Are cysts typically hard on palpation?

Are Cysts Hard on Palpation?

Cysts are typically not hard on palpation—they are usually soft, mobile, and well-circumscribed, though they cannot reliably be distinguished from solid masses by physical examination alone, which is why imaging is essential for definitive characterization. 1

Physical Examination Characteristics

Simple and Complicated Cysts

• Simple cysts are fluid-filled structures that feel soft or fluctuant on palpation, with smooth, well-defined margins and mobility within the tissue. 1
• Complicated cysts (containing internal debris or low-level echoes but no solid components) also present as soft, mobile masses that cannot be reliably distinguished from simple cysts by palpation alone. 1
• Only 58% of palpable breast cysts were correctly identified as cystic by physical examination in one study, demonstrating the unreliability of palpation for determining cyst consistency. 1

Complex Cysts

• Complex cysts (containing discrete solid components, thick walls, thick septa, or intracystic masses) may feel firmer than simple cysts due to their solid elements, but they still cannot be definitively characterized by palpation. 1, 2
• The presence of solid components increases firmness, but this finding overlaps significantly with solid benign and malignant masses. 1, 2

Contrast with Solid Masses

Benign Solid Masses

• Benign solid masses typically feel mobile with discrete, well-defined margins and a soft or rubbery texture—similar to how cysts may feel. 1

Malignant Masses

• Cancerous masses are typically firm to hard, with indistinct borders, and may have attachments to skin or deep fascia causing dimpling or nipple retraction—distinctly different from typical cyst characteristics. 1

Critical Limitation of Palpation

• Physical examination alone cannot reliably differentiate cysts from solid masses, with significant disagreement even among experienced examiners (four surgeons agreed on biopsy indication in only 73% of 15 subsequently proven malignant masses). 1
• Imaging evaluation with ultrasound is necessary in almost all cases to definitively characterize a palpable lesion as cystic versus solid and to identify any solid components within cystic lesions. 1, 2

Location-Specific Considerations

Breast Cysts

• Breast cysts are classified as simple, complicated, or complex based on ultrasound characteristics, not palpation findings. 1
• Cysts meeting all criteria of a simple cyst on ultrasound are benign (BI-RADS 2) if clinical and ultrasonographic findings are concordant. 1

Scrotal Cysts

• Scrotal cystic lesions typically present as palpable lumps but require high-resolution ultrasonography to characterize architecture and confirm benign versus complex features. 3, 4, 5

Pericardial Cysts

• Pericardial cysts are usually asymptomatic and detected incidentally on imaging rather than by palpation. 1

Common Pitfalls to Avoid

• Never rely on palpation alone to determine whether a mass is cystic or solid—the sensitivity and specificity are inadequate for clinical decision-making. 1
• Do not assume a soft, mobile mass is benign—many benign solid masses have similar palpation characteristics to cysts, and imaging is required for differentiation. 1
• Do not confuse complex cysts with simple cysts—complex cysts contain solid components and carry a 14-23% malignancy risk, mandating biopsy rather than observation. 1, 2, 3