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

© 2014 Yiğit Akın 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 License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. UNIVERSITY OF SARAJEVO FACULTY OF HEALTH STUDIES ABSTRACT


INTRODUCTION
Scrotal masses can be diagnosed by transillumination or a scrotal ultrasonography examination. At transillumination these masses may show primarily fl uid, such as a tense hydrocele, or solid, such as testicular tumors. If a much fi rm intratesticular mass is palpated, evaluation for lymphoma, leukemia, or metastatic disease should be performed with examination of the lymph nodes. Children with a non-tender 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 located within the epididymis (2). Th ey 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 outpatient clinic with painless left hemi-scrotal enlargement. Th ere was no history of scrotal trauma or in-

CASE REPORT
Open Access fection. At physical examination, in left epididymal zone a nodular mass was palpated without enlargement and tenderness of the testis. Additionally, there was a round small cyst palpated in the right epididymis. In scrotal Doppler ultrasonography, there was no fi ndings of left testicular torsion, and epididymal cyst was found bilaterally ( Figure 1A and 1B).
In laboratory tests, the testicular tumor markers including lactate dehydrogenase (LDH), human chorionic 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 scrotal pain and patient was discharged. Th e same day later the patient was admitted again at emergency department with the same symptoms. Th e day after, surgical operation was carried out through a scrotal incision to remove the mass. Th e 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 epithelium. As a result of these fi ndings, a pathological diagnosis of epididymal cyst was made ( Figure 2B). After two months patient referred to pediatric sur-  geon for postoperative check-up. Physical examination showed a round small cyst palpated on the right epididymis while left hemiscrotum was without any pathological fi ndigs. A scrotal ultrasonography was performed which revealed a cyst in the right epididymis measuring 4.5x3 mm. (Figure 3). Th ere was no cyst in kidneys or other organs in abdomen. Again the tumor markers, the other blood parameters, urine analysis, and biochemical tests were unremarkable. Th e patient did not have any additional comorbid disease or history of exposure to diethylstilboestrol, cryptorchidism, cystic fi brosis or von Hippel-Lindau disease. Th e follow-up period of the patient is still ongoing.

DISCUSSION
Unilateral epididymal cysts are common and happen at all ages. Th ey are fl uid fi lled cysts arising from the outfl ow duct of the testis (the epididymis). Th ey 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). Th ere are few published reports on bilateral epididymal cysts in childhood, in the literature. Herein, we reported a case of bilateral epdidymal cysts. Th e pathophysiology of epididymal cysts is still unknown but there are some reports that these cysts were related to an altered hormonal environment (1). Th ese lesions are diff erent ultrasonographi-cally and pathologically from the multicystic/solid epididymal cystadenomas that occur in von Hippel-Lindau disease (4). Additionally, sometimes spontaneous resolution can occur in pediatric population, and surgical intervention is rarely needed (5). Medical treatment options are the fi rst line of therapy, as in our case. Still, the conservative treatment may sometimes be uneff ective and surgery has to be performed to relieve an acute scrotum symptoms. Epididymal cysts are diagnosed on physical examination. Th ey are palpated as extratesticular masses but also they are characteristically smooth, round, and located within the epididymis. For diff erential diagnosis, laboratory tests and scrotal ultrasonography should be performed. Th ese 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 ultrasonography examination, epididymal cysts appear simple or minimally complex cysts and they can be diagnosed easily (5). Th e treatment options depend on patients' fi ndings. 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 performed to remove the cyst or cysts (8). Th e incision is performed through a median raphe or a unilateral 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 outfl ow duct of the testis. Children need to consider this risk. In the surgery of epididymal cyst in children, microsurgical techniques can be used by using optical magnifi cation glasses (5). We used 4 optical magnifi cation glasses during surgery. Epididymal cysts can be drained with a syringe 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).