Testicular Atrophy Does Not Directly Cause Saggy Testicles
Testicular atrophy itself does not cause saggy testicles (scrotal laxity); these are separate anatomical phenomena. Testicular atrophy refers to reduced testicular volume and parenchymal dysfunction, while scrotal sagging relates to cremasteric muscle tone, dartos muscle function, and scrotal skin elasticity—none of which are directly affected by the size of the testicular parenchyma itself.
Understanding the Distinction
Testicular atrophy is defined as reduced testicular volume, typically below 12 mL, often accompanied by impaired spermatogenesis and hormonal dysfunction 1, 2. This condition results from:
- Ischemic injury from testicular torsion, trauma, or surgical complications (particularly after inguinal hernioplasty or orchiopexy) 3, 4, 5, 6
- Gonadotoxic treatments including chemotherapy and radiotherapy 1
- Genetic conditions such as Klinefelter syndrome 7
- Chronic diseases including liver cirrhosis, chronic alcoholism, and hemochromatosis 7
Scrotal laxity (saggy testicles), conversely, is determined by the tone and elasticity of scrotal structures—the dartos muscle, cremasteric muscle, and scrotal skin—which are independent of testicular parenchymal volume.
Clinical Implications of Testicular Atrophy
When testicular atrophy is present, the critical concerns are:
Fertility Assessment
- Elevated FSH levels above 7.6 IU/L combined with testicular atrophy strongly indicates spermatogenic failure 8
- However, up to 50% of men with non-obstructive azoospermia and testicular atrophy may still have retrievable sperm with microsurgical testicular sperm extraction (micro-TESE) 2
- Semen analysis remains the definitive test for fertility status, as ultrasound and hormonal findings are suggestive but not diagnostic 9
Malignancy Risk
- Atrophic testes (volume <12 mL) carry increased risk for testicular germ cell tumors, particularly in men under 40 years of age 1, 2, 8
- Men with testicular atrophy should perform regular testicular self-examination and be monitored for malignancy 8
- Testicular biopsy should be considered when atrophy is combined with testicular microcalcifications or other high-risk features 1, 8
Hormonal Function
- Testicular atrophy, particularly bilateral, may result in Leydig cell dysfunction and hypogonadism 1
- Testosterone levels should be evaluated, though testosterone replacement should be delayed until continuous signs or symptoms of deficiency are present 1
Common Pitfalls to Avoid
Do not assume that a smaller testis automatically means permanent infertility—a slightly smaller testis with normal vascularity and homogeneous ultrasound structure does not indicate irreversible damage 9. Conversely, non-homogeneous testicular architecture, reduced blood flow on Doppler, and elevated FSH are the true markers of irreversible testicular dysfunction 9, 8.
Avoid confusing scrotal appearance with testicular function—the cosmetic concern of scrotal laxity is unrelated to the medical significance of testicular atrophy, which centers on fertility potential and cancer risk.