Bilateral Epididymal Cyst in 14 year-old Boy: a case report

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Bilateral Epididymal Cyst in 14 year-old Boy: a case report
  Yi ğ it Ak ı n et al.  Journal of Health Sciences 2014;4(1):68-71 Journal of Health Sciences   © 2014 Yi ğ it Ak ı n et al.; licensee University of Sarajevo - Faculty of Health Studies. This is an Open Access article distributed under the terms of the Creative Commons Attribution Li-cense (, which permits unrestricted use, distribu-tion, and reproduction in any medium, provided the srcinal work is properly cited. UNIVERSITY OF SARAJEVO FACULTY OF HEALTH STUDIES ABSTRACT Bilateral epididymal cysts are rare in childhood. Clinically they may present as acute scrotum and should be differentiated from other pathologies. Herein, we report bilateral epididymal cysts in a 14-year-old boy. He was admitted to emergency department with symptoms of acute left scrotum. There was no history of trauma or infection. Blood analyses, including testis tumor markers were unremarkable. Bilateral epi-didymal cysts were diagnosed on ultrasonography evaluation. Medical treatment did not stop his scrotal pain. During scrotal exploration, there was no evidence of testicular torsion or any other pathology. An excision of cyst was performed. Histopathologically, the cyst wall was lined by columnar epithelia. As a result of these fi ndings, a pathological diagnosis of epididymal cyst was made. The synchronized evalua-tion of clinical and ultrasonography fi ndings with an appropriate histopathological evaluation can usually diagnose this rare pathology. Keywords : Epididymal cyst, microsurgery, pediatrics. Bilateral Epididymal Cyst in 14 year-old Boy: a case report Yi ğ it Ak ı n 1 , Mehmet Sarac 2 , Isil Basara 3 , Selcuk Yucel 4 , Ahmet Kazez 2 1 Department of Urology, Harran University School of Medicine, 63100, Sanliurfa, Turkey. 2 Department of Pediatric Surgery, Firat University School of Medicine, 23042, Elazig, Turkey. 3 Department of Radiology, Harput State Hospital, 23050, Elazig, Turkey. 4 Department of Urology, Akdeniz University School of Medicine, 07059, Antalya, Turkey. INTRODUCTION Scrotal masses can be diagnosed by transillumina-tion or a scrotal ultrasonography examination. At transillumination these masses may show primarily 󿬂uid, such as a tense hydrocele, or solid, such as tes-ticular tumors. If a much 󿬁rm intratesticular mass is palpated, evaluation for lymphoma, leukemia, or metastatic disease should be performed with exami-nation of the lymph nodes. Children with a non-ten-der testicular mass and signs of precocious puberty should be evaluated for a Leyding cell tumor or less commonly a Sertoli cell tumors (1, 2). Epididymal cysts may present as extratesticular masses but they are usually smooth, round, and characteristically lo-cated within the epididymis (2). Tey cause acute scrotum which is referred as the new onset of pain, swelling, and/or tenderness of intrascrotal contents. Herein, we report that a 14-year-old boy with acute scrotum. Bilateral epididymal cysts were diagnosed at emergency deparment. CASE REPORT  A 14 year-old-boy was admitted emergency outpa-tient clinic with painless left hemi-scrotal enlarge-ment. Tere was no history of scrotal trauma or in- *Corresponding author: Yigit Ak ı n, MD. Assistant Professor of UrologyHarran University School of Medicine, 63100 Sanliurfa, TurkeyTel: +90-506-5334999E-mail: [email protected] October 21, 2014/Accepted March 30, 2014  CASE REPORT Open Access  69 Yi ğ it Ak ı n et al.  Journal of Health Sciences 2014;4(1):68-71 fection. At physical examination, in left epididymal zone a nodular mass was palpated without enlarge-ment and tenderness of the testis. Additionally, there  was a round small cyst palpated in the right epididy-mis. In scrotal Doppler ultrasonography, there was no 󿬁ndings of left testicular torsion, and epididymal cyst was found bilaterally (Figure 1A and 1B).In laboratory tests, the testicular tumor markers in-cluding lactate dehydrogenase (LDH), human cho-rionic gonadotropin (HCG), and alpha-fetoprotein (AFP), blood parameters, urine analysis and the other biochemical tests were within reference ranges.Non-steroid analgesics were prescribed for scro-tal pain and patient was discharged. Te same day later the patient was admitted again at emergency department with the same symptoms. Te day after, surgical operation was carried out through a scrotal incision to remove the mass. Te paratesticular mass  was found to be a simple epididymal cyst that was excised intact (Figure 2A). Histological examination showed the cyst wall was lined by columnar epithe-lium. As a result of these 󿬁ndings, a pathological diagnosis of epididymal cyst was made (Figure 2B). After two months patient referred to pediatric sur- FIGURE 1.  Ultrasonograhic view of epididymal cyst. a. On the left side, left epididymal cyst size 9x7mm, b. On the right side right epididymal cyst size 4,5x3mm. FIGURE 2.  Operational and pathological view of cysts a. The arrow and clemp shows epididymal cyst. b. Hispatological fi ndings are, the low columnar epitelium are spreaded by the wall of cyst, arrow. (HEX400).  70 Yi ğ it Ak ı n et al.  Journal of Health Sciences 2014;4(1):68-71 geon for postoperative check-up. Physical examina-tion showed a round small cyst palpated on the right epididymis while left hemiscrotum was without any pathological 󿬁ndigs. A scrotal ultrasonography was performed which revealed a cyst in the right epidid-ymis measuring 4.5x3 mm. (Figure 3).Tere was no cyst in kidneys or other organs in ab-domen. Again the tumor markers, the other blood parameters, urine analysis, and biochemical tests  were unremarkable. Te patient did not have any additional comorbid disease or history of exposure to diethylstilboestrol, cryptorchidism, cystic 󿬁brosis or von Hippel-Lindau disease. Te follow-up period of the patient is still ongoing. DISCUSSION Unilateral epididymal cysts are common and happen at all ages. Tey are 󿬂uid 󿬁lled cysts arising from the out󿬂ow duct of the testis (the epididymis). Tey are most often felt as a pea-sized swelling at the top part of the testis but they can become larger. Sometimes they cause acute scrotum in children (3). Tere are few published reports on bilateral epididymal cysts in childhood, in the literature. Herein, we reported a case of bilateral epdidymal cysts. Te pathophysiology of epididymal cysts is still un-known but there are some reports that these cysts  were related to an altered hormonal environment (1). Tese lesions are different ultrasonographi-cally and pathologically from the multicystic/solid epididymal cystadenomas that occur in von Hippel-Lindau disease (4). Additionally, sometimes sponta-neous resolution can occur in pediatric population, and surgical intervention is rarely needed (5). Medi-cal treatment options are the 󿬁rst line of therapy, as in our case. Still, the conservative treatment may sometimes be uneffective and surgery has to be per-formed to relieve an acute scrotum symptoms.Epididymal cysts are diagnosed on physical exami-nation. Tey are palpated as extratesticular masses but also they are characteristically smooth, round, and located within the epididymis. For differential diagnosis, laboratory tests and scrotal ultrasonog-raphy should be performed. Tese tests help us to make the distinction between epididymal cyst and testicular cancer. If a epididymal cyst is diagnosed, there should be no high level of LDH, HCG, and  AFP in the laboratory tests. As radiological, in ultra-sonography examination, epididymal cysts appear simple or minimally complex cysts and they can be diagnosed easily (5).Te treatment options depend on patients’ 󿬁nd-ings. Most epididymal cysts involute with time (6, 7). Conservative treatment options are usually used for palliation (8). Epididymal cysts are treated when they cause symptoms like acute scrotum, scrotal and/or inguinal pain (8). Primary excision is per-formed to remove the cyst or cysts (8). Te incision is performed through a median raphe or a unilat-eral transverse scrotal incision to deliver the testis. Great care has to be taken in children and younger men of reproductive age because the operation to remove an epididymal cyst may cause scar tissue to form and block the out󿬂ow duct of the testis. Chil-dren need to consider this risk. In the surgery of epi-didymal cyst in children, microsurgical techniques can be used by using optical magni󿬁cation glasses (5). We used 4 optical magni󿬁cation glasses during surgery. Epididymal cysts can be drained with a sy-ringe under local anaesthetic but this is not advised because epididymal cysts can return and there is a risk of introducing infection each time the cysts are needled and also this includes infection risk of cyst. Sclerotheraphy is the other option for treatment but there is not enough study that has not been reported effi ciency of this treatment on children (9, 10). FIGURE 3.  Postoperative control scrotal ultrasonogram, the size of epididymal cyst on the right epididymis is 4,5x3mm. Upper arrow shows vaz deferens, the other shows cyst.  71 Yi ğ it Ak ı n et al.  Journal of Health Sciences 2014;4(1):68-71  Although diagnosing epididymal cyst may not rep-resent signi󿬁cant problem, it is important to make the distinction between epididymal cyst and tes-ticular cancer in childhood. Conservative treatment options are the 󿬁rst choice of treatment, but when surgery is needed microsurgical techniques are safe and effective for epididmal surgery in children. REFERENCES 1. Agarwal PK, Palmer JS. Testicular and paratesticular neoplasms in prepu-bertal males. J Urol 2006;176:875-81.2. Wein, Kavoussi,Novick, Partin, Peters: Campbell’s Urology, 10th ed. Phila-delphia, PA,Saunders, 2011, p 3060-1.3. Rioja J, Sánchez-Margallo FM, Usón J, Rioja LA. Adult hydrocele and sper-matocele. BJU Int. 2011;107:1852-64.4. Choyke PL, Glenn GM, Wagner JP, Lubensky IA, Thakore K, Zbar B, Line-han WM, Walther MM. Epididymal cystadenomas in von Hippel-Lindau disease. Urology. 1997;49:926-315. Kauffman EC, Kim HH, Tanrikut C, Goldstein M. Microsurgical spermato-celectomy: technique and outcomes of a novel surgical approach. J Urol. 2011;185:238-42.6. Homayoon K, Suhre CD, Steinhardt GF. Epididymal cysts in children: natu-ral history. J Urol. 2004;171:1274-6.7. Chillon Sempere FS, Dominquez Hinarejos C, Serrano Durba A, Estornell Moragues F, Martinez-Verduch M, Garcia Ibarra F. Epididymal cysts in childhood. Arch Esp Urol. 2005; 58: 325-8.8. Erikci V, Hosgor M, Aksoy N, Okur O, Yildiz M, Dursun A, Demircan Y, Or-nek Y, Genisol I. Management of epididymal cyst in childhood. J Pediatr Surg. 2013;48:2153-6.9. Jahnson S, Sandblom D, Holmäng S.A randomized trial comparing 2 doses of polidocanol sclerotherapy for hydrocele or spermatocele. J Urol. 2011;186:1319-23.10. Niedzielski J, Miodek M, Krakos. Epididymal cysts in childhood-conserva-tive or surgical approach? Pol Przegl Chir. 2012; 84: 406-10.
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