Can Inguinal Surgery Cause Testicular Atrophy?
Yes, inguinal surgery can cause testicular atrophy, though it remains an uncommon complication with rates ranging from 1-8% in pediatric hernia repairs and occurring at 5.1/10,000 person-years in children overall. 1, 2
Risk Varies by Patient Population and Surgical Context
Pediatric Patients (Highest Risk Groups)
- Children under 2 years have the highest risk, with 72% of all testicular atrophy cases occurring in children younger than 2 years following inguinal hernia repair 2
- Infants with undescended testis face substantially elevated risk at 13.9/10,000 person-years compared to the general pediatric population 2
- Preterm infants at 43 weeks corrected gestational age or younger demonstrate higher complication rates, likely due to greater friability of the hernia sac 1
Adult Patients
- Testicular atrophy occurs in adults primarily with identifiable risk factors present in 80% of cases, including previous groin or scrotal surgery, recurrent hernias requiring multiple repairs, and large scrotal hernias 3, 4
- Long-standing incarcerated hernias (particularly those present for years) can cause testicular atrophy through chronic compression of testicular vessels, independent of surgical intervention 5
Mechanism and Timing of Atrophy
How Atrophy Develops
The complication arises through ischemic orchitis caused by:
- Overzealous dissection of the distal hernia sac from the spermatic cord, particularly in complete indirect inguinal hernias 3, 4
- Injury to the vas deferens or testicular vessels during surgical manipulation 1
- Mesh placement causing vascular compromise 6
- Dislocation of the testis from the scrotum into the surgical wound 3
When Atrophy Manifests
- 30% of cases are diagnosed within 1 year of surgery 2
- 75% occur within 3 years, with median time to diagnosis of 2.4 years 2
- Early recognition is critical: prompt exploration and mesh loosening or removal within 8-20 hours of symptom onset can reverse testicular ischemia and prevent atrophy 6
Surgical Techniques to Minimize Risk
Critical Preventive Measures
- Avoid complete dissection of distal hernia sac in scrotal hernias; leave the distal portion in place rather than dissecting it entirely from the spermatic cord 4
- Use inguinal approach with early vascular control at the internal inguinal ring before testicular manipulation 1, 7
- Never violate the scrotum for biopsy or open surgery; always use inguinal incision 1
- Avoid concomitant scrotal surgery during hernia repair 3
- Consider preperitoneal approach in recurrent hernias to avoid re-dissecting previously mobilized spermatic cords 4
Preoperative Counseling Requirements
Mandatory Patient Discussions
For high-risk patients (scrotal hernias, recurrent hernias, previous groin surgery):
- Explicitly warn about increased risk of ischemic orchitis and testicular atrophy before surgery 3, 4
- Patients with 2 or more prior hernia operations should provide written permission for orchiectomy, though this is rarely necessary 4
- Document this counseling given the litigious nature of this complication 3, 4
For testicular-sparing surgery in cancer patients:
- Discuss higher risk of local recurrence, need for monitoring with physical examination and ultrasound, and risk of testicular atrophy requiring testosterone replacement therapy 1
Special Considerations
Testicular Sparing Surgery Context
When performing organ-preserving testicular surgery (for bilateral tumors, solitary testis, or contralateral atrophic testis):
- Mandatory postresection testicular radiotherapy renders residual tissue azoospermic but retains some testosterone production 1
- This represents an intentional trade-off rather than a complication 1