Scrotal Sagging vs. Testicular Atrophy: Key Distinction
No, a sagging scrotum is not a sign of testicular atrophy—these are distinct clinical entities that must be differentiated through proper physical examination and measurement of testicular volume.
Understanding the Distinction
A sagging or pendulous scrotum reflects laxity of the scrotal skin and dartos muscle, which is a normal age-related change or anatomical variant. In contrast, testicular atrophy refers to reduction in actual testicular parenchymal volume, typically defined as testicular volume <12 mL or significant volume differential between testes 1, 2.
Clinical Assessment of True Testicular Atrophy
Physical examination must differentiate the scrotum from the testis itself:
- Palpation technique: The testis must be isolated and distinguished from the epididymis during examination 3
- Volume measurement: Use orchidometer or ultrasound to objectively measure testicular volume 4
- Volume differential: A significant difference between testes (typically >20% or >2 mL) suggests pathology 4
- Texture assessment: Atrophic testes may feel softer or have altered consistency 1
Clinical Scenarios Associated with True Testicular Atrophy
High-risk conditions where atrophy occurs:
- Post-torsion: Ischemia from testicular torsion is the most frequent cause of primary and secondary testicular atrophy 5
- Cryptorchidism: Especially after orchiopexy for high undescended testis, secondary atrophy is frequent 5
- Varicocele: Associated with testicular atrophy in 15-40% of affected men, with worse outcomes at higher grades 1, 4
- Testicular cancer: 5-30% of testicular cancer patients have contralateral testicular atrophy, with highest risk (~30%) when testicular volume <12 mL and age <40 years 2
- Scrotal trauma: Results in testicular atrophy in approximately 50% of cases at follow-up 6
- Post-hernioplasty: Thrombosis of spermatic cord veins from surgical trauma can cause atrophy 7
Critical Clinical Pitfall
Do not confuse scrotal appearance with testicular pathology. A visually sagging scrotum may contain normal-sized testes, while a normal-appearing scrotum may harbor atrophic testes. The key is objective measurement of testicular volume through palpation with orchidometer or ultrasound assessment 4, 3.
When Testicular Atrophy Matters Clinically
Atrophy has significant implications for:
- Fertility: Non-obstructive azoospermia commonly presents with testicular atrophy, though 50% still have retrievable sperm with microsurgical extraction 2
- Hormonal function: Leydig cell dysfunction and hypogonadism risk increases with atrophy 1
- Cancer risk: Marked testicular atrophy warrants consideration of contralateral testis biopsy in testicular cancer patients, particularly with cryptorchid history 2
- Testicular microcalcification: When combined with atrophy and infertility, significantly increases testicular cancer risk 1