In an asymptomatic 69-year-old man with bilateral epididymal head cysts (right 0.8 cm) and a right intratesticular simple cyst (0.6 cm) containing layered debris on scrotal ultrasound, what is the most likely diagnosis and recommended management?

Diagnosis and Management of Bilateral Epididymal Cysts and Intratesticular Cyst with Debris

In this asymptomatic 69-year-old man, the bilateral epididymal head cysts are benign and require no treatment, while the 0.6 cm intratesticular cyst with layering debris warrants clinical correlation but likely represents a benign simple cyst given the patient's age and lack of symptoms.

Diagnosis

Epididymal Cysts

• Bilateral epididymal head cysts (up to 0.8 cm) are benign extratesticular lesions that are extremely common findings on scrotal ultrasound and do not require intervention when asymptomatic. 1
• Epididymal cysts are the most common finding in patients referred for testicular evaluation, accounting for 27% of all scrotal masses in one large series. 2
• These cysts are benign sac-like structures that are typically asymptomatic and considered self-limiting in the majority of cases. 3

Intratesticular Cyst with Debris

• The 0.6 cm right testicular cyst with layering debris requires careful interpretation because ultrasound cannot definitively differentiate benign from malignant intratesticular lesions. 1
• However, simple intratesticular cysts are almost certainly benign (<1% malignancy risk) when they demonstrate smooth thin walls, acoustic enhancement, and anechoic appearance. 1
• The presence of "layering debris" may represent proteinaceous material, hemorrhage, or inflammatory debris rather than solid tissue, which can occur in benign cysts. 4
• Palpable intratesticular lesions carry approximately 90% malignancy risk, but non-palpable small cysts detected incidentally on ultrasound have much lower risk. 2

Management Algorithm

For the Bilateral Epididymal Cysts

No treatment is indicated for asymptomatic epididymal cysts regardless of size. 3, 4

• Reassurance that these are benign findings is appropriate. 3
• Treatment is only considered if the patient develops symptoms (pain, discomfort, or significant enlargement causing distress). 5
• If symptoms develop in the future, options include:
  • Percutaneous sclerotherapy with 3% Polidocanol achieves 84% symptom resolution with minimal complications for cysts >5 cm. 5
  • Microscopic epididymal cyst resection is recommended for symptomatic cysts, particularly those >0.8 cm, to preserve epididymal patency and reduce postoperative complications. 6

For the Intratesticular Cyst with Debris

The key decision point is whether this represents a true simple cyst versus a complex or solid lesion:

Step 1: Clinical Correlation

• Confirm the patient is truly asymptomatic with no palpable testicular mass on physical examination. 1
• Obtain serum tumor markers (AFP, β-HCG, LDH) if there is any clinical suspicion of malignancy, though these are typically reserved for palpable masses or suspicious ultrasound features. 7

Step 2: Ultrasound Re-evaluation

• Request a repeat high-frequency (>10 MHz) scrotal ultrasound with Doppler to better characterize the cyst and confirm measurements. 1
• The radiologist should specifically assess:
  • Whether the "debris" represents true solid tissue (which would show vascularity on Doppler) versus layering proteinaceous material or hemorrhage (which would be avascular). 1, 4
  • The exact location (intratesticular versus extratesticular). 1
  • The presence of any suspicious features such as irregular walls, septations, or solid components. 1

Step 3: Management Based on Characterization

If confirmed as a simple cyst with avascular debris:

• No immediate intervention is required for a 0.6 cm simple intratesticular cyst in an asymptomatic 69-year-old man. 1
• Consider optional follow-up ultrasound at 1 year in the postmenopausal-age equivalent (>50 years) to ensure stability, though the risk of malignancy in a true simple cyst is <1%. 1

If the lesion shows any solid vascular component or suspicious features:

• Immediate urology referral for consideration of radical inguinal orchiectomy is mandatory, as all solid or mixed intratesticular lesions must be managed as potentially malignant. 1, 7
• Obtain tumor markers (AFP, β-HCG, LDH) before any surgical intervention. 7
• Discuss sperm banking before orchiectomy in men of reproductive age, though less relevant at age 69. 7

Critical Pitfalls to Avoid

• Never perform scrotal biopsy or trans-scrotal incision for suspected testicular malignancy—only inguinal orchiectomy is appropriate to prevent tumor seeding and local recurrence. 7, 8
• Do not assume all intratesticular lesions are malignant—true simple cysts have <1% malignancy risk and can be managed conservatively with surveillance. 1
• Avoid treating asymptomatic epididymal cysts—surgery carries risks of hematoma, chronic pain, and epididymal obstruction that outweigh benefits in asymptomatic patients. 5, 6
• Ensure proper ultrasound technique with high-frequency probes (>10 MHz) to accurately characterize small lesions and avoid misclassification. 1, 9
• Recognize that "debris" on ultrasound does not automatically indicate malignancy—layering material in cysts can represent proteinaceous fluid, old hemorrhage, or inflammatory debris in benign lesions. 4