Causes of Sagging Scrotal Skin in Males
Primary Physiological Cause
Sagging scrotal skin in males is primarily a normal age-related phenomenon caused by loss of skin elasticity and progressive relaxation of the dartos muscle and cremasteric fascia over time. This is a natural consequence of aging rather than a pathological condition requiring medical intervention 1, 2.
Normal Anatomical Changes
- Age-related laxity develops as collagen and elastin fibers in the scrotal skin degrade with advancing age, leading to progressive descent of the scrotum 1, 2
- The dartos muscle, which normally contracts to maintain scrotal tone and temperature regulation, loses its contractile function over decades 2
- This process is universal among aging men and does not indicate underlying disease in most cases 1
Pathological Causes to Consider
While most scrotal sagging is benign, certain conditions can contribute to or mimic excessive laxity:
Chronic Scrotal Conditions
- Chronic hydrocele can cause progressive stretching of scrotal skin over time, leading to persistent laxity even after the fluid is resolved 3, 4
- Large varicoceles may contribute to scrotal heaviness and apparent sagging due to venous engorgement 3
- Chronic epididymitis with recurrent inflammation can lead to tissue changes and altered scrotal contour 5
Dermatological Conditions
- Lichen sclerosus affecting the scrotum can cause skin thinning, atrophy, and altered texture, though this typically presents with white plaques and scarring rather than simple sagging 5
- Chronic inflammatory skin conditions may alter scrotal skin quality over time 5
Important Clinical Distinctions
When Sagging is NOT the Primary Problem
Critical pitfall: Do not overlook acute scrotal conditions that may present with apparent swelling or changes in scrotal appearance:
- Testicular torsion presents with acute pain and swelling, not gradual sagging, and requires surgical exploration within 6 hours 5, 3
- Epididymoorchitis causes acute painful swelling with erythema, not chronic laxity 5
- Inguinal hernias can create intermittent scrotal bulging that appears and disappears with position changes or Valsalva maneuver 6
- Testicular masses require urgent evaluation with scrotal ultrasound to rule out malignancy 6, 3
Red Flags Requiring Evaluation
Patients presenting with "scrotal sagging" should be evaluated for:
- Any palpable masses within the scrotum require duplex Doppler ultrasound to differentiate intratesticular from extratesticular pathology 6, 3
- Pain, erythema, or acute changes suggest infection or torsion rather than simple laxity 5
- Urinary symptoms may indicate associated conditions like phimosis with meatal stenosis or Fournier's gangrene 5
Management Considerations
Conservative Management
- Most men with age-related scrotal laxity require no medical treatment as this is a normal physiological change 1, 2
- Supportive undergarments can provide comfort for men experiencing discomfort from excessive laxity 2
Surgical Options
- Scrotoplasty (scrotal reduction surgery) is available for men with significant functional impairment, skin chafing, or aesthetic concerns 2
- A nonsurgical alternative using absorbable suspension sutures (the SCROTUM procedure) has been proposed but lacks robust outcome data 1
- Surgical complications include hematoma (most common), requiring meticulous hemostasis during the procedure 2
- Recurrence requiring revision surgery is uncommon, and patient satisfaction is typically high 2
Clinical Approach Algorithm
- Determine acuity: Acute onset (hours to days) versus chronic/gradual (months to years) 5
- Assess for pain: Painful conditions require urgent evaluation for torsion or infection 5, 3
- Perform careful palpation: Any discrete masses mandate scrotal ultrasound 6, 3
- Evaluate functional impact: Determine if laxity causes physical discomfort, hygiene issues, or quality of life concerns 2
- Reassure when appropriate: Most age-related laxity is benign and requires only reassurance 1, 2