Epididymal Cyst Treatment
For asymptomatic epididymal cysts, observation with clinical follow-up is the recommended approach, while symptomatic cysts require intervention—either surgical excision or percutaneous sclerotherapy, with sclerotherapy offering an effective, less invasive alternative that achieves symptom resolution in 84% of cases.
Initial Assessment and Diagnosis
Epididymal cysts are benign fluid-filled structures that commonly present as painless scrotal masses or are discovered incidentally on ultrasound examination 1, 2.
High-frequency testicular ultrasound (>10 MHz) should be used to confirm the diagnosis, demonstrating an echo-free cystic structure arising from the epididymis and distinguishing it from intratesticular masses 3.
Physical examination must assess both testes, the characteristics of the palpable mass (size, location, consistency), and any associated symptoms such as discomfort or pain 3.
Treatment Algorithm Based on Clinical Presentation
Asymptomatic Epididymal Cysts
Conservative management with clinical follow-up is the treatment of choice for asymptomatic cysts, regardless of size 2, 4.
Serial ultrasound examinations can document stability of the mass over time, particularly in pediatric and adolescent patients 4.
No intervention is required unless the cyst becomes symptomatic or shows concerning changes on follow-up imaging 2.
Symptomatic Epididymal Cysts
For cysts causing discomfort or significant scrotal enlargement, two primary treatment options exist:
Option 1: Percutaneous Sclerotherapy (Preferred for Large Cysts >5 cm)
Ultrasound-guided percutaneous sclerotherapy with 3% Polidocanol achieves technical success in 100% of cases and symptom resolution in 84% of patients after one or two sessions 1.
The procedure is performed on an outpatient basis with ultrasound guidance, involving aspiration of cyst fluid followed by injection of sclerosing agent 1.
Mean fluid evacuation is approximately 36 ml with mean sclerosing agent injection of 4.5 ml 1.
Follow-up at 3,6, and 12 months demonstrates cyst disappearance in 60% of cases after initial treatment, with symptom resolution in 68% 1.
A second sclerotherapy session can be offered if symptoms persist or the cyst remains >5 cm, improving overall success to 84% 1.
Advantages include: no complications, lower cost than surgery, outpatient procedure, and local anesthetic properties of Polidocanol for superficial structures 1.
Option 2: Surgical Excision
Surgical excision is the standard treatment for symptomatic epididymal cysts, particularly in pediatric and adolescent patients 2, 4.
Surgery is indicated when: patients refuse or fail sclerotherapy, cysts are symptomatic despite conservative management, or there is diagnostic uncertainty requiring tissue diagnosis 4.
The procedure involves excision of the cyst with preservation of testicular and epididymal function when possible 5, 4.
Surgical risks include: higher complication rates compared to sclerotherapy, potential impact on fertility, and need for general anesthesia 1.
Special Clinical Scenarios
Torsion of Epididymal Cyst (Rare Emergency)
Torsion of an epididymal cyst is a rare cause of acute scrotal pain that mimics testicular torsion clinically 6, 5.
Ultrasound findings include: a large epididymal cyst with internal echoes, dependent debris, and normal testicular perfusion 6.
Immediate surgical exploration is required when torsion is suspected, with excision of the torted cyst providing definitive treatment 6, 5.
The diagnosis is often made intraoperatively, revealing an inflamed, discolored cyst with rotation on its pedicle (up to 720 degrees reported) 5.
Pediatric and Adolescent Considerations
Epididymal cysts in children are more common than previously recognized but remain underdiagnosed 2, 4.
Conservative management is preferred for asymptomatic cysts discovered on ultrasound, with clinical follow-up to document stability 2, 4.
Surgical excision is recommended only for symptomatic cases in pediatric patients, as the natural history is generally benign 2, 4.
Differential diagnosis must include spermatocele (which contains sperm), testicular tumors, and other scrotal masses 2, 4.
Key Clinical Pitfalls to Avoid
Do not perform routine surgery on asymptomatic cysts, as this exposes patients to unnecessary surgical risks without clinical benefit 1, 2.
Ultrasound is essential but not infallible—some solid epididymal tumors may present with sonographic characteristics of a cyst, requiring careful interpretation 4.
In acute scrotal pain scenarios, always consider torsion of an epididymal cyst in the differential diagnosis, particularly when ultrasound shows a large cyst with internal debris and normal testicular flow 6, 5.
Sclerotherapy should be reserved for cysts >5 cm to optimize success rates and minimize need for repeat procedures 1.