The futility of continued surveillance of epididymal cysts – A study of the prevalence and clinico-demographics in pre- vs. post-pubertal boys

  • Fardod O'Kelly The Hospital for Sick Children (Sick Kids)
  • Kristen McAlpine
  • Nishard Abdeen
  • Melise A. Keays
  • Luis A. Guerra
  • Michael P. Leonard
Keywords: Epididymal cysts, Surveillance, Cost, Pubertal


Introduction: The first description of epididymal cysts in children appears from a 1976 case study. Since then, there have been a total of 24 indexed publications relating to pediatric epididymal cysts. Risk factors that may exist for children presenting with epididymal cyst remain unknown, as has the best method of management. And there have not been any studies looking at the cost implications of this diagnosis. The aim of this study was to assess the incidence, clinico-demographics, outcomes, and costs of epididymal cysts in pre-pubertal boys compared with a post-pubertal epididymal cyst cohort, and to assess whether this cohort requires continued surveillance.

Methods: Our institutional ultrasound (US) database was searched for all scrotal US. From these, a filtered, institution review board-approved search was performed for any reports containing the word “cyst.” These were then cross-referenced with a retrospective chart review (October 2006 to September 2017). Clinico-demographics, cyst characteristics, and outcomes were analyzed for both pre- and post-pubertal boys using descriptive and non-parametric statistical methods.

Results: Of 4508 boys undergoing scrotal US during the study period, 191 were indicated to contain cysts. This was manually reduced to 109 scans (2.4%) that met inclusion criteria (85 pre-pubertal; 24 post-pubertal). Thirty-one scans were ordered by urology, including all those with abnormal testicular echotexture (n=5). The average age of the post-pubertal cohort was 15.8 years, compared with 3.8 years in the pre-pubertal cohort. Most (70.5%) epididymal cysts were incidental. There was no difference between the pre- and post-pubertal cohorts in terms of presence of hydrocoeles (p=0.9), symptoms (p=0.9), ordering service (p=0.61), rate of resolution (4.2% vs. 8.2%; p=0.68), or length of followup (4 vs. 4.5 years; p=0.44). Pre-pubertal cysts were significantly smaller in size (3.35 vs. 14.52 mm; p=0.025) and more likely to trigger repeat scanning (67 vs. 10; p=0.008). There were no operative interventions and no subsequent clinical deterioration occurred with observation. At a cost of $71.10 CAD per US, $15 002.10 CAD was expended on epididymal cyst surveillance in direct cost to the healthcare system.

Conclusions: Epididymal cysts are comparable in both pre- and post-pubertal boys and can be safely managed non-operatively without the use of continued US surveillance or urological referral. The higher than expected rate of detection may be a result of the improved ultra-resolution of modern scanners. These children should not require continued followup with repeat surveillance imaging solely for epididymal cysts and could be managed in the primary care setting as part of routine clinical examination


Bissada NK, Redman JF. Unusual masses in the spermatic cord: report of six cases and review of the literature. South Med J. 69(11): 1410-1412 (1976)

Whitaker RH. Benign testicular swellings. Practitioner. 226(1373): 1851-1859 (1982)

Finkelstein MS, Rosenberg HK, Snyder HM 3rd, Duckett JW. Ultrasound evaluation of scrotum in pediatrics. Urology. 27(1): 1-9 (1986)

Homayoon K, Suhre CD, Steinhardt GF. Epididymal cysts in children: natural history. J Urol. 171(3): 1274-6127 (2004)

Posey ZQ, Ahn HJ, Junewick J, Chen JJ, Steinhardt GF. Rate and associations of epididymal cysts on pediatric scrotal ultrasound. J Urol. 184(4 Suppl): 1739-1742 (2010)

Niedzielski J, Miodek M, Krakós M. Epididymal cysts in childhood - conservative or surgical approach? Pol Przegl Chir. 84(8): 406-410 (2012)

Shah VS, Nepple KG, Lee DK. Routine pathology evaluation of hydrocele and spermatocele specimens is associated with significant costs and no identifiable benefit. J Urol. 192(4): 1179-1182 (2014)

Ministry of Health and Long-Term Care. Schedule of Benefits for Physician Services Under the Health Insurance Act. Toronto: Government of Ontario, 2015

Sorenson JR, Levy HL, Mangione TW et al. Parental response to repeat testing of infants with ‘false-positive’ results in a newborn screening program. Pediatrics 73: 183–187 (1984)

Racine NM, Riddell RR, Khan M et al. Systematic review: predisposing, precipitating, perpetuating, and present factors predicting anticipatory dis- tress to painful medical procedures in children. J Pediatr Psychol 41: 159–181 (2016)

Jelloul L, Billerey C, Ait Ali Slimane M, Mboyo A, Aubert D. Epididymal cysts in adolescents. Ann Urol (Paris). 33 (2): 104-108 (1999)

Annam A, Munden MM, Mehollin-Ray AR, Schady D, Browne LP. Extratesticular masses in children: taking ultrasound beyond paratesticular rhabdomyosarcoma. Pediatr Radiol. 45(9): 1382-1391 (2015)

Karaman A, Afşarlar CE, Arda N. Epididymal cyst: not always a benign condition. Int J Urol. 20(4): 457-458 (2013)

Woodward PJ, Schwab CM, Sesterhenn IA. From the archives of the AFIP: extratesticular scrotal masses: radiologic-pathologic correlation. Radiographics. 23(1): 215-240 (2003)

Aragona F, Pescatori E, Talenti E, Tomà P, Malena S, et al. Painless scrotal masses in the pediatric population: prevalence and age distribution of different pathological conditions -A 10 year retrospective multicenter study. J Urol. 155(4): 1424-6 (1996)

Patoulias D, Kalogirou M, Patoulias I. Intraparenchymal Epididymal Cyst (IEC) 4 cm in Diameter in a 15-Year Old Male Patient; a Case Report and Review of the Literature. Acta Medica (Hradec Kralove). 59(4): 137-139 (2016)

Erikci V, Hoşgör M, Aksoy N, Okur Ö, Yildiz M, et al. Management of epididymal cysts in childhood. J Pediatr Surg. 48(10): 2153-2156 (2013)

Erikçi V, Hoşgör M, Yıldız M, Aksoy N, Okur Ö, et al. Torsion of an epididymal cyst: a case report and review of the literature. Turk J Pediatr. 55(6): 659-661 (2013)

Yilmaz E, Batislam E, Bozdogan O, Basar H, Basar MM. Torsion of an epididymal cyst. Int J Urol. 11(3): 182-183 (2004)

Odabaş O, Aydin S, Yilmaz Y. Torsion of a spermatocele. J Urol. 154(6): 2143 (1995)

Lord PH. A bloodless operation for spermatocoele or cyst of the epididymis. Br J Surg 57(9): 641-644 (1970)

Menon VS, Sheridan WG. Benign scrotal pathology: should all patients undergo surgery? BJU Int. 88(3): 251-254 (2001)

Heindorff H, Johansen JR, Lausten GS. Spermatocele of the testis A follow-up study of 42 surgically treated patients. Ugeskr Laeger. 145(17): 1302-1303 (1983)

Tammela TL, Hellström PA, Mattila SI, Ottelin PJ, Malinen LJ, et al. Ethanolamine oleate sclerotherapy for hydroceles and spermatoceles: a survey of 158 patients with ultrasound follow-up. J Urol. 147(6): 1551-1553 (1992)

Mattila SI, Tammela TL, Makarainen HP, Hellstrom PA. Ultrasound follow-up of ethanolamine oleate sclerotherapy for spermatoceles. Eur Urol 23(3): 361-365 (1993)

Hicks N, Gupta S. Complications and risk factors in elective benign scrotal surgery. Scand J Urol. 50(6): 468-471 (2016)

Kiddoo DA, Wollin TA, Mador DR. A population based assessment of complications following outpatient hydrocoelectomy and spermatocoelectomy. J Urol 171: 746-748 (2004)

Shah VS, Nepple KG, Lee DK. Routine pathology evaluation of hydrocele and spermatocele specimens is associated with significant costs and no identifiable benefit. J Urol. 192(4): 1179-1182 (2014)

Skakkebaek NE, Rajpert-DeMeyts E, Main KM. Testicular dysgenesis syndrome: an increasingly common developmental disorder with environmental aspects. Hum Reprod. 16(5): 972-978 (2001)

How to Cite
O’Kelly, F., McAlpine, K., Abdeen, N., Keays, M. A., Guerra, L. A., & Leonard, M. P. (2019). The futility of continued surveillance of epididymal cysts – A study of the prevalence and clinico-demographics in pre- vs. post-pubertal boys. Canadian Urological Association Journal, 13(12).
Original Research