Is a saggy scrotum a sign of testicular atrophy?

Is a Saggy Scrotum a Sign of Testicular Atrophy?

No, a saggy scrotum is not a sign of testicular atrophy—testicular atrophy is diagnosed by reduced testicular size and firmness on physical examination, not by scrotal skin laxity.

Understanding Testicular Atrophy

Testicular atrophy refers to actual reduction in testicular volume and is a pathological finding with clinical significance, not a cosmetic or anatomical variation of the scrotal skin. The key diagnostic features are:

Physical Examination Findings of True Testicular Atrophy

• Reduced testicular volume is the hallmark finding, which can be assessed using a Prader orchidometer or scrotal ultrasound 1
• Decreased testicular firmness on palpation, with the testis feeling softer than normal 1
• Associated biochemical abnormalities including elevated FSH (typically >7.6 IU/L) when atrophy is due to spermatogenic failure 1

What Scrotal Sagging Actually Represents

A "saggy scrotum" refers to laxity or redundancy of the scrotal skin and dartos muscle, which is:

• A normal anatomical variation related to age, temperature regulation, and individual anatomy
• Not indicative of testicular pathology unless accompanied by actual reduction in testicular size
• The scrotum naturally relaxes in warm environments and contracts in cold environments as a thermoregulatory mechanism

Clinical Causes of True Testicular Atrophy

When actual testicular atrophy is present (reduced testicular volume), the following etiologies should be considered:

Ischemic Causes

• Testicular torsion is a primary cause of testicular atrophy due to ischemia, particularly when treatment is delayed beyond 6-8 hours 2, 3
• Scrotal trauma causes testicular atrophy in approximately 50% of cases, with reduced testicular volume documented on follow-up ultrasound 4
• Surgical complications from inguinal hernioplasty can cause atrophy due to thrombosis of spermatic cord veins from surgical dissection trauma 5, 6

Hormonal and Developmental Causes

• Cryptorchidism (undescended testis) with delayed or complicated orchiopexy frequently results in secondary testicular atrophy 3
• Hormonal therapy, particularly estrogen treatment, causes marked testicular atrophy with reduced spermatogenesis and Leydig cell reduction 7
• Genetic conditions such as Klinefelter syndrome (47,XXY) present with testicular atrophy and elevated FSH 1

Diagnostic Approach When Testicular Atrophy Is Suspected

Physical Examination Priorities

• Measure testicular volume using a Prader orchidometer—this is the primary assessment tool 1
• Assess testicular consistency—atrophic testes are typically softer and smaller 1
• Evaluate for associated findings such as epididymal abnormalities, absent vas deferens, or varicocele 1

Laboratory Evaluation

• FSH level: Elevated FSH (>7.6 IU/L) suggests primary testicular failure with atrophy 1
• Testosterone level: May be reduced in bilateral testicular atrophy
• Karyotype testing: Recommended when testicular atrophy is accompanied by azoospermia or severe oligospermia (<5 million/mL) 1

Imaging When Indicated

• Scrotal ultrasound is useful when physical examination is difficult (large hydrocele, inguinal testis, thickened scrotal skin) or to assess testicular architecture 1
• Ultrasound can detect non-homogeneous testicular architecture and microcalcifications associated with testicular dysgenesis 1

Critical Clinical Pitfall

Do not confuse normal scrotal skin laxity with testicular atrophy. The diagnosis of testicular atrophy requires documentation of reduced testicular volume (typically <12-15 mL in adults) and should prompt investigation for underlying causes including genetic abnormalities, prior torsion, trauma, or hormonal disorders 1. Scrotal appearance alone, without palpable reduction in testicular size, does not warrant extensive workup.