What is the treatment recommendation for an adult patient with symptomatic hydrocele and bilateral 5mm epidermal (skin) cysts?

Treatment of Symptomatic Hydrocele and Bilateral 5mm Epidermal Cysts

For symptomatic hydrocele, surgical excision via scrotal approach is the definitive treatment, while bilateral 5mm epidermal cysts require incision and drainage only—cultures and antibiotics are unnecessary unless systemic signs of infection are present. 1

Management of Symptomatic Hydrocele

Surgical Intervention

• Surgery is the gold standard for symptomatic hydrocele causing functional impairment or discomfort. 2
• The two principal surgical techniques are Lord's plication procedure and excision (Winkelmann's or Bergman's procedure), both performed through a scrotal incision. 2, 3
• Winkelmann's procedure (61% of cases) and Bergman's procedure (33% of cases) have proven highly satisfactory with low complication rates when proper surgical technique is employed. 3
• A novel pull-through technique through a 15mm transverse scrotal incision achieves 95% cure rate with minimal complications, allowing patients to resume normal activity within an average of 6 days. 4

Alternative for High-Risk Patients

• For patients unfit for general anesthesia or surgery, aspiration and sclerotherapy with sodium tetradecyl sulphate (STDS) achieves 76% cure rate after single injection and 94% after multiple treatments. 5
• STDS has the best cure rate among sclerosing agents with low side effect rates and 95% patient satisfaction at 40 months follow-up. 5
• Complication rates with aspiration/sclerotherapy are much lower than surgical repair, with shorter recovery times. 5

Common Pitfalls

• Main surgical complications include hematoma, injury to epididymis, vas deferens, or cord structures—these occur primarily with poor surgical technique, damaged local tissue, or inadequate hemostasis. 2, 3
• Scrotal ultrasonography is mandatory if the testicle is nonpalpable to rule out underlying testicular mass requiring inguinal exploration rather than scrotal approach. 6

Management of Bilateral 5mm Epidermal Cysts

Primary Treatment

• Incision and drainage is the recommended treatment for inflamed epidermoid cysts. 1
• Gram stain and culture of pus from inflamed epidermoid cysts are NOT recommended. 1

When to Add Antibiotics

• Antibiotics directed against S. aureus should be added only if systemic inflammatory response syndrome (SIRS) is present: temperature >38°C or <36°C, tachypnea >24 breaths/minute, tachycardia >90 beats/minute, or white blood cell count >12,000 or <4,000 cells/µL. 1
• An antibiotic active against MRSA is recommended for patients with markedly impaired host defenses or SIRS. 1
• Simply covering the incision site with sterile gauze after drainage is usually the most effective wound treatment—packing causes more pain without improving healing. 1

Pitfalls to Avoid

• Do not routinely culture or prescribe antibiotics for simple inflamed epidermal cysts without systemic signs of infection. 1
• Ultrasonographically guided needle aspiration is not recommended—it has only 25% success rate overall and <10% success with MRSA infections. 1