What are the symptoms and treatment options for testicular atrophy?

Testicular Atrophy: Clinical Presentation and Management

Understanding the Statement About Firmness

The assertion that "true testicular atrophy looks very different" and involves increased firmness rather than softness requires clarification based on the clinical context and underlying pathology.

Clinical Presentation of Testicular Atrophy

Physical Examination Findings

Testicular atrophy is primarily defined by reduced testicular volume (<12-16 ml), not by changes in consistency 1, 2. The texture and firmness depend entirely on the underlying cause:

• Post-torsion atrophy: The testis typically becomes firm and fibrotic due to ischemic injury and subsequent scarring, which occurs in approximately 54% of patients who undergo testicular salvage 3
• Post-surgical atrophy: Following inguinal hernioplasty or orchiopexy, atrophy results from venous thrombosis and ischemia, leading to firm, fibrotic tissue 4, 5
• Cryptorchidism-related atrophy: The undescended testis may have variable consistency but is characterized primarily by small volume 1, 6
• Chronic compression: Long-standing incarcerated hernias can cause atrophy with variable consistency depending on the degree of vascular compromise 7

Key Diagnostic Criteria

Volume measurement is the gold standard for diagnosing testicular atrophy, with <12 ml considered atrophic 1. This should be assessed by:

• Testicular ultrasound with 7.5 MHz transducer for accurate volume measurement and to rule out underlying malignancy 1, 2
• Prader orchidometer for clinical assessment 3
• Comparison with contralateral testis, with >50% volume difference indicating significant atrophy 3

Comprehensive Diagnostic Workup

Initial Laboratory Assessment

When testicular atrophy is identified, obtain:

• Hormone panel: Total testosterone, LH, FSH to assess for hypogonadism 2, 8
• Tumor markers: AFP, β-HCG, LDH if malignancy is suspected, as atrophic testes have significantly increased cancer risk 1, 2
• Complete blood count, creatinine, electrolytes, liver function tests 1

Imaging Protocol

Duplex Doppler ultrasound of both testes is mandatory to:

• Confirm atrophy and measure precise volume 2
• Assess the contralateral testis for abnormalities 1, 2
• Rule out intratesticular masses, as atrophic testes have elevated malignancy risk 1
• Evaluate blood flow patterns 9

High-Risk Populations Requiring Biopsy

Contralateral testis biopsy is recommended in patients with testicular atrophy (<16 ml) and age <40 years, as they have a ≥34% risk of testicular intraepithelial neoplasia (TIN) 1, 6. The biopsy must be:

• Open incisional approach (not needle biopsy) via inguinal incision with early spermatic cord control 6
• Tissue preserved in Stieve's or Bouin's solution (not formalin) for accurate TIN detection 6
• Performed at time of orchiectomy for the affected testis to avoid a second procedure 6

Treatment Algorithm Based on Etiology

Unilateral Atrophy with Normal Contralateral Testis

If the contralateral testis is normal and functioning, orchiectomy of the atrophic testis should be considered due to increased malignancy risk 2, 6. This is particularly important in:

• Post-pubertal cryptorchidism with atrophy 6
• History of testicular torsion with documented atrophy 3
• Atrophy following inguinal hernia with chronic compression 7

Bilateral Atrophy or Solitary Atrophic Testis

Organ-preserving approaches must be prioritized when both testes are affected or only one testis remains 1, 2:

• Testosterone replacement therapy is indicated for symptomatic hypogonadism (low testosterone with symptoms) 8
• Regular surveillance with ultrasound and tumor markers due to elevated cancer risk 2
• Partial orchiectomy may be considered in highly experienced centers if a focal lesion develops 1

Fertility Preservation Considerations

Sperm banking must be discussed before any surgical intervention, radiotherapy, or chemotherapy that might affect fertility 1, 2, 6. This is critical because:

• Patients with unilateral atrophy often have baseline fertility impairment 6
• The contralateral testis may have subclinical dysfunction 6
• Any additional intervention (surgery, radiation) will further compromise fertility 1

Specific Management of TIN in Atrophic Testis

If biopsy confirms TIN in an atrophic testis:

Radiotherapy (20 Gy in 10 fractions over 2 weeks) definitively treats TIN but destroys fertility 1, 6. Patients must understand:

• Untreated TIN progresses to invasive cancer in 70% of cases within 7 years 6
• Surveillance is an acceptable alternative with regular ultrasound monitoring, accepting delayed cancer detection risk 6
• Radiotherapy should be delayed in patients desiring fertility, but for as short a period as possible 1

Follow-Up Protocol

Monitoring Schedule

All patients with testicular atrophy require long-term surveillance 2:

• Hormone levels (testosterone, LH, FSH) monitored regularly to detect hypogonadism 2
• Testicular ultrasound at regular intervals to detect malignancy early 2
• Self-examination education due to increased cancer risk 2
• Follow-up for at least 5 years in surveillance protocols 1

Timeline for Atrophy Development

Clinical evidence of atrophy typically manifests by 12-14 months post-injury, with median time to atrophy of 12.5 months after testicular salvage 3. However:

• Some patients may not present until years later if they default follow-up 3
• All patients with salvaged testes after torsion should be counseled that 54% will develop atrophy despite intraoperative viability assessment 3

Critical Pitfalls to Avoid

Surgical Technique Errors

Testicular atrophy after inguinal hernioplasty results from venous thrombosis due to surgical trauma, not infection or incorrect ring reconstruction 4, 5. To minimize risk:

• Leave the distal portion of indirect hernia sacs in situ whenever possible 4, 5
• Never dissect beyond the pubic tubercle 5
• Use properitoneal approach for recurrent hernias to avoid cord dissection entirely 5

Diagnostic Errors

• Never perform scrotal biopsy or scrotal incision for suspected malignancy—only inguinal orchiectomy is appropriate 1, 9
• Do not rely on consistency alone to diagnose or exclude atrophy; volume measurement is essential 1, 2
• Never delay evaluation of a testicular mass, even if intermittent, as cancer risk is elevated in atrophic testes 9

Timing Errors

Duration of symptoms >1 day in testicular torsion predicts 91% atrophy rate, and no testes survive when pain ≥3 days 3. Therefore:

• Immediate surgical exploration is mandatory for suspected torsion 9
• Patients undergoing salvage must be counseled about high atrophy risk 3
• Heterogeneous echogenicity on ultrasound predicts atrophy 3

Fertility Counseling Failures

Failing to discuss fertility preservation before definitive treatment is a critical error 2, 6. This must occur:

• Before orchiectomy 1, 2
• Before radiotherapy 1
• Before chemotherapy 1, 2