Acute Scrotal Swelling Caused by Torsion of an Epididymal Cyst in an Adolescent Athlete

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Description

A fifteen-year-old male adolescent presented to the emergency department with sudden onset left scrotal pain that developed during a school football match. The patient described sharp pain beginning immediately after rapid sprinting activity without direct trauma to the genital region. Within two hours, progressive swelling and nausea developed, prompting urgent hospital evaluation. He denied fever, urinary symptoms, or previous episodes of similar discomfort. The patient had no known chronic illness and no prior surgical history. Physical examination demonstrated an anxious adolescent with marked tenderness and enlargement of the left hemiscrotum. The overlying skin appeared mildly erythematous. The left testis could not be examined adequately because of pain and surrounding edema. Cremasteric reflex was difficult to assess. The right testis appeared normal.

Laboratory studies showed mild leukocytosis without pyuria or elevated inflammatory markers. Urinalysis remained unremarkable. Because testicular torsion could not be excluded clinically, urgent color Doppler ultrasonography was performed. Imaging demonstrated preserved arterial flow to both testes. Adjacent to the superior pole of the left testis, a cystic lesion measuring approximately 2.4 cm displayed heterogeneous internal echoes and absent vascularity. Surrounding reactive hydrocele and scrotal wall thickening were also identified. Radiological interpretation suggested torsion of an epididymal cyst.

Despite preserved testicular perfusion, the patient continued to experience severe pain with increasing swelling during observation. Surgical exploration was therefore undertaken to exclude evolving spermatic cord torsion and relieve acute symptoms. Under general anesthesia, a left scrotal incision was made. Exploration revealed a dark hemorrhagic cyst attached to the head of the epididymis through a narrow pedicle twisted approximately 720 degrees. The adjacent epididymal tissue appeared edematous, although the testis itself remained viable with satisfactory perfusion. A small reactive hydrocele containing blood-stained fluid surrounded the structures.

The torsed cyst was excised carefully after detorsion of the pedicle. Inspection confirmed no evidence of testicular torsion or appendage necrosis. The remaining epididymal tissue appeared healthy following irrigation and hemostasis. The excised lesion was sent for histopathological examination. Postoperative recovery progressed without complication. Pain decreased substantially within twenty-four hours, and the patient resumed oral intake the same evening. Histopathological evaluation confirmed a benign epididymal cyst with hemorrhagic infarction secondary to torsion. No malignant features were present.

At six-week follow-up, the adolescent reported complete resolution of symptoms and return to normal physical activity. Ultrasonography demonstrated preserved testicular volume and vascularity without recurrent cyst formation. Semen analysis was not performed because of patient age and absence of fertility-related concerns.

Acute scrotum represents a surgical emergency in pediatric and adolescent populations because delayed treatment of testicular torsion may result in irreversible gonadal injury. However, several less common conditions can produce similar clinical presentation. Torsion of epididymal cysts remains an uncommon cause of acute scrotal pain and may closely imitate spermatic cord torsion.

Epididymal cysts themselves are relatively uncommon in children compared with adults. Most lesions remain asymptomatic and are discovered incidentally during ultrasonography or physical examination. Symptomatic enlargement, infection, or torsion may occasionally occur, particularly in larger cysts attached through elongated pedicles. The pathophysiological mechanism of cyst torsion likely involves increased mobility of pedunculated lesions during physical activity or sudden body movement. In this patient, vigorous athletic exertion may have contributed to twisting of the cyst pedicle, leading to vascular compromise and hemorrhagic infarction. Progressive edema and inflammatory response then produced severe scrotal pain and swelling.

Prompt surgical treatment in this patient prevented unnecessary risk to the testis and provided rapid symptom relief. Simple cyst excision generally achieves excellent outcomes when the epididymal blood supply remains intact. Preservation of epididymal tissue remains important because extensive excision near the epididymal head could theoretically influence future sperm transport. Histopathological examination remains advisable following excision of paratesticular lesions to exclude rare neoplastic conditions. Pediatric epididymal tumors are uncommon, although benign and malignant masses may occasionally resemble cystic abnormalities clinically or radiologically. Conservative observation may remain suitable for asymptomatic epididymal cysts detected incidentally. Surgical intervention is usually reserved for persistent pain, progressive enlargement, uncertainty of diagnosis, or complications such as torsion. Families should receive counseling regarding symptoms that warrant urgent reassessment, including sudden scrotal pain or rapid swelling.

Conclusion