The testicles are one of the important organs of the genital system in men. The testis has two important functions such as producing sperm and secreting testosterone (male hormone). In addition to these, testicles are also important in the development of male secondary sexual characteristics. In some cases, testicular sizes are smaller than normal and this can lead to significant problems. In this article, I will give general information about testicular atrophy (atrophic testis).

What are the normal testis sizes?

The average normal testicle length in adults is 5 cm, 2 cm in width and 3 cm in height. Average testicular volume is around 18 ml in adults.

What does atrophic testis mean?

Testicular atrophy, or atrophic testis, means that the testis is smaller than its normal size. It can be seen unilaterally, that is, in only one testis, or in both testicles (bilateral) as testicular atrophy.

The sac (scrotum) that contains the testicles is a heat sensitive organ. In cases of exposure to cold, the testicles are pulled upwards by contracting, and in hot environments, they relax and cause the testicles to hang down. The testicles are heat sensitive organs. This contraction and relaxation of the scrotum against temperature change is to protect the testicles against the negative effects of excessive heat. In cases where the scrotum is contracted in this way, it may be misleading to evaluate the testicular dimensions. To truly examine the testicles, the patient must be standing and the scrotum in a relaxed position.

What are the causes of atrophic testis?

The causes of atrophic testicles are very diverse. Many causes, from infections of the testicles to cancers, cause testicular atrophy. We can list the causes of testicular atrophy as follows;

• Orchitis: Orchitis is an inflammatory disease of the testis. It can be bilateral and unilateral, or bilateral and unilateral. At the onset of orchitis, the testis is large and painful. Later, after the infection is treated and the disease is eliminated, reduction in testicular size, that is, atrophy, develops. This atrophic state varies according to the severity of the infection and the appropriate and timely treatment.

There are two types of orchitis (testicular inflammation) according to the cause:

Viral orchitis: The causative agent here is a virus. The most common cause of viral orchitis is mumps orchitis. About one-third of men who get mumps after puberty develop orchitis after 4-7 days.

Bacterial orchitis: Testicular infection caused by bacteria. It is more common than viral orchitis. It is more common in men of sexually active age. It often develops due to sexually transmitted diseases such as gonorrhea and chlamydia. Apart from this, bacterial orchitis can be seen as a result of urinary tract infection or insertion of a catheter into the urinary tract or endoscopic procedures.

• Varicocele: Varicocele is the enlargement of testicular veins (testicular veins), that is, its varicose veins. It can often be seen on the left side and sometimes bilaterally. If varicocele disease is not treated, the testicle size decreases over time and atrophy develops. It is one of the important diseases that cause testicular atrophy in young men. It is possible to prevent testicular atrophy if it is diagnosed and treated in the early period. If testicular atrophy has developed due to varicocele disease in adulthood, this situation cannot be corrected with surgery. Atrophy due to varicocele in the testicles in childhood is corrected with surgery and the testicles return to their normal size. In this regard, children’s varicoceles should not be neglected.
• Testicular torsion: This is a condition that occurs when the structure called the spermatic cord, in which the testicular vessels are located, rotates around itself and as a result, insufficient blood flow to the testis is not reached. Testicular torsion is an emergency. It is necessary to intervene within hours. If not intervened in time, it results in testicular atrophy. The most effective treatment is to surgically return the spermatic cord to its normal position and fix the testis to the scrotum.
• Old age: Due to aging, testicular sizes decrease in men. Testicular atrophy due to aging is bilateral, that is, there is a reduction in the size of both testicles.
• Excessive alcohol use: Especially in those who drink excessively, the serum testosterone hormone (male hormone produced by the testicles) decreases and testicular sizes are reduced. Alcohol-induced testicular atrophy (testicular atrophy) is bilateral, that is, it occurs in both testicles.
• Receiving external testosterone therapy: One of the most important tasks of the testicles is to produce the hormone testosterone. Some people take the hormone testosterone externally (Testosterone replacement therapy). In this case, the testicles do not work and the size of the testicles decreases, atrophic testis develops.
• Estrogen or anabolic steroid use: Men who receive external anabolic steroid or estrogen therapy develop atrophic testicles, just like those who take tertosterone. Atrophy is seen bilaterally in these individuals.
• Athletes taking drugs unconsciously: Atrophy can be seen in both testicles in those who receive external anabolic steroid or testosterone treatment (supplement) for body building.
• Trauma: As a result of unilateral or bilateral testicular trauma, the testicles may atrophy.
• Undescended testis (cryptorchidism): Sometimes the testicles are not in their normal place at birth, they are later lowered. In these cases, the normal scrotum should be lowered until 1 year of age. If the testicles are not lowered into the scrotum on time or if they are lowered late, atrophy develops.
• Surgical procedures: Testicular atrophy can be seen as a result of surgical interventions in which the vessels of the testis are adversely affected. These situations often occur in cases such as hernia and varicocele surgery. If great care is not taken during surgery, testis arteries are damaged and atrophy develops. In microsurgical varicocele surgery, testicular atrophy development is not seen since the artery is seen with a microscope.

What are the risks of testicular atrophy?

Atrophic testis is an important disease. It is a risk factor for some diseases. The risks (complications) of testicular atrophy include:

• Infertility: The testicles have 2 most important tasks: to produce testosterone and to produce pserm. If there is atrophy of the testis, these functions are negatively affected. If the atrophy is bilateral, both functions are severely affected. If the atrophy is unilateral and the other testis is normal, testosterone and sperm production may be normal.
• Erection problem: Erectile dysfunction (erectile dysfunction, ED, impotence) may occur due to the deficiency of testosterone hormone produced by the testicles.
• Testicular cancer: One of the most important risks (complications) of testicular atrophy is the development of testicular cancer. These patients should be followed closely for testicular cancer.
• Psychological problems: Atrophic testicles cause psychological problems and lack of self-confidence in people.

Can people with atrophic testicles have children?

One of the frequently asked questions by our patients is “whether atrophic testis will cause infertility or not”. If the testicular atrophy is unilateral and the other testicle is normal in size and function, these people can have children.

Does atrophic testis produce perm?

Even if there is no sperm in patients with atrophic testicles as a result of the spermogram, some patients may find sperm in the testis under the microscope (TESE), and in this way, it is possible to have children with the in vitro fertilization method.

Does atrophic testis cause erectile dysfunction?

If one of the testicles is atrophic and the other is normal, these patients will not have sexual function problems since the testosterone hormone will be normal. However, if the atrophy is bilateral and the testosterone level is low, there may be an erection problem. Atrophic testicles also negatively affect people psychologically and as a result, erectile dysfunction can be seen.

Should the atrophic testis be surgically removed?

If testicular atrophy is evident and the other testicle is normal, then the atrophic testis should be surgically removed. Because they have a high risk of developing cancer in the future.

How should patients with atrophic testicles be followed up?

Patients with atrophic testicles should be checked at regular intervals if they do not want the testicle to be removed by surgery. Since testicular cancer is common between the ages of 18-38, this period is a risky period in terms of cancer. These patients should be checked with physical examination, scrotal USG, testicular tumor markers (alpha foetoprotein LDH-1 and beta HCG).

Is there a drug treatment for testicular atrophy?

There is no drug to enlarge the atrophic testis. Herbal treatments also do not have any effect on enlarging the small testicle.

What does hypoplastic testis mean?

Hypoplasia is the small development of an organ in the prenatal development period due to the low number of congenital cells. In other words, hypoplasia is congenitally small size due to insufficient development of the organ. A hypoplastic organ shows the anatomical features of the whole tissue and performs its functions.

What is the difference between atrophic and hypoplastic testis?

Hypoplasia is the shrinkage of the organ due to the developmental disorder that occurs during the development period of the prenatal organs. Atrophy, on the other hand, is the decrease in the number of cells in an organ that has completed its normal development due to later reasons, and the organs and tissues are smaller than normal. In other words, hypoplasia refers to congenital, atrophy refers to the shrinkage of the organ that occurs later.

What are the symptoms of atrophic testicles?

In the genital examination of patients with atrophic testicles, it is seen that testicular development is not sufficient for age, that is, it is small. The testosterone hormone produced by the testicles is important in the development of the male body structure. In this respect, it is necessary to examine the atrophic testis symptoms in two groups as before and after puberty.

Symptoms of atrophic testicles before puberty

If there is testicular atrophy before puberty and not enough testosterone is produced, the following symptoms are seen in men;

• Beard development is insufficient
• Pubic hair (groin hair) does not develop well
• Penis size does not develop enough

Symptoms of atrophic testicles after puberty

The symptoms of atrophic testicles seen in men after puberty are as follows;

• Decreased libido (decreased sexual desire)
• Infertility (infertility)
• Insufficient development of muscle mass
• Beard growth is not good
• Pubic hair growth is not enough
• Testes have a soft consistency

How is atrophic testis diagnosed?

As in the diagnosis of all diseases, a systemic approach is required to diagnose atrophic testis. The roadmap to be followed in order to diagnose testicular atrophy;

• Anamnesis: Anamnesis or patient history means a general questioning of the patient about the disease. Here, the patient is asked questions that may cause testicular suppuration: A general inquiry is made, such as past illnesses, previous surgeries, trauma history, medications used, whether he had a urinary tract or sexually transmitted disease, or whether he had mumps in childhood.
• Examination: The patient’s genital examination is performed while standing and lying down. The size, consistency, and presence of varicocele of both testicles are evaluated according to age. In addition, the development of the testis and whether the pubic hair growth is normal are evaluated.
• Failure of the scrotum to develop (scrotal hypoplasia): In the examination, it is seen that the scrotum on the side of the atrophic testis remains small and is not fully developed.
• General body examination: Secondary male-specific sex characteristics such as general body muscle development, facial beard and mustache development are evaluated.
• Laboratory tests: The most important laboratory test in diagnosing atrophic testicles is serum testosterone level. In cases where testicular functions are not sufficient, serum testosterone values ​​are found to be low. Testosterone level is found to be normal in unilateral atrophic testicles if the other testis is normal.
• Radiological evaluation: Scrotal ultrasonography (scrotal USG) is an important diagnostic method in evaluating the size of the testicles. Both testicular sizes are evaluated by ultrasound.

How is atrophic testis treated?

Treatment of testicular atrophy is based on the underlying cause. Apart from this, if testosterone is permanently low, external testosterone therapy (TRT) is required.

• Infection: If the patient has orchitis, atrophy can be prevented by starting appropriate antibiotic treatment in the early period according to the specific agent. If there are urinary tract infections and sexually transmitted diseases, these should also be treated appropriately.
• Varicocele: If there is varicocele in childhood, it must be treated. In childhood, testicular atrophy due to varicocele is corrected by surgery, while atrophic testis due to varicocele in adults does not improve with surgery.
• Testicular torsion: Testicular torsion is a urological emergency. These patients must be operated within 4-5 hours without losing much time.
• Undescended testis: Sometimes one or both testicles do not descend into the scrotum. These patients should be operated within 1-2 years at the latest. In delayed cases, testicular atrophy develops.
• Lifestyle changes: Excessive alcohol intake is harmful for testicles. Quitting or limiting alcohol in these patients prevents the development of testicular atrophy.
• Cessation of external anabolic steroid or testosterone intake: Since testicular atrophy will develop in patients taking such drugs, such habits should be abandoned.
• Surgical removal of the atrophic testis (orchiectomy): If the testicular atrophy is severe and there is no function, then this testicle should be removed (orchiectomy). Because such patients have a high risk of cancer. After the testicle is removed, it is very useful to put a testicular prosthesis to relieve the patients psychologically. We attach testicular prosthesis to such patients. The prosthesis relieves the patients by creating a normal appearance in the scrotum.
• Hormone replacement therapy: If the patient has low testosterone levels due to testicular atrophy, it must be treated. We start testosterone therapy for such patients. Testosterone therapy should be lifelong. Because this hormone is not produced by the testicles and it must be replaced. We call this type of treatment “testosterone replacement therapy, TRT” (replacement of reverse sterosterone therapy). There are different methods for this. With long-term testosterone injections, patients are given external testosterone every few months.

In summary; The testicles are one of the genital system organs with important functions in men. Due to various reasons, deterioration of the testicular structure and atrophy lead to serious problems such as infertility, erectile dysfunction and testicular cancer development. Patients with atrophic testicles should be followed closely for the development of testicular cancer. If testosterone levels are below normal, they should be treated appropriately.

Prof. Dr. Emin ÖZBEK

Urology Specialist