Urology Journal

UNRC/IUA

Vol. 2, No. 4, 224-226 Autumn 2005

Printed in IRAN

224

Introduction

Epidermoid cysts of the testis are benign

tumor-like intratesticular masses. They are rare,

representing less than 1% of all testicular tumors,

and approximately 300 cases have been reported

in the literature. Treatment of epidermoid cysts

is controversial with the traditional treatment

being radical orchidectomy. Awareness of this

entity and the criteria for differential diagnosis

will enhance the possibility of testicular

preservation, averting unnecessary orchidectomy,

especially for bilateral lesions. We report a case

of bilateral epidermoid cysts in a 19-year-old man

in whom the testes were preserved with

conservative surgical management. 

Case Report

A 19-year-old Bahraini man presented with

bilateral testicular pain of 5 months' duration.

Three years earlier, he had undergone right

scrotal exploration and evacuation of a

hematocele following blunt trauma to the

scrotum. Physical examination revealed 2

nontender masses (2 × 2 cm) in the midportion

of both testes bilaterally. They were separate

from the scrotal wall and epididymides. There

was no clinically detectable hydrocele,

gynecomastia, or palpable abdominal or inguinal

mass. High-resolution testicular ultrasonography

showed a 1.6 × 1.5 cm well-defined, spherical

hypoechoic bilateral lesions with peripheral

hyperechogenicity and normal surrounding

parenchyma. Serum levels of tumor marker 

(β-human chorionic gonadotropin and 

α-fetoprotein) were in the reference ranges. The

patient underwent bilateral inguinal exploration.

A soft clamp was placed on the spermatic cord,

prior to delivery of the testis from the scrotum.

The testes were bisected, and well-circumscribed

cysts were identified. The lesions were completely

enucleated. On incision of the cysts, yellow-white,

putty-like material was extruded, revealing

smooth cystic lesions (Figure 1). The testes were

replaced in the scrotum after tunical closure.

Frozen section histopathologic examination of

both lesions confirmed the diagnosis of an

epidermoid cyst. Histologic examination of

paraffin sections validated this (Figure 2). The

patient's postoperative course was uneventful,

and he was well on follow-ups at 3, 6, and 12

months. Results of analysis of his semen are

normal 1 year after the surgery, and no

recurrence has been detected clinically or by

ultrasonography. 

Conservative Surgical Management of Bilateral Epidermoid

Cysts of the Testis: a Case Report and Review of Literature

Mohammed H Al-Durazi,* Hamad A Al-Helo, Ashok K Malik, Abdulameer E Kadhim

Urology Unit, Surgical Department and Pathology Department, Salmaniya Medical Complex,

Kingdom of Bahrain

KEY WORDS: epidermoid cyst, testes, conservative surgical management

Received October 2005

Accepted November 2005

*Corresponding author: PO Box 12, Kingdom of

Bahrain. Tel: ++973 3965 5977

E-mail: mddurazi@hotmail.com

FIG. 1. Macroscopic appearance of the epidermoid cyst

filled with pale pasty material



Al-Durazi et al 225

Discussion

Epidermoid cysts of the testis are uncommon,

accounting for 1.5% to 2% of testicular tumors.(2,3)

Since their first report in 1942 by Dockerty and

Priestly, more that 300 cases have been reported

in the literature.(1) To our knowledge, this case

represents the fourth reported case of bilateral

epidermoid cyst in an adult patient and the third

reported case with bilateral conservative

management.(4,5)

The histogenesis of epidermoid cysts has not

been completely elucidated; however, the

prevailing hypothesis is that of germ-cell origin,

developing along the line of epidermoid

differentiation as a monodermal expression of a

teratoma.(2,6) Other theories have been

postulated, such as squamous metaplasia of the

seminiferous epithelium, metaplasia of the rete

testis, and inclusion of epidermoid cysts.(2,6) Its

relationship with other germ cell tumors is

supported by the age and racial distribution of

patients affected, and by its reported occurrence

in the ovary and cryptorchid testes.(2)

Diagnosis of a lesion as a simple benign

epidermoid cyst of the testis is confirmed

pathologically when the following 5 criteria, set

by Prince in 1969, are met: the lesion is a cyst

located within the parenchyma of the testis; the

lumen is filled by keratinized debris; the wall of

the cyst is composed of fibrous tissue with

complete or incomplete lining of squamous

epithelium; no teratomatous elements or dermal

adnexal elements are present either within the

cyst wall or elsewhere within the parenchyma of

the testis; and no scar is present in the

remaining testicular parenchyma.(2) Strict

adherence to these criteria clearly separates this

benign entity from the more complex bidermal

and tridermal testicular teratomas, all of which

have malignant potential.(2) Pathologically, an

epidermoid cyst is typically a round or oval

encapsulated lesion. The lumen contains

squamous epithelium and keratin debris that may

vary from complex fluid to a thick, pasty

consistency.(6) The wall is composed of fibrous

tissue that may be calcified.(6)

Epidermoid cysts of the testis usually present

as incidental findings of a painless nodule during

self-examination or routine physical

examination.(1) Most epidermoid cysts of the

testis (86%) occur in young men in the second to

fourth decades of life, but neither the young nor

the aged are spared.(2) Clinically, epidermoid cyst

cannot be differentiated from other testicular

tumors. They usually measure 2 to 3 cm on

average, with a slight predominance to the right

testis, similar to germ cell tumor.(1) Bilateral

occurrence is rare. Clinically, an epidermoid cyst

appears as a circumscribed, firm, smooth, and

nontender intratesticular mass.(1) They

apparently have no predilection for central-hilar

parts rather than polar regions of the testis.(2)

Tumor markers, such as serum β-human

chorionic gonadotropin and α-fetoprotein, are

negative.(6)

Scrotal ultrasonography is a common

diagnostic procedure for evaluating palpable

scrotal masses to distinguish intratesticular from

extratesticular lesions, and to exclude

contralateral lesions. The ultrasonographic

characteristics of epidermoid cysts include a well-

circumscribed hypoechoic mass with a

hyperechogenic rim.(7) The ongoing deposition of

keratinized material inside the cyst creates an

echogenic whorl forming an onion-skin typical

appearance.(1,7) The wall may calcify, and it may

even develop a bony shell.(6) Absence of flow on

color Doppler ultrasonography is consistent with

the avascular nature of these lesions. Several

authors have found typical patterns that are

highly suggestive of malignancy rather than

benign conditions. The presence of a hypoechoic

mass and bright echoic foci, as well as

heterogeneous parenchymal echo patterns, all

have been found to be suspicious for tumors.(8)

On magnetic resonance imaging, epidermoid

cysts show concentric rings of alternating high-

signal and low-signal intensity corresponding to

FIG. 2. Pathologic examination shows epidermoid lining

with distinct granular layers and keratin flakes filling the

lumen of the cyst (hematoxylin-eosin, × 100).



Management of Bilateral Epidermoid Cyst of the Testis226

the pathologic finding of multiple layers of

keratin.(1,6) There is no contrast enhancement.(6)

Testicular lesions have traditionally been

treated by radical orchidectomy when any mass

was detected, but up to a third of these

operations may be unnecessary.(8) Treatment of

epidermoid cysts remains controversial. It may be

that the controversy regarding the histogenesis of

epidermoid cysts has had a direct effect on the

surgical approaches. Nevertheless, radical

orchidectomy has been the gold standard,

although is now less frequently used.(1,3-6,9,10)

Indeed, more conservative approaches based on

testis-sparing surgery are gaining more

acceptance. A most recent literature review

shows that almost all of reports published in the

last decade on this subject invariably emphasize

the safety and importance of conservative

treatment of epidermoid cysts in all age groups.(1)

The rationale of a less aggressive approach is

that no local recurrence, distant metastases, or

deaths have been reported in patients treated

conservatively, from follow-up information

available for up to 37 years.(2,3) Many factors have

led to this shift in the surgical approach. The

typical ultrasonographic features of epidermoid

cyst have facilitated a more accurate preoperative

diagnosis allowing preoperative planning of

testicular preservation.(7) The high accuracy of

intraoperative frozen section is another factor

that has promoted safe testicular preservation.(1)

Moreover, the macroscopic appearance of an

epidermoid cyst at the time of testicular

exploration is typical, with a light yellowish-tan

well-encapsulated tumor that contains keratin

plug and shells out easily from the testis.(9,10) If

the ultrasonographic characteristics before

surgery, age, physical examination, and tumor

markers are in concordance with a strong

possibility that a given mass is benign, a limited

inguinal exploration and subsequent frozen-

section analysis can be used to reduce the

number of unnecessary orchidectomies.(8)

Considering the psychological implications,

preservation of a testicle in a young man is

crucial. Furthermore, most patients are of

reproductive age, and preservation of fertility is

a major issue in testicular surgery. However, it

should be emphasized that all solid intratesticular

lesions must be presumed as being malignant.

The principles of cancer surgery must be

followed, the testis should be isolated with

nontraumatic clump, and the wound protected

from potential spillage of tumor cells. The tunica

albuginea should be opened over the mass, and

the tumor must be excised in-toto and submitted

for frozen section examination.

References

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testis: a critical analysis. Br J Urol. 1986;58:55-9.

2. Chitale S, Morrow DR, Jena R, Ball RY, Webb RJ.

Conservative surgery for epidermoid cyst of the testis.

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3. Lev R, Mor Y, Leibovitch I, et al. Epidermoid cyst of the

testis in an adolescent: Case report and review of the

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2002;37:121-3.

4. Shenoy V, Triest WE, el-Bash O. Bilateral epidermoid

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Jenkins BJ. Epidermoid cysts of the testis: the case for

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10. Ross JH, Kay R, Elder J. Testis sparing surgery for

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