What is the recommended treatment for an epididymal cyst?

Treatment of Epididymal Cysts

For asymptomatic epididymal cysts, observation is the recommended approach, as these are benign lesions that frequently resolve spontaneously, particularly in adolescents where approximately 50% involute within 17 months. 1

Initial Management Strategy

Asymptomatic Cysts

• Cysts <1 cm in diameter should be managed conservatively with observation alone, as they have high rates of spontaneous resolution 1
• Cysts >1 cm but <5 cm should be observed for 24-48 months before considering intervention, even if asymptomatic, as many will regress during this period 1
• Routine follow-up ultrasound at 6-12 month intervals is reasonable to document stability or regression 2

Symptomatic Cysts

• Surgical excision is indicated for symptomatic cysts causing persistent pain, discomfort, or functional impairment, regardless of size 1
• For symptomatic cysts >5 cm, either surgical excision or percutaneous sclerotherapy are appropriate first-line treatments 3

Treatment Options for Symptomatic Disease

Percutaneous Sclerotherapy

• Sclerotherapy with 3% Polidocanol under ultrasound guidance achieves symptom resolution in 84% of cases after one or two sessions, making it a valid alternative to surgery 3
• This approach has 100% technical success, no reported complications, and is performed on an outpatient basis 3
• Mean fluid evacuation is approximately 36 mL with 4.5 mL of sclerosing agent injected 3
• After initial treatment, 68% of patients are symptom-free at 3-6 months, with 60% showing complete cyst disappearance 3
• A second sclerotherapy session can be offered if symptoms persist or the cyst remains >5 cm at follow-up, improving success rates to 84% 3

Surgical Excision

• Surgical removal is the definitive treatment and should be performed for cysts that fail conservative management or sclerotherapy 1, 4
• Surgery is mandatory for acute presentations with suspected torsion, inflammation, or intracystic hemorrhage 1
• Postoperative recovery is typically uncomplicated with immediate symptom relief 1
• The main drawback is higher complication risk compared to sclerotherapy, though specific rates are not detailed in the evidence 3

Aspiration Alone

• Simple aspiration without sclerotherapy can provide temporary relief but has high recurrence rates 4
• May be considered as a temporizing measure in select cases, though sclerotherapy is preferred for definitive non-surgical management 4

Acute Presentations Requiring Emergency Intervention

Any adolescent or young adult presenting with acute scrotal pain and a known or suspected epididymal cyst requires urgent surgical exploration to rule out torsion, as torsion of epididymal cysts can occur with 180-720° rotation and may be associated with concurrent testicular torsion 4, 5

• Ultrasound findings suggestive of torsion mandate immediate scrotal exploration 4
• Emergency surgery should include detorsion if viable, cyst excision, and testicular fixation if indicated 4, 5
• Delayed diagnosis can compromise testicular viability when synchronous testicular torsion is present 4

Age-Specific Considerations

Pediatric and Adolescent Patients

• Epididymal cysts in prepubertal boys are more common than previously recognized and are typically benign 2
• Conservative management is the treatment of choice in the majority of pediatric cases, as these cysts are self-limiting 2
• Frequency of epididymal cysts doubles after age 14-15 years 1
• Parents should be counseled that observation is safe and appropriate for asymptomatic lesions 2

Adult Patients

• Epididymal cysts are common benign findings in adults, typically presenting as painless scrotal enlargements 3
• Treatment indications are identical to younger patients: observation for asymptomatic lesions, intervention for symptomatic disease 3

Common Pitfalls and Caveats

• Do not confuse epididymal cysts with spermatoceles—while often used interchangeably, they are distinct entities best differentiated by ultrasound 2
• Avoid routine surgical intervention for small asymptomatic cysts, as this exposes patients to unnecessary operative risks when natural resolution is likely 1, 2
• Maintain high clinical suspicion for torsion in any acute presentation, even with a known benign cyst, as torsion is a surgical emergency 4, 5
• Be aware that epididymal cysts may be associated with other urogenital malformations or complex syndromes, warranting comprehensive evaluation in some cases 2
• Post-excision acute epididymitis can occur (reported in approximately 10% of cases) and responds well to antibiotic therapy 1