In testicular atrophy, does the testicle hang lower and does the scrotal skin become baggy?

Testicular Atrophy and Scrotal Appearance

In testicular atrophy, the testicle typically does not hang lower; instead, the scrotum often appears smaller and more contracted due to reduced testicular volume, though the scrotal skin itself may appear relatively redundant or "baggy" in comparison to the diminished testicular mass within. 1

Physical Changes in Testicular Atrophy

Testicular Position and Scrotal Contour

• Atrophic testicles (volume <12 mL) do not characteristically descend lower in the scrotum; rather, the reduced testicular mass results in a smaller, more contracted scrotal sac. 1

• The cremasteric reflex and dartos muscle tone typically maintain testicular position regardless of size, so atrophy does not cause the testicle to "hang lower" as might occur with a hydrocele or other fluid collections. 2

• The scrotal skin may appear relatively excessive or "baggy" compared to the reduced testicular volume, creating a visual impression of redundant skin, but this is a relative change rather than true skin laxity. 2

Associated Scrotal Changes

• Reactive hydrocele (fluid accumulation around the atrophic testis) can develop alongside testicular atrophy, which may alter scrotal appearance and create the impression of a larger or more pendulous scrotum despite the underlying testicular atrophy. 2

• Scrotal wall thickening may occur with inflammatory conditions like epididymo-orchitis, which can both contribute to testicular atrophy and change the texture and appearance of the scrotal skin. 2

• In cases of unilateral testicular atrophy, the affected side of the scrotum may appear smaller and more contracted compared to the contralateral normal side, creating asymmetry rather than bilateral "bagginess." 2

Clinical Assessment of Atrophic Testicles

Physical Examination Findings

• Testicular atrophy is defined as volume <12 mL, which can be assessed through physical examination using a Prader orchidometer or confirmed via scrotal ultrasound. 1, 2

• Physical examination should assess testicular size, consistency (atrophic testes often feel softer), and presence of associated abnormalities such as varicoceles, epididymal abnormalities, or hydroceles. 2

• Scrotal ultrasound is indicated when physical examination is difficult due to large hydrocele, inguinal testis, epididymal enlargement/fibrosis, thickened scrotal skin, or when the epididymis appears disproportionately large compared to testicular volume. 1, 2

Common Causes of Testicular Atrophy

• Cryptorchidism (undescended testicles) is the single most important risk factor for testicular atrophy, with the cryptorchid testis often remaining small even after surgical correction due to prenatal testicular damage or injury to blood vessels during orchiopexy. 3, 4, 5

• Scrotal trauma causes testicular atrophy in approximately 50% of cases, with significant reduction in testicular volume observed months to years following blunt scrotal injury. 6

• Inguinal hernia repair can result in testicular atrophy due to thrombosis of spermatic cord veins from surgical trauma, particularly with overzealous dissection of the distal hernia sac or dislocation of the testis during surgery. 7, 8

• Testicular torsion, mumps orchitis, and other ischemic events frequently lead to testicular atrophy through vascular compromise and subsequent tissue loss. 4, 5

• Systemic conditions including liver cirrhosis, chronic alcoholism, hemochromatosis, and myotonic dystrophy can cause bilateral testicular atrophy. 4

• Klinefelter syndrome (47,XXY) is the most common genetic cause of testicular atrophy, presenting with a spectrum from eunuchoid hypogonadism to normally virilized but sterile males with small testes. 1, 4

• Chemotherapy, radiation therapy, and immunosuppressive drugs may lead to testicular atrophy as a side effect of treatment. 4

Clinical Significance and Monitoring

Cancer Risk Considerations

• Men with testicular atrophy (volume <12 mL) have a significantly increased risk of intratubular germ cell neoplasia (TIN), particularly those under age 30-40 years with a history of cryptorchidism, with a ≥34% risk of TIN in the contralateral testis if testicular cancer develops. 1

• Untreated TIN progresses to invasive testicular cancer in approximately 70% of cases within 7 years, making surveillance and early detection critical. 1

• Men with testicular atrophy should be taught testicular self-examination and monitored for development of masses or rapid changes in testicular size. 1, 2

Fertility Implications

• Testicular volume <12 mL strongly correlates with impaired spermatogenesis, reduced total sperm count, and decreased sperm concentration, though complete azoospermia is not universal. 1, 2

• Elevated FSH levels (>7.6 IU/L) combined with testicular atrophy indicate reduced testicular reserve and warrant semen analysis and hormonal evaluation. 2, 9

• Sperm cryopreservation should be discussed with men who have testicular atrophy and desire future fertility, particularly before any gonadotoxic treatments or if semen parameters show declining trends. 9