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

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

15. Feedback & Suggestions

16. Thank You
https://www.youtube.com/watch?v=hZovqzif3ck