Management of Epididymal Cysts
Asymptomatic Epididymal Cysts: Observation is Recommended
For asymptomatic epididymal cysts, observation with clinical follow-up is the appropriate management strategy, as approximately 50% of these cysts involute spontaneously within an average of 17 months. 1, 2
High-frequency testicular ultrasound (>10 MHz) should be performed 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
For asymptomatic cysts smaller than 1 cm in diameter, conservative management with observation is recommended. 1
For large asymptomatic cysts greater than 1 cm in diameter that do not regress after 24-48 months of follow-up, surgical excision should be considered. 1
Average time to complete regression is 17 months, with resolution occurring in approximately 50% of cases during conservative management. 1, 2
Symptomatic Epididymal Cysts: Two Primary Treatment Options
For symptomatic epididymal cysts, percutaneous sclerotherapy is recommended as the first-line treatment, achieving symptom resolution in 84% of cases with minimal complications, while surgical excision remains an effective alternative. 3, 4
Percutaneous Sclerotherapy (Preferred Initial Approach)
Sclerotherapy offers an effective, less invasive alternative that achieves symptom resolution in 84% of cases. 3, 4
The procedure is performed on an outpatient basis with ultrasound guidance using 3% Polidocanol as the sclerosing agent. 4
Technical success rate is 100%, with mean fluid evacuation of 36 ml and mean sclerosing agent injection of 4.5 ml. 4
After initial treatment, 68% of patients are symptom-free at 3-6 months, with cyst disappearance in 60% of cases. 4
A second session may be required if symptoms persist or the cyst remains larger than 5 cm in diameter, increasing the success rate to 84%. 4
The procedure is safe, effective, free of complications, and less costly than surgical excision. 4
Surgical Excision (Alternative or Second-Line)
Surgical excision is indicated for cysts responsible for persistent symptoms regardless of diameter, particularly when sclerotherapy fails or is not feasible. 1
Microscopic cyst resection is superior to traditional nonmicroscopic techniques, significantly reducing postoperative complications including scrotal hematoma, edema, and long-term pain. 5
Surgery should ideally be performed before the epididymal cyst reaches 0.8 cm in diameter, as larger cysts (>0.9 cm) can cause complete destruction of all tubules of the ipsilateral epididymis. 5
Microscopic manipulation provides improved visualization of subtle epididymal tissue structures, allowing complete intact cyst removal with minimal bleeding (2-3 mL) and no requirement for wound drainage. 5
Postoperative complications are minimal with microscopic technique, though acute ipsilateral epididymitis may occur (successfully treated with antibiotics). 1
Acute Presentations Requiring Urgent Evaluation
For acute scrotal symptoms due to inflammation, intracystic bleeding, or secondary torsion of the epididymis, urgent ultrasound evaluation is necessary to rule out testicular torsion. 6
A twisted cyst may appear as a large mass connected to the epididymal head on ultrasound examination. 6
Surgical exploration and cyst removal are indicated for acute symptomatic presentations. 1
Critical Clinical Pitfalls to Avoid
Do not perform premature surgical intervention for small asymptomatic cysts that are likely to resolve spontaneously within 17 months. 6, 2
Always distinguish epididymal cysts from testicular masses, which have entirely different management implications and may require oncologic evaluation. 6
Despite ultrasound findings, maintain awareness that some solid epididymal tumors may present with all sonographic characteristics of a cyst, necessitating careful clinical correlation. 7
Traditional nonmicroscopic surgical techniques carry high risks of complications including postoperative edema, hematoma, sustained pain, and seminal tract obstruction—microscopic techniques should be preferred when surgery is indicated. 5