Orris
attachment
attachment

Tenderness from 2 days and how to treat this case

analyse_media
Reading File
Finding Sources
Finding Sources
Searching Images

epidermoid cyst scrotum

A multi-panel medical figure documenting a case of a scrotal epidermoid cyst in a pediatric patient. (a) A clinical photograph shows a prominent, smooth, midline scrotal mass (white arrow). (b1, b2) T2-weighted axial and coronal MRI scans reveal a tubular, high-signal cystic lesion (white arrows) extending from the scrotum toward the pelvic floor, demonstrating penetration of the penile corpora cavernosa (black arrows). (c) Intraoperative photograph highlights the elongated, reddish-tan tumor (white arrows) being dissected as it traverses the corporal tissue (black arrows). (d) Gross specimen image shows the excised tumor components, including a larger peripheral segment and a smaller central segment, with a 10 mm scale bar for reference. (e) A histopathological micrograph (H&E stain, 100x) displays a cyst wall lined by mature stratified squamous epithelium with focal lymphocytic infiltration, confirming the diagnosis of a benign epidermoid cyst. This case illustrates the rare clinical presentation of an epidermoid cyst penetrating deep into penile erectile structures, requiring precise surgical management to preserve functional anatomy.

A multi-panel medical figure documenting a case of a scrotal epidermoid cyst in a pediatric patient. (a) A clinical photograph shows a prominent, smooth, midline scrotal mass (white arrow). (b1, b2) T2-weighted axial and coronal MRI scans reveal a tubular, high-signal cystic lesion (white arrows) extending from the scrotum toward the pelvic floor, demonstrating penetration of the penile corpora cavernosa (black arrows). (c) Intraoperative photograph highlights the elongated, reddish-tan tumor (white arrows) being dissected as it traverses the corporal tissue (black arrows). (d) Gross specimen image shows the excised tumor components, including a larger peripheral segment and a smaller central segment, with a 10 mm scale bar for reference. (e) A histopathological micrograph (H&E stain, 100x) displays a cyst wall lined by mature stratified squamous epithelium with focal lymphocytic infiltration, confirming the diagnosis of a benign epidermoid cyst. This case illustrates the rare clinical presentation of an epidermoid cyst penetrating deep into penile erectile structures, requiring precise surgical management to preserve functional anatomy.

Multi-modal imaging and histopathology of an atypical Testicular Epidermoid Cyst (TEC) in a 26-year-old male. (A) Scrotal ultrasonography displays a large, heterogeneous intratesticular mass with a central focus of hyperechogenicity and significant posterior acoustic shadowing (yellow arrow), suggesting calcification. (B-E) Multi-sequence MRI of the scrotum shows a well-defined mass. A mural nodule (yellow circle) appears hyperintense on T1-weighted imaging (B) and hypointense on T2-weighted (C) and SPAIR (D) sequences. Post-contrast THRIVE sequence (E) demonstrates gadolinium enhancement of the nodule, indicating vascularity. (F) Histopathology (H&E, 20x) reveals a cyst wall with keratinized epithelium and a disorderly internal accumulation of keratin (black arrow), lacking the classic 'onion-skin' arrangement. (G-J) Focused MRI sequences highlight a 'small black ring sign' on T2-weighted and SPAIR images (yellow arrows), which remains non-enhanced on post-contrast THRIVE imaging (J), consistent with a calcified component. This case demonstrates atypical radiological features of TEC, including the absence of alternating concentric rings and the presence of a vascularized mural nodule.

Multi-modal imaging and histopathology of an atypical Testicular Epidermoid Cyst (TEC) in a 26-year-old male. (A) Scrotal ultrasonography displays a large, heterogeneous intratesticular mass with a central focus of hyperechogenicity and significant posterior acoustic shadowing (yellow arrow), suggesting calcification. (B-E) Multi-sequence MRI of the scrotum shows a well-defined mass. A mural nodule (yellow circle) appears hyperintense on T1-weighted imaging (B) and hypointense on T2-weighted (C) and SPAIR (D) sequences. Post-contrast THRIVE sequence (E) demonstrates gadolinium enhancement of the nodule, indicating vascularity. (F) Histopathology (H&E, 20x) reveals a cyst wall with keratinized epithelium and a disorderly internal accumulation of keratin (black arrow), lacking the classic 'onion-skin' arrangement. (G-J) Focused MRI sequences highlight a 'small black ring sign' on T2-weighted and SPAIR images (yellow arrows), which remains non-enhanced on post-contrast THRIVE imaging (J), consistent with a calcified component. This case demonstrates atypical radiological features of TEC, including the absence of alternating concentric rings and the presence of a vascularized mural nodule.

This clinical photograph displays a gross examination of the male genital region featuring a significant midline scrotal swelling. The image identifies a 'MIDLINE CYST' situated centrally within the scrotum, positioned between the 'RIGHT TESTIS' and 'LEFT TESTIS'. The cyst is spherical, prominently larger than the individual testicles, and causes visible stretching of the overlying scrotal skin, resulting in a smoother surface texture compared to the adjacent wrinkled and rugose scrotal folds. The lesion appears discrete and non-inflammatory, with no signs of erythema or ulceration. This visual demonstrates a typical presentation of a large scrotal midline cyst, which in a clinical context could represent an epidermoid cyst or a median raphe cyst. The educational focus is on the anatomical localization of scrotal masses and the differentiation between intratesticular and extratesticular pathology through physical inspection and labeling.

This clinical photograph displays a gross examination of the male genital region featuring a significant midline scrotal swelling. The image identifies a 'MIDLINE CYST' situated centrally within the scrotum, positioned between the 'RIGHT TESTIS' and 'LEFT TESTIS'. The cyst is spherical, prominently larger than the individual testicles, and causes visible stretching of the overlying scrotal skin, resulting in a smoother surface texture compared to the adjacent wrinkled and rugose scrotal folds. The lesion appears discrete and non-inflammatory, with no signs of erythema or ulceration. This visual demonstrates a typical presentation of a large scrotal midline cyst, which in a clinical context could represent an epidermoid cyst or a median raphe cyst. The educational focus is on the anatomical localization of scrotal masses and the differentiation between intratesticular and extratesticular pathology through physical inspection and labeling.

Reading File
Finding Sources
Based on the image analysis and authoritative textbook sources, here is a thorough clinical assessment:

Clinical Assessment

What the Image Shows

The image shows a solitary, dome-shaped, tense nodule on the scrotal skin, approximately 1-1.5 cm in diameter, with a pale yellowish-white center and mild surrounding erythema. The patient reports 2 days of tenderness.
This presentation is most consistent with an inflamed/infected scrotal epidermoid cyst (sometimes called a "sebaceous cyst," though this term is technically inaccurate). A furuncle (boil) arising from a scrotal hair follicle is the second most likely diagnosis.

Differential Diagnosis

DiagnosisFavoring features
Inflamed epidermoid cystDome-shaped, tense, well-circumscribed, yellowish center, scrotal location (most common scrotal cyst), sudden onset pain
Furuncle / abscess2-day tender history, hair-bearing area, fluctuant feel
Scrotal calcinosisUsually multiple, firmer lesions - less likely here

Pathophysiology

As stated in Campbell-Walsh-Wein Urology: "Epidermoid or epidermal-inclusion cysts are the most common cutaneous cysts... particularly common on the scrotum. Although not painful at baseline, rupture of the cyst wall can lead to a severe inflammatory reaction that is extremely painful." The 2-day tenderness suggests either spontaneous wall rupture or early secondary infection.
Dermatology (2-Volume Set, 5e) confirms: "Epidermoid cysts are frequently encountered on the... scrotum, and may be multiple. They are yellow, vary in size, and may become inflamed. Treatment is by excision, but this is only necessary if the cyst is symptomatic."

Treatment

Step 1 - Initial management of the inflamed/infected cyst:
  • Incision and Drainage (I&D) - This is the indicated procedure for a fluctuant, tender scrotal cyst or abscess. A small sterile incision is made to express the contents. This should be done by a physician/surgeon under sterile conditions.
  • Antibiotics - Indicated if there is surrounding cellulitis (spreading redness, warmth, induration beyond the cyst margin). Use an antibiotic covering Staphylococcus aureus:
    • Co-amoxiclav (amoxicillin-clavulanate) 625 mg orally three times daily for 5-7 days, OR
    • Cefalexin 500 mg four times daily for 5-7 days
    • If MRSA is suspected (recurrent/treatment-resistant): Trimethoprim-sulfamethoxazole (TMP-SMX) or Doxycycline
  • Warm compresses - Apply a warm, moist cloth to the area 3-4 times daily for 10-15 minutes. This promotes localization and can aid spontaneous drainage.
  • Do NOT squeeze or self-drain - The scrotum is highly vascular. Attempting to pop this at home can drive bacteria deeper, cause severe pain, and risk spreading infection.
Step 2 - Definitive treatment (after acute inflammation resolves):
Per Campbell-Walsh-Wein Urology: "Definitive treatment requires surgical excision of the entire cyst wall to prevent cyst recurrence." This is done as a minor elective procedure under local anaesthesia once the active infection has settled.

Red Flag Warning Signs - Seek Emergency Care Immediately If:

  • Rapidly spreading redness or swelling
  • High fever or chills (suggests systemic infection/sepsis)
  • The swelling extends to the perineum or inner thighs (risk of Fournier's gangrene, a life-threatening necrotizing fasciitis)
  • Severe, worsening pain that is disproportionate to the size of the lesion

Summary

This is most likely an inflamed scrotal epidermoid cyst requiring:
  1. See a doctor promptly for formal examination and possible I&D
  2. Oral antibiotics if cellulitis is present
  3. Warm soaks at home in the meantime
  4. Elective surgical excision once the inflammation resolves to prevent recurrence
Disclaimer: This is educational information only. Please consult a urologist, surgeon, or dermatologist for proper diagnosis and treatment. Do not attempt to drain or pop this lesion at home.
This is a shared conversation. Sign in to Orris to start your own chat.