Is a Saggy Scrotum a Sign of Testicular Atrophy?
No, a saggy scrotum is not a sign of testicular atrophy—testicular atrophy refers to reduced testicular size and firmness, not scrotal skin laxity. The scrotum is simply the skin and muscle layer that contains the testicles, and its appearance (saggy or not) does not indicate the health or size of the testicles themselves.
Understanding Testicular Atrophy vs. Scrotal Appearance
Testicular atrophy is characterized by decreased testicular volume and firmness, not by the appearance of the scrotal skin. 1 The key clinical finding in testicular atrophy is reduced testicular size, which is assessed by palpating the actual testicle within the scrotum, not by observing the scrotal sac itself. 1
What Testicular Atrophy Actually Means
- Atrophic testes are smaller in volume and often softer in consistency compared to normal testes. 1
- In non-obstructive azoospermia (testicular dysfunction), atrophic testes are a characteristic finding, typically associated with elevated FSH levels (>7.6 IU/L). 1
- Normal testicular volume is approximately 15-25 mL, and volumes below 12 mL may indicate atrophy, particularly in men under 40 years of age. 2
How to Properly Assess for Testicular Atrophy
During scrotal palpation, the testis must be differentiated from the epididymis and assessed for size and consistency. 3 The examination should focus on:
- Testicular volume: Compare both testicles for symmetry and size. 1
- Testicular consistency: Atrophic testes may feel softer or less firm than normal. 1
- Comparison to contralateral side: Use the opposite testicle as an internal control. 4
When physical examination is difficult or inadequate, scrotal ultrasonography is indicated to accurately measure testicular volume and assess architecture. 1 Ultrasound can objectively measure testicular dimensions and identify features associated with atrophy, including non-homogeneous testicular architecture and reduced blood flow. 1
Common Causes of Testicular Atrophy
Understanding the actual causes of testicular atrophy helps clarify that scrotal appearance is unrelated:
- Ischemic injury: Most frequently occurs after testicular torsion (intrauterine, prepubertal, or adult), which can lead to primary or secondary testicular atrophy. 5
- Surgical complications: Testicular atrophy can occur after inguinal hernioplasty due to thrombosis of spermatic cord veins from surgical trauma. 6
- Trauma: Blunt scrotal trauma can result in testicular atrophy in approximately 50% of cases, with reduced testicular volume and blood flow on follow-up ultrasound. 7
- Hormonal causes: Prolonged estrogen therapy leads to testicular atrophy with reduced spermatogenesis and decreased Leydig cells. 8
- Primary testicular dysfunction: Non-obstructive azoospermia presents with atrophic testes and elevated FSH. 1
Clinical Pitfall to Avoid
Do not confuse scrotal skin laxity or a "saggy" appearance with testicular atrophy. The scrotum naturally becomes more lax with age due to loss of skin elasticity and cremasteric muscle tone, but this has no bearing on testicular health or size. Proper assessment requires palpation of the actual testicles within the scrotum to evaluate their volume and consistency. 3