Scrotal swellings 3- Epididymal cyst

Epididymal cyst is a smaller scrotal cystic swelling that resembles like a third testis. It has a characteristic Chinese lantern appearance

1. SCROTAL SWELLINGS C ase No:3 PROBLEM ORIENTED CASE BASED LEARNING Dr.B.Selvaraj MS;Mch;FICS Professor of Surgery Melaka Manipal Medical college Melaka Malaysia 75150

2. OVERVIEW Various causes (Differential diagnosis) of scrotal swellings Classical clinical vignette with probable diagnosis The diagnosis in detail- only one pathology in each episode Mind map of the diagnosis Tabular column of differential diagnosis depicting their characteristic features to differentiate them from your diagnosis References and feedback

3. Causes of Scrotal Swellings ACUTE PAINFUL Torsion testis Acute epididymo-orchitis Torsion of testicular appendages CHRONIC PAINLESS Hydrocele Epididymal cyst Spermatocele Chronic epididymo - orchitis Testicular tumor Varicocele

4. Classical Clinical vignette Epididymal Cyst A 45 years old male patient presented with a swelling in right side of the scrotum for last 3 years which is increasing very slowly in size. There is no pain over the swelling. O/E: There is a soft cystic swelling in relation to the head of the right epididymis . The swelling has a lobulated surface and feels like a bunch of grapes . Testis can be felt separately from the swelling The swelling is brilliantly transilluminant and has Chinese lantern pattern appearance

5. Epididymal Cyst- Etiopathogenesis These are cysts in connection with the epididymis divided into the following types: 1. Degeneration cysts occur due to cystic degeneration of the epididymis Epididymal cyst 2. Retention cysts due to obstruction of the sperm conducting mechanism Spermatocele Ex: after vasectomy

6. Epididymal Cyst- Clinical Features Most epididymal cysts occur in males over the age of 40 years An epididymal cyst usually contains clear fluid The variety that contains slightly grey, opaque, ‘ barleywater ’-like fluid and few spermatozoa is sometimes termed a S permatocele They are often multiple or multilocular and are frequently bilateral and feels like bunch of grapes Brilliantly transilluminant  “Chinese lantern pattern” Testis palpable separately Cysts are connected to the head of the epididymis, so lie above the testis 3rd testis

7. Epididymal Cyst- Clinical Features

8. Epididymal Cyst- Clinical Features

9. Epididymal Cyst Vs Spermatocele

10. Epididymal Cyst - Treatment Single large cyst  Excision of cyst Recurrent or multilocular cyst Excision + partial or total epididymectomy No role for aspiration because cysts are multilocular Spermatocele if big aspiration or excision; If small no intervention

11. Epididymal Cyst - Mindmap

12. Scrotal Swellings- Algorithm

13. Scrotal Swellings Ex & Px Hx Sx Dx Tx 1 . Hydrocele Primary-Idiopathic Secondary- under lying pathology Painless big swelling; not reducible No cough impulse Get above swelling+ Transilluminant + Clinical In doubt- USG of scrotum Lord’s operation Jaboulay’s operation 2 . Epididymal cyst & Spermatocele Degenaration of epididymis, occlusion of pathway Swelling in scrotum resembles 3 rd testis Testis palpable separately; Chinese lantern appearance Clinical USG of scrotum Conservative Excision 3 . Varicocele Idiopathic Absence of valves in testicular vein Worm like in upper scrotum; infertility Disappears on lying down; Bag of worms appearance Clinical USG color doppler Varicocelectomy Inguinal or Retroperitoneal 4. Testicular torsion & Epididymo - orchitis Abnormal fixation and lie of testis UTI & trauma Severe pain& swelling scrotum Nausea & vomiting Tender hemi scrotum; cremasteric reflex absent Clinical USG color doppler Explore,detorse , orchiopexy or orchidectomy Conservative 5 . Testicular carcinoma UDT, Kieinfelter’s Germ cell- Seminoma & Non seminoma Non germ cell tumor Painless heavy swelling Not reducible Hard in consistency Testis felt separately Clinical; No FNAC USG OF scrotum High orcidectomy with or without RPLND+ RT+CT D/D for Scrotal Swellings (Compare & Contrast) (Vertical Reading)

14. References Hunt & Marshall’s clinical problems in surgery 2 nd edition Clinical surgery made easy- a companion to PBL by Mohan De silva 1 st edition 100 cases in surgery 2 nd edition Case files surgery 4 th edition Clinical scenarios in surgery- decision making 1 st edition Surgery- a case based clinical review 1 st edition Surgery Review by Carlos Pestana Clinical surgery pearls by Dr Dayananda Babu 2 nd edition NMS casebook surgery 2 nd edition General Surgery- Correlations & clinical scenarios 1 st edition Surgery review by Makary 3 rd edition Surgery- Clinical cases uncovered by Harold Ellis 1st edition Shelf life surgery 1 st edition

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