What could be causing my testicular atrophy, which has progressed over the past 6 weeks?

Testicular Atrophy Over 6 Weeks: Urgent Evaluation Required

You need urgent scrotal ultrasound with Doppler to rule out testicular torsion, testicular cancer, and other serious causes—testicular shrinkage over 6 weeks is abnormal and requires immediate medical evaluation. 1, 2

Immediate Concerns to Rule Out

Testicular Torsion (Acute or Intermittent)

• Testicular torsion causes progressive testicular damage and atrophy if not surgically corrected, even if blood flow is partially restored 2, 3
• Color Doppler ultrasound is the recommended initial imaging modality with high sensitivity for detecting torsion 3
• The "whirlpool sign" on ultrasound indicates twisted spermatic cord with 96% sensitivity and 99% specificity 3
• Testicular atrophy occurs in 50% of patients even after successful salvage surgery, particularly when symptoms exceed 24 hours 4
• Duration of pain >1 day and heterogeneous echogenicity on ultrasound predict atrophy 4

Testicular Cancer

• Men with testicular atrophy (volume <12 ml) under age 40 have ≥34% risk of testicular intraepithelial neoplasia (TIN), which progresses to invasive cancer in 70% within 7 years if untreated 1
• Infertile men have nearly 2-fold increased risk of testicular cancer (OR 1.91) 1
• Scrotal ultrasound is essential for detecting testicular tumors, assessing testicular anatomy, and identifying microcalcifications 1

Other Important Causes to Consider

Cryptorchidism (Acquired/Secondary Ascent)

• Undescended or ascending testes undergo progressive germ cell loss starting after 15-18 months of age 2, 5
• Acquired cryptorchidism (secondary ascent) occurs when a previously descended testis ascends and cannot be manipulated back into the scrotum 5
• Retractile testes carry 2-45% risk of becoming truly undescended during childhood 5

Trauma

• Scrotal trauma causes testicular atrophy in 50% of cases at follow-up, with reduced volume and heterogeneous appearance on ultrasound 6
• Ischemia from trauma leads to progressive testicular damage 7

Hormonal/Medication Causes

• Exogenous testosterone and anabolic steroids cause testicular atrophy through feedback inhibition of the hypothalamic-pituitary-testicular axis, suppressing spermatogenesis 8
• This effect may be irreversible even after discontinuation 8
• Testicular atrophy, subfertility, and infertility are reported in men who abuse anabolic androgenic steroids 8

Post-Surgical

• Inguinal hernia repair can cause testicular atrophy due to thrombosis of spermatic cord veins from surgical trauma 9
• Orchiopexy for undescended testis carries risk of secondary testicular atrophy, especially in high undescended testis 7

Recommended Evaluation Algorithm

1. Immediate scrotal ultrasound with color Doppler to assess:

   • Testicular volume and echogenicity 1
   • Blood flow to rule out torsion or vascular compromise 3
   • Presence of masses or microcalcifications 1
   • Testicular architecture (homogeneous vs heterogeneous) 1

2. Physical examination focusing on:

   • Testicular position (descended, retractile, or undescended) 5
   • Consistency and size comparison to contralateral testis 1
   • Presence of pain, tenderness, or masses 1

3. Laboratory evaluation:

   • Testosterone, LH, FSH to assess hormonal status 1
   • Tumor markers (AFP, β-hCG, LDH) if cancer suspected 1

4. Medication/exposure history:

   • Anabolic steroids or testosterone use 8
   • Recent trauma or surgery 9, 6

Critical Pitfalls to Avoid

• Do not delay imaging for suspected torsion—even intermittent torsion causes progressive atrophy 2, 4
• Do not assume a retractile testis is benign—it requires annual monitoring for secondary ascent 5
• Do not dismiss small testicular volume in young men—this is the highest risk group for TIN and cancer 1
• Do not overlook medication history—testosterone/steroid use is a reversible but often overlooked cause 8