A Tunica Albuginea Cyst

Adam J. Singer, MD

Disclosures

November 29, 2001

Discussion

Left radical orchiectomy is not correct. A radical orchiectomy is generally reserved for malignant conditions of the testicle and paratesticular structures. A benign cyst of the tunica albuginea of the testicle, as demonstrated in the present case, does not require surgery. Cysts of the tunica albuginea are uncommon. The first 4 cases were reported in 1841 by Cooper.[1] Martinez-Berganza and associates[2] reported on a 4-year study of 392 consecutive sonograms of 775 testicles performed for "any kind of scrotal disorder." Ages of the patients ranged from 1 to 86 years. Three cases (0.76%) of tunica albuginea cysts were found. Nistal and colleagues[3] reported an incidence of 0.3% in adult males at autopsy. Warner and coworkers[4] found that most males were affected in the fifth and sixth decades of life. Cysts were either asymptomatic and discovered incidentally or associated with pain and swelling.

Observation is correct. Cysts of the tunica albuginea do not require surgical intervention except when the diagnosis is in question.[5] They are readily identifiable as anechoic structures on sonography and are most often found on the anterior and lateral aspects of the superior pole of the testicle, although cysts on the anterior inferior pole of the testicle have been described.[2,3] Cysts of the tunica albuginea are classified as extratesticular, because they occur within the fibrous capsule of the testicle. They can present a diagnostic dilemma because they may be unilocular, multilocular, or septate. Serial ultrasounds reveal that individual cysts commonly become larger or smaller over time. The present case is unique, because complete resolution of the cyst occurred over a 5-month period. This has not been described previously.

The etiology of cysts of the tunica albuginea is unknown. Several theories have been proposed including trauma, hemorrhage, infection, and the result of embryonic remnants trapped in the tunica albuginea during the developmental phase.[4,6,7,8] Several embryonic remnants have been implicated such as mesothelial rests, congenital ducts of cul-de-sac structure, dilated efferent ductules that pass through the tunica en route to the epididymis, müllerian remnants, and wolffian structures.[2,6,7,8]

Transscrotal incision and drainage of the cyst is not correct. Pain and swelling of tunica albuginea cysts are common; however, incision and drainage are not indicated, because these cysts are not abscess cavities. Surgical management is both diagnostic and therapeutic. Surgical options may include transscrotal excision, excisional biopsy through an inguinal incision, and radical orchiectomy.[6] The operation of choice should be individualized based on the level of clinical suspicion for malignancy. Intraoperative frozen sections are very helpful in making a decision about the appropriate surgical approach. Histologically, cyst fluid ranges in color from brown to clear. The amount of cellular debris and degree of turbidity varies. The cysts are lined by flattened, nonstratified, cuboidal to low columnar epithelium with or without cilia and microvilli. The surface epithelium is usually unicellular; however, cuboidal cells underlying a layer of flattened cells have also been described.[3] The epithelial lining rests on a basal lamina surrounded by a fibrous capsule of varying thickness. The capsule consists of mature collagen and often contains gland-like structures.

Computerized tomographic scan of the abdomen and pelvis to rule out metastasis is not correct. There is no indication to perform a computerized tomographic scan of the abdomen and pelvis. Cysts of the tunica albuginea are uniformly benign. There are no reports of metastasis in the literature.

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