Is a Recent Saggy Scrotum a Sign of Testicular Atrophy?
A recently saggy scrotum is NOT a reliable indicator of testicular atrophy; testicular atrophy is diagnosed by actual reduction in testicular size (>50% volume difference compared to the contralateral testis), not by scrotal appearance. 1
Understanding Testicular Atrophy vs. Scrotal Changes
Testicular atrophy is defined by measurable reduction in testicular volume, not by scrotal skin laxity or appearance. The key diagnostic criteria include:
- Volume reduction >50% compared to the contralateral testis, measured by Prader orchidometer or ultrasound 2
- Elevated FSH levels (>7.6 IU/L) in the presence of small, atrophic testes suggests spermatogenic failure 1
- Palpable testicular firmness and size on physical examination are the actual indicators, not scrotal skin characteristics 1
What Actually Causes Testicular Atrophy
The most common causes of testicular atrophy involve ischemic injury, not changes in scrotal appearance:
- Testicular torsion is the most frequent cause, particularly when diagnosis is delayed beyond 6-8 hours 3, 4
- Post-surgical complications including inguinal hernioplasty with venous thrombosis of the spermatic cord 5
- Scrotal trauma causes atrophy in approximately 50% of cases 6
- Cryptorchidism and orchiopexy complications, especially in high undescended testes 7
Critical Diagnostic Approach
If you suspect testicular atrophy, perform a focused physical examination measuring actual testicular size:
- Palpate both testes and compare volumes directly 1
- Order testicular ultrasound to objectively measure testicular volume and assess echogenicity 2
- Check FSH levels if atrophy is confirmed, as elevated FSH (>7.6 IU/L) indicates spermatogenic failure 1
- Obtain karyotype testing if atrophy is accompanied by infertility, azoospermia, or oligospermia with sperm concentration <5 million/mL 1
Common Pitfalls to Avoid
Do not confuse normal scrotal relaxation with testicular atrophy. The scrotum naturally becomes more lax with:
- Age-related changes in scrotal skin elasticity
- Temperature regulation causing cremasteric relaxation
- Weight loss affecting scrotal fat content
None of these represent true testicular atrophy, which requires documented reduction in testicular parenchymal volume 2
When to Worry About Recent Changes
Acute scrotal changes warrant urgent evaluation only when accompanied by:
- Sudden severe pain suggesting testicular torsion requiring intervention within 6-8 hours 3, 4
- Palpable reduction in testicular size compared to baseline or contralateral side 1
- History of recent trauma, surgery, or infection that could cause ischemic injury 5, 6, 7
Testicular atrophy develops over months, with median time to clinical evidence of 12.5 months post-injury, and all cases showing atrophy by 14 months except those who defaulted follow-up 2