Torsion of huge epididymal cyst in a 16-year-old boy: case report and review of the literature

Abstract

Epididymal cysts (ECs) are relatively common in adults, rare in children. Normally their treatment is conservative. They may be situated anywhere in the organ, frequently in the region of the head. Torsion of these cysts is extremely rare in both children and adults, causing acute scrotal swelling. The diagnosis is intraoperative. A 16-year-old boy was referred to our Divisional Clinic by the treating physician for scrotal swelling appeared 4 months earlier.Absence of a history of minor scrotal trauma. Ultrasonography showed a 40×50 mm fluid-filled right para-testicular mass. We performed surgery finding a large black cyst connected to the head of the epididymis with 720°-degrees rotation. Histology revealed an acquired EC. The particularity of our case is due to the absence of symptoms in association with a big EC twisted of 720° degrees. This is the only case reported in literature. All patients with EC torsion reported presented symptoms related to acute scrotum. IntroductionEpididymal cysts (ECs) is a benign mass that usually develop in adult men, but it is rare in children, with a prevalence of 5-20% according to varying series reported in the literature. 1 They present as single or multiple, uni-or bi-lateral spherical cysts localized most frequently in the head of the epididymis. Although the cause of EC and spermatocele is often unknown, it may be caused by epididymal ducts obstruction. They are usually of lymphatic origin. When small, ECs remain undetected and can be found in approximately 30% of asymptomatic patients having scrotal ultrasound for other reasons. On the contrary to adolescent in adults most of these cysts are spermatocele. 2 With a certain diagnosis (ultrasound), their treatment is conservative under elective condition. Rarely, as result of trauma or torsion of these cysts, exploration of the scrotum is required to rule out other pathologies such as testicular torsion. An EC torsion is extremely rare especially in young boys and to the best of our knowledge only 6 cases have been reported in literature. 3 Case ReportThe treating physician has referred a 16-year-old boy to our Service for right scrotal swelling appeared 4 months before. The patient reported the absence of a history of minor scrotal trauma. He had no fever or urinary symptoms. Physical examination demonstrated left scrotal region and left testis normal. On the right side, tenderness and swelling of the right hemiscrotum; the testis was appreciated of regular consistency, with vague margins, located on the inferior-posterior area. Superiorly was appreciated an elastic area as loculated hydrocele. No pain on palpation. At the lower pole of the testis was appreciable a hard consistency area, 1 cm in length, painless. Abdominal examination was unremarkable. The inguinal canal was not engaged. Routine hematology, serum biochemistry, and urine analysis were normal. Color-Doppler-Ultrasonography showed both testes with normal parenchymal architecture and echogenicity with no perfusion defect as the left epididymis. On the...

Bilateral epididymal cyst with spontaneous resolution

“…They should also be considered as differential diagnosis. 5 Epididymal cyst has also been associated with conditions like polycystic kidney disease, cystic fibrosis, Von Hippel-lindau disease and also reported in children exposed to diethylstilbestrol in utero life. 1 Treatment for epididymal cysts includes conservative management, aspiration of cyst, sclerotherapy, and excision of cyst.…”

“…Ultrasonographic appearance of epididymal cyst is similar to those of cystic tumors such as adenomatoid tumor of epididymis, epidermoid cyst (monodermal teratoma) of the testis. They should also be considered as differential diagnosis 5 . Epididymal cyst has also been associated with conditions like polycystic kidney disease, cystic fibrosis, Von Hippel‐lindau disease and also reported in children exposed to diethylstilbestrol in utero life 1 …”

“…1 Conservative management has been suggested in most cases although there is no consensus about the most adequate therapy of pubertal patients and the majority of these cysts involute with time. 5 The average time to complete involution varies from 4 to 50 months. 2 A study by BK Arora et al, reported that no spontaneous resolution was observed in the group of patients with cysts between 21 and 50 mm over a 1-year follow-up period.…”

“…Treatment for epididymal cysts includes conservative management, aspiration of cyst, sclerotherapy, and excision of cyst 1 . Conservative management has been suggested in most cases although there is no consensus about the most adequate therapy of pubertal patients and the majority of these cysts involute with time 5 . The average time to complete involution varies from 4 to 50 months 2 .…”

“…However, if they become symptomatic, suddenly start increasing in size, or do not resolve spontaneously, nonconservative management should be considered such as surgery or sclerotherapy. However, Niedzielski et al, do not approve and recommend sclerotherapy in the developing testes of pubertal boys 5 …”