What are the treatment options for a male in his late 20s to 30s with age-related scrotal relaxation?

Age-Related Scrotal Relaxation: Treatment Options

For men in their late 20s to 30s with bothersome scrotal laxity, surgical scrotoplasty with vertical midline skin resection is the definitive treatment, while a novel nonsurgical option using absorbable suspension sutures (the SCROTUM procedure) may be considered for those seeking less invasive intervention. 1, 2

Understanding the Condition

Age-related scrotal relaxation manifests as an enlarged scrotal bag hanging more than 1-2 cm below the tip of the penis, often associated with persistent penoscrotal webbing 1. This condition causes:

• Discomfort while wearing loose clothing 1
• Pain or difficulty during walking and sports activities 1
• Interference with sexual intercourse 1
• Significant impact on quality of life and daily activities 1

Important caveat: This is a poorly defined entity in medical literature with limited high-quality evidence, and no established clinical guidelines exist for diagnosis or management 1.

Treatment Algorithm

First-Line: Surgical Scrotoplasty

For patients with excessive scrotal skin causing functional impairment, vertical midline scrotal skin resection is the recommended surgical approach 1. The procedure involves:

• Resection of redundant scrotal skin through a vertical midline incision 1
• If penoscrotal webbing is present, addition of Z-plasty at the penoscrotal junction 1
• This addresses both the hanging scrotum and any associated webbing deformity 1

Key consideration: Most published literature consists of case reports and surgical technique descriptions rather than comparative studies, reflecting the limited evidence base for this condition 1.

Alternative: Nonsurgical SCROTUM Procedure

For men seeking nonsurgical management, the Sutures Can Raise by Orienting Threads in an Upward Manner (SCROTUM) procedure offers a minimally invasive option 2. This technique:

• Uses bidirectional, fully absorbable suspension sutures and cones 2
• Provides nonsurgical lifting of the sagging scrotum 2
• Represents the only described nonsurgical treatment alternative to traditional scrotoplexy 2

Critical limitation: This is a novel technique with minimal published outcomes data, and long-term efficacy remains unknown 2.

Differential Diagnosis Considerations

Before attributing symptoms solely to age-related laxity, exclude:

• Chronic orchialgia: Affects men in their mid to late 30s and can present with scrotal discomfort; 25-50% of cases are idiopathic 3
• Varicocele, epididymal cysts, or hydrocele: Can contribute to scrotal heaviness and discomfort 3
• Testicular pathology: Any new scrotal mass or asymmetry requires ultrasound evaluation to exclude malignancy 4

Physical examination should specifically assess: scrotal skin redundancy (>1-2 cm below penile tip), presence of penoscrotal webbing, testicular position and consistency, and any associated masses or fluid collections 1.

Clinical Pitfalls to Avoid

• Do not confuse with pathologic conditions: Age-related laxity is distinct from scrotomegaly due to lymphedema, infection, or other pathologic processes 1
• Avoid invasive testing: For isolated scrotal laxity without concerning features, extensive diagnostic workup is not indicated 3
• Recognize psychological factors: In cases where symptoms seem disproportionate to physical findings, consider psychosocial contributors to symptom perception 3
• Set realistic expectations: The evidence base for both surgical and nonsurgical treatments remains limited, and outcomes data are sparse 1, 2

Evidence Quality Assessment

The available evidence for treating age-related scrotal relaxation is notably weak:

• No randomized controlled trials exist comparing treatment modalities 1
• Most literature consists of case reports and technique descriptions 1
• No consensus exists on nomenclature, diagnostic criteria, or treatment algorithms 1
• The nonsurgical SCROTUM procedure has minimal published outcomes 2

Given this limited evidence base, treatment decisions should be made cautiously, with thorough informed consent regarding the experimental nature of interventions and uncertain long-term outcomes.