrotal Pearls:

• Observation is appropriate for small, asymptomatic cysts with typical benign ultrasound features 1
• Educate patients to monitor for changes in size, pain, or signs of infection 1

For Inflamed or Symptomatic Cysts:

• Treat acute inflammation first with warm compresses before attempting definitive excision, as inflamed cysts are difficult to excise completely 1
• Consider systemic antibiotics only if there is extensive surrounding cellulitis, systemic signs of infection, multiple lesions, or severely impaired host defenses 1
• Perform incision and drainage for acutely inflamed epidermoid cysts as recommended by the Clinical Infectious Diseases society 1
• Postpone definitive surgical excision until inflammation has subsided to ensure complete removal and minimize recurrence 1

For Definitive Surgical Management:

• Complete surgical excision with removal of the entire cyst wall is the treatment of choice to prevent recurrence 1, 4
• Most cases can be performed under local anesthesia with a low complication rate (approximately 2.2%) 4
• Send all excised specimens for histopathological examination to confirm diagnosis and exclude malignancy 1, 5, 4

Critical Pitfalls to Avoid

Do not assume all scrotal lesions are benign:

• Malignant transformation of epidermoid cysts into squamous cell carcinoma, though rare, has been documented 5
• Maintain a low threshold for excision and histological examination if there are unusual clinical features, rapid growth, or suspicion of malignancy 1, 5
• Free-floating scrotal calculi (scrotoliths) can mimic tumors and should be considered in the differential diagnosis 6, 7

Do not attempt excision during acute inflammation:

• Inflamed cysts are difficult to excise completely, leading to higher recurrence rates 1
• Treat inflammation first, then perform elective excision 1

Follow-Up Recommendations

• Advise patients to seek medical attention if they develop new cysts or signs of infection at the surgical site 1
• Monitor for recurrence if incomplete excision occurred 4