Testicular Problems

The Key Players Down Below: A Closer Look

Understanding the basic components helps make sense of potential issues:

• • The Testicles (Testes): These are the primary reproductive organs in men. They contain tightly coiled tubes called seminiferous tubules where sperm are produced (spermatogenesis). Between these tubules are Leydig cells, which produce testosterone under the influence of Luteinising Hormone (LH) from the pituitary gland. Healthy adult testes are typically firm but slightly yielding, smooth, and roughly 4-5cm long.
• • The Epididymis: This is a C-shaped, tightly coiled tube attached to the back of each testicle. It acts like a finishing school and storage depot for sperm. Sperm produced in the testis travel into the epididymis where they mature over several weeks, gaining the ability to swim (motility). The epididymis can be felt as a soft, comma-shaped structure; it's a common site for cysts and inflammation (epididymitis).
• • The Spermatic Cord: This is the 'lifeline' structure running from the abdomen down to each testicle. It contains:
• • The Vas Deferens (or Ductus Deferens): A muscular tube that transports mature sperm from the epididymis up towards the urethra during ejaculation. This is the tube cut or blocked during a vasectomy.
• • Blood Vessels: The testicular artery supplies oxygenated blood, while a network of veins (the pampiniform plexus) drains blood away. This plexus helps cool the blood before it reaches the testis, essential for optimal sperm production (testes need to be slightly cooler than core body temperature). Issues here can lead to varicoceles.
• • Nerves and Lymphatics: Providing sensation and fluid drainage.
• • The spermatic cord is what twists during testicular torsion.
• • The Scrotum: The sac of skin and muscle (dartos muscle) that holds the testicles, epididymis, and lower spermatic cords. Its ability to contract (pulling testes closer to the body for warmth) and relax (letting them hang lower to cool) helps regulate testicular temperature. It has several layers derived from the abdominal wall layers during development.

Simplified anatomical illustration of the male scrotal region

The Journey Downstairs: Testicular Development and Descent

Testicles don't start in the scrotum. In a developing male fetus, they form high up in the abdomen, near the kidneys. Guided by hormonal signals and anatomical structures, they gradually descend through the abdomen, pass through a passage in the groin called the inguinal canal, and (usually) reach their final destination in the scrotum by the time of birth or shortly after. This journey is crucial for normal function later in life.

What Are Undescended Testes?

Cryptorchidism is the medical term for when one or both testicles fail to complete their descent into the scrotum. It's one of the most common genital abnormalities in newborn boys, affecting around 3-4% of full-term infants and up to 30% of premature infants. In many cases, the testicle(s) will descend naturally within the first few months of life (usually by 6 months).

Why Does it Matter if a Testicle Doesn't Descend?

If a testicle remains outside the scrotum (e.g., in the groin or abdomen), it's exposed to a higher body temperature. This is significant because:

• • Impaired Fertility: The higher temperature can damage the sperm-producing cells over time, potentially reducing fertility later in life, especially if both testes are affected or if treatment is delayed.
• • Increased Risk of Testicular Cancer: Men born with undescended testes have a higher lifetime risk of developing testicular cancer in that testicle (even after surgical correction), although the overall risk is still low. Bringing the testicle down allows for easier self-examination and monitoring.
• • Increased Risk of Torsion: An undescended testicle may be more prone to twisting (torsion).
• • Associated Hernia: An inguinal hernia (a bulge in the groin) is often present alongside an undescended testicle.

How Are Undescended Testes Managed? (Orchidopexy)

If a testicle hasn't descended by around 6 months of age, surgical intervention, called orchidopexy (or orchiopexy), is usually recommended. Waiting much longer can increase the risk of fertility problems.

• • Timing: The optimal timing for surgery is generally considered to be between 6 and 12 months of age.
• • The Surgery (Orchidopexy): This is typically a day-case procedure performed under general anaesthesia.
• • For Palpable Testes (felt in the groin): A small incision is usually made in the groin crease to find the testicle and spermatic cord. The cord is carefully freed up (mobilised) to gain enough length. A second small incision is made on the scrotum, creating a small pouch. The testicle is then gently brought down into the scrotal pouch and secured (fixed) in place with stitches. Any associated hernia is usually repaired at the same time.
• • For Non-Palpable Testes (cannot be felt): A laparoscopy ('keyhole surgery') is often performed first. A small camera is inserted through the belly button to locate the testicle inside the abdomen. If a healthy testicle is found, it can often be brought down in one or two stages using laparoscopic techniques or a standard groin incision approach. If the testicle is absent or very poorly formed, it might be removed laparoscopically.
• • Post-operative Care: Recovery is usually straightforward. Pain relief is provided, and activities are restricted for a short period. Follow-up checks ensure the testicle remains in place and heals well.

Sudden, severe pain in one testicle is a potential urological emergency. Time is critical, and you must seek help immediately (attend A&E - Accident & Emergency).

When the Ache Doesn't Go Away: Chronic Orchialgia

Chronic testicular pain, also known as orchialgia or chronic scrotal content pain, is defined as constant or intermittent testicular/scrotal pain lasting for three months or longer, significantly affecting the patient's quality of life.

Causes and Evaluation: Why Does it Happen?

Frustratingly, in many cases, a specific cause for chronic testicular pain cannot be identified (idiopathic orchialgia). However, potential contributing factors include:

• • Post-infection changes: Lingering inflammation or nerve sensitivity after epididymo-orchitis.
• • Post-surgical pain: Following vasectomy (Post-Vasectomy Pain Syndrome - PVPS), hernia repair, or other scrotal surgery.
• • Nerve-related issues: Nerve entrapment or irritation in the groin or spermatic cord (e.g., genitofemoral nerve).
• • Varicocele: Though less common, large varicoceles can sometimes cause a dull ache.
• • Interstitial cystitis/Painful bladder syndrome: Pain can sometimes refer to the scrotum.
• • Musculoskeletal causes: Pain referred from the back or hip.
• • Psychological factors: Stress and anxiety can sometimes manifest as or exacerbate physical pain.

Evaluation is crucial to rule out any underlying treatable pathology. This involves:

• • Detailed history of the pain (onset, character, triggers, relieving factors).
• • Thorough physical examination, including scrotal contents, groin, and sometimes abdomen/back.
• • Urine tests to exclude infection.
• • Scrotal ultrasound to rule out structural abnormalities (cysts, tumours, varicoceles) and assess testicular tissue.
• • Sometimes, further investigations like MRI or specialised nerve tests might be considered.

Management: A Challenging Condition

Treating chronic testicular pain can be challenging and often requires a multi-modal approach. Patience is key, as finding effective relief can take time.

• • Conservative Measures: Supportive underwear, heat/cold packs, lifestyle adjustments (avoiding triggers).
• • Medical Therapy:
• • Painkillers: Simple analgesics (paracetamol) and anti-inflammatories (NSAIDs).
• • Nerve Pain Medications: Drugs typically used for nerve pain, like amitriptyline, gabapentin, or pregabalin, may be helpful, started at low doses.
• • Antibiotics: Sometimes a prolonged course is tried if post-infectious inflammation is suspected, though evidence is limited.
• • Injections: Spermatic cord blocks (injecting local anaesthetic, sometimes with steroid, around the nerves in the cord) can provide temporary or sometimes longer-lasting relief and help diagnostically.
• • Pelvic Floor Physiotherapy: Can be beneficial if muscular tension is contributing.
• • Psychological Support/Pain Management Programmes: Addressing coping strategies, anxiety, and depression associated with chronic pain.
• • Surgical Options (Considered Carefully):
• • Microsurgical Denervation of the Spermatic Cord (MDSC): A specialised procedure to carefully divide the nerve fibres in the spermatic cord while preserving the blood supply and vas deferens. Reserved for severe, refractory pain where cord blocks provide temporary relief.
• • Epididymectomy (Removal of Epididymis): Considered if pain seems clearly localised to the epididymis (e.g., chronic epididymitis, post-vasectomy pain).
• • Orchidectomy (Testicle Removal): A last resort for debilitating pain unresponsive to all other measures, with no guarantee of complete pain relief as 'phantom' pain can persist. Requires extensive counselling.
• • Varicocelectomy: If a varicocele is present and thought to be the source of the ache (discussed further on our Varicocele page).

Managing chronic testicular pain often involves working closely with a urologist specialising in male pain conditions and potentially a multidisciplinary pain team.

Know Your Nuts: A Simple Guide to Self-Exam

Checking your testicles regularly (ideally monthly) helps you become familiar with what's normal for you, making it easier to spot any changes early. The best time is often during or after a warm bath or shower when the scrotal skin is relaxed.

1. 1. Get Comfortable: Stand in front of a mirror if possible. Check for any visible swelling on the scrotal skin.
2. 1. Examine Each Testicle Separately: Use both hands. Place your index and middle fingers under the testicle and your thumbs on top.
3. 1. Roll Gently: Gently roll the testicle between your thumbs and fingers. Don't squeeze hard. Familiarise yourself with its size, shape, and consistency – it should feel smooth, oval-shaped, and fairly firm but not rock-hard. It's normal for one testicle to be slightly larger or hang lower than the other.
4. 1. Feel the Epididymis: At the back of the testicle, you should feel the soft, tube-like structure of the epididymis. It can feel a bit lumpy or tender normally – learn what feels normal for you here, as this is where harmless cysts often form.
5. 1. Check for Lumps or Changes: Feel for any hard lumps, smooth rounded bumps, or changes in the size, shape, or consistency of the testicle itself.
6. 1. Repeat on the Other Side.

What to look out for:

• • A hard lump on the front or side of the testicle.
• • Swelling or enlargement of one testicle.
• • An increase in firmness.
• • A feeling of heaviness in the scrotum.
• • A dull ache in the lower abdomen, groin, or scrotum (though pain is less common with cancer lumps).

These conditions are far more common than testicular cancer:

What You Need to Know About Testicular Cancer

Testicular cancer is the most common cancer in young men, typically affecting those between the ages of 15 and 40, although it can occur at any age. The good news is that it's also one of the most curable forms of cancer, especially when detected early. Cure rates exceed 95% overall.

Risk Factors and Presentation:

Known risk factors include:

• • Undescended testicle (cryptorchidism): Even if surgically corrected.
• • Family history of testicular cancer.
• • Previous testicular cancer in the other testicle.
• • Certain genetic conditions (less common).
• • Subfertility is also associated with a slightly increased risk.

The most common presentation is:

• • A painless lump or swelling *within* the testicle itself.
• • An increase in firmness or hardness of the testicle.
• • A feeling of heaviness in the scrotum.
• • Less commonly, dull ache, sharp pain, or symptoms from spread (metastasis) like back pain, cough, or swollen lymph nodes (rare at presentation).

Diagnosis and Why Ultrasound is Key:

If testicular cancer is suspected based on examination:

• • Scrotal Ultrasound: This is the cornerstone investigation. It's highly accurate at distinguishing between lumps arising *within* the testicle (suspicious for cancer) and those outside it (like epididymal cysts or hydroceles, usually benign).
• • Tumour Markers: Blood tests for specific proteins (Alpha-fetoprotein - AFP, human Chorionic Gonadotropin - hCG, Lactate Dehydrogenase - LDH) that can be elevated in certain types of testicular cancer. These help with diagnosis, staging, and monitoring treatment response.
• • Staging Scans: If cancer is confirmed or highly suspected, CT scans of the chest, abdomen, and pelvis are usually performed to check if the cancer has spread (metastasised) to lymph nodes or other organs.

Inguinal Orchidectomy: The Surgical Approach

If investigations strongly suggest testicular cancer, the primary treatment is surgical removal of the affected testicle and spermatic cord. This procedure is called a radical inguinal orchidectomy.

• • Performed under general anaesthesia.
• • An incision is made in the groin (like a hernia repair incision), *not* on the scrotum.
• • The spermatic cord is identified and clamped high up near the internal inguinal ring to control blood vessels and prevent tumour cell spread.
• • The testicle and entire spermatic cord are removed through the groin incision.
• • The tissue is sent to pathology for detailed analysis to confirm the cancer type and extent.
• • At the time of surgery, insertion of a testicular prosthesis (artificial testicle) can often be performed through the same incision if desired for cosmetic reasons (discussed beforehand).

Life After Orchidectomy and Further Treatment:

Removal of one testicle generally does not affect sexual function or fertility significantly, as the remaining testicle usually produces enough testosterone and sperm. However, fertility preservation (sperm banking) is strongly recommended *before* orchidectomy and any subsequent treatments (like chemotherapy or radiotherapy), especially as subfertility can pre-exist.

Following surgery and confirmation of the cancer type and stage (based on pathology and staging scans), further management is decided by a specialist multidisciplinary team (MDT) and may involve:

• • Surveillance: For early-stage cancers, close monitoring with regular blood tests, scans, and check-ups may be all that's needed.
• • Chemotherapy: Highly effective for testicular cancer that has spread or for certain types/stages to reduce the risk of recurrence.
• • Radiotherapy: Sometimes used for a specific type called seminoma that has spread to nearby lymph nodes.
• • Further Surgery: Rarely, removal of lymph nodes at the back of the abdomen (Retroperitoneal Lymph Node Dissection - RPLND) might be required.

With timely diagnosis and appropriate treatment tailored by experts, the outlook for testicular cancer is excellent.

The Basics of Vasectomy

Vasectomy works by blocking the tubes that carry sperm from the testicles to the penis. Remember the vas deferens we discussed in the anatomy section? That's the target. Sperm are still produced in the testicles after a vasectomy, but they can no longer travel through the vas deferens to mix with the seminal fluid during ejaculation.

Instead, the sperm are simply reabsorbed by the body, which is a natural and harmless process (similar to what happens with unused sperm normally). The procedure does not affect:

• • Your testosterone levels (produced directly by the testicles into the bloodstream).
• • Your sex drive (libido).
• • Your ability to get an erection.
• • The sensation of orgasm.
• • The volume, colour, or appearance of your ejaculate fluid (semen) - sperm make up only a tiny fraction (about 2-5%) of the total volume. Most of the fluid comes from the seminal vesicles and prostate gland, which are unaffected.

Think of it like closing the gate (vas deferens) between the sperm factory (testicles) and the exit route, while everything else continues to function normally.

How is a Vasectomy Performed?

Vasectomy is typically a quick procedure (often 15-30 minutes) performed in an outpatient clinic or day surgery setting, usually under local anaesthesia, meaning you'll be awake but the area will be completely numb.

Anaesthesia:

• • Local Anaesthetic: This is the most common method. A fine needle is used to inject anaesthetic solution into the skin of the scrotum and around each vas deferens. You might feel a brief sting, but the area quickly becomes numb. Some surgeons use 'no-needle' jet injectors for the initial skin numbing. Sedation is rarely required but can be discussed if you are particularly anxious.

Surgical Techniques:

There are two main approaches to accessing the vas deferens:

• • Conventional Vasectomy: One or two small incisions (cuts) are made in the scrotum with a scalpel to reach each vas deferens.
• • No-Scalpel Vasectomy (NSV): This technique is increasingly preferred by many surgeons due to potentially lower rates of bleeding and infection. Instead of cutting, the surgeon uses a special pointed instrument to make a tiny puncture hole in the scrotal skin. The vas deferens is gently stretched and brought out through this small opening. Often, both vasa can be accessed through a single central puncture.

Blocking the Vas Deferens:

Once accessed, each vas deferens is blocked. There are several methods surgeons use, often in combination:

• • Division: The vas is cut.
• • Ligation: The cut ends are tied with sutures or clipped with tiny metal clips.
• • Excision: A small segment of the vas may be removed.
• • Fascial Interposition: A layer of tissue sheath surrounding the vas is stitched over one or both cut ends to create a barrier between them, further reducing the chance of them rejoining (recanalisation).
• • Cautery: Heat is used to seal the inside lining (mucosa) of the cut ends.

Your surgeon will discuss their preferred technique with you.

Closure:

• • With the no-scalpel technique, the tiny puncture hole often seals itself and may not require stitches.
• • With the conventional technique, the small incision(s) are usually closed with one or two dissolvable stitches.
• • A dressing is applied, and supportive underwear is recommended immediately.

Confirming Success: Post-Vasectomy Semen Analysis (PVSA)

Vasectomy is highly effective (>99% successful at preventing pregnancy), but it is NOT effective immediately. Sperm can remain in the vas deferens 'downstream' from the blockage for several weeks or months after the procedure.

The PVSA Process:

• • You will be given instructions on when and how to produce semen samples after your vasectomy.
• • Typically, the first sample is checked around 12 weeks after the procedure AND after you have had at least 20 ejaculations. This helps ensure the remaining sperm have been cleared out.
• • The sample is examined under a microscope in a laboratory to look for the presence and motility (movement) of sperm.
• • Clearance ('Special Clearance'): Is usually given when a sample shows azoospermia (no sperm at all) or only contains very small numbers of non-motile (dead) sperm, based on specific laboratory criteria and national guidelines (e.g., ASRM, EAU, FSRH guidelines in the UK often state <100,000 non-motile sperm/mL may be considered equivalent to azoospermia for clearance).
• • Further Samples: If motile sperm are still present, or higher numbers of non-motile sperm, repeat samples will be required until clearance can be given.
• • Persistent Motile Sperm: In a very small number of cases (early failure or recanalisation), motile sperm may persist, which might indicate the procedure needs repeating.

Following PVSA instructions carefully and achieving clearance is essential before relying on vasectomy for contraception.

Considering Permanence and Reversal

Vasectomy should always be considered a permanent form of contraception. While microsurgical vasectomy reversal (vasovasostomy or vasoepididymostomy) is possible, it is:

• • Complex and Technically Demanding: Requires specialist microsurgical skills.
• • Not Always Successful: Success rates (return of sperm to ejaculate and subsequent pregnancy) vary depending on factors like the time since vasectomy, the surgeon's experience, and whether epididymal blockage has occurred.
• • Not Usually Available on the NHS: Reversal is typically self-funded privately and can be expensive.

Therefore, the decision to have a vasectomy should only be made if you are certain you do not want to father children in the future. Pre-vasectomy counselling should explore your circumstances, relationship status, and certainty about this decision.

Sperm banking *before* vasectomy is an option for men who want permanent contraception now but wish to keep open the possibility of fathering children later, although ongoing storage costs apply.

Understanding the Potential Downsides

While vasectomy is generally very safe, like any surgical procedure, it carries potential risks and complications, although serious ones are uncommon. These include:

• • Short-Term (Usually within days/weeks):
• • Bleeding/Haematoma: Collection of blood under the skin or around the testicle, causing significant swelling and bruising. Usually settles with rest, ice, support, but large haematomas might rarely require surgical drainage. Risk is low (<1%-5%), possibly lower with NSV.
• • Infection: Infection of the skin wound or deeper structures (epididymitis/orchitis). Usually treated with antibiotics. Risk is low (around 1-2%).
• • Mild Pain/Discomfort: Common in the first few days, managed with painkillers, ice, and support.
• • Longer-Term (Potential):
• • Sperm Granuloma: A small, sometimes tender lump caused by sperm leaking from the cut vas end. Usually harmless, may resolve spontaneously or require anti-inflammatories. Rarely needs excision if persistently painful.
• • Congestion/Epididymitis: Some men experience temporary discomfort or inflammation in the epididymis due to sperm build-up shortly after the procedure; usually settles.
• • Post-Vasectomy Pain Syndrome (PVPS): This is persistent or intermittent scrotal pain lasting for 3 months or more after vasectomy, significantly impacting quality of life. The cause is often unclear but may involve nerve irritation, chronic inflammation, or epididymal pressure. It affects a small percentage of men (estimates vary, perhaps 1-5% experience bothersome pain, severe debilitating pain is rarer). Management can be challenging and may involve medication, injections, or further surgery (like reversal or denervation) in refractory cases. Pre-vasectomy counselling should mention this possibility.
• • Failure/Recanalisation: Very rarely, the cut ends of the vas deferens can spontaneously rejoin (early or late recanalisation), leading to vasectomy failure and the return of sperm to the ejaculate. This is why PVSA clearance is vital. The risk of failure after confirmed clearance is extremely low (estimated around 1 in 2000 or less).

Your surgeon will discuss these risks with you in detail during the consultation process.

Getting Ready: Key Considerations

Preparation involves both mental and practical steps:

• • Consultation & Counselling: This is essential. You should have a clear discussion with the surgeon or counsellor covering:
• • Confirmation that vasectomy is the right choice for you.
• • Understanding that it is permanent contraception.
• • Discussion of alternative methods (e.g., female sterilisation, long-acting reversible contraception like coils or implants).
• • Explanation of the procedure technique, risks, benefits, failure rates, and the PVSA process.
• • Assessment of your medical fitness.
• • Opportunity to ask any questions.
• • Written consent is required. You should feel entirely comfortable and informed before proceeding.
• • Certainty: You must be sure about your decision. If you have any doubts, it's better to postpone and reconsider.
• • Medications: Inform the surgeon about all medications you take, especially blood thinners. Adjustments may be needed.
• • Scrotal Shaving: You will likely be asked to shave the scrotal area beforehand (or it may be done at the clinic) to allow for cleaning and clear access. Follow the specific instructions given.
• • Arrange Transport: You should not drive yourself home immediately after the procedure, especially if you had any sedation or are feeling uncomfortable. Arrange for someone to collect you.
• • Bring Supportive Underwear: Have snug-fitting briefs or an athletic support ready to wear immediately after the procedure.

Post-Vasectomy Care: Taking it Easy

Following the post-operative instructions carefully helps ensure a smooth recovery and minimises complications.

• • Immediate Care: Rest quietly for the remainder of the day. Apply ice packs (wrapped) intermittently to the scrotum for 15-20 minutes at a time for the first 24-48 hours to reduce swelling and bruising.
• • Pain Relief: Take regular simple painkillers like paracetamol. Ibuprofen or similar anti-inflammatories can also help with swelling, if suitable for you.
• • Scrotal Support: Wear supportive underwear continuously (day and night initially) for the first few days, and then during the day for at least a week, or longer if comfortable.
• • Rest & Activity: Take it easy for the first 2-3 days. Avoid heavy lifting, straining, strenuous exercise, sports, and cycling for at least 1-2 weeks, or as advised by your surgeon. Gradual return to normal activity.
• • Wound Care: Keep the dressing clean and dry for the first 24-48 hours (follow specific instructions). Showering is usually okay after this, gently pat the area dry. Avoid soaking in a bath for about a week. Small wounds often need no further dressing; dissolvable stitches will disappear.
• • Work: Most men return to office-based work after 2-3 days. Manual labourers may need a week or more off.
• • Sexual Activity: Usually okay to resume after about a week, once discomfort has settled. Remember to use other contraception!
• • PVSA Schedule: Crucially, follow the instructions precisely regarding when and how to provide your post-vasectomy semen samples for analysis (usually starting around 12 weeks post-op and after 20+ ejaculations). Continue other contraception until clearance is confirmed.
• • Follow-up: Often not routine unless PVSA results are abnormal or you experience problems. Contact the clinic if you have concerns like increasing pain, fever, significant swelling, or wound discharge.

Most men experience only mild discomfort and recover quickly, but listening to your body and avoiding over-exertion initially is important.

What Causes Testicles to Shrink?

Testicular atrophy refers to the shrinkage of a testicle. It implies damage to the sperm-producing tubules or the testosterone-producing Leydig cells, leading to a reduction in size and often firmness.

Potential causes include:

• • Varicocele: A large varicocele can sometimes lead to ipsilateral (same side) testicular atrophy over time, particularly if it develops during adolescence.
• • Aging: Testicular size and testosterone production can naturally decline slightly with age, though significant atrophy is not typical.
• • Hormonal Imbalances: Low levels of pituitary hormones (FSH/LH) can lead to testicular shrinkage (secondary hypogonadism). Conversely, taking external testosterone or anabolic steroids shuts down the pituitary signals, causing the testes to shrink.
• • Previous Torsion: Even if a testicle was saved after torsion, some degree of atrophy can occur later due to temporary oxygen deprivation.
• • Previous Infection: Severe epididymo-orchitis, particularly mumps orchitis occurring after puberty, can damage testicular tissue.
• • Undescended Testicle History: A previously undescended testicle may remain smaller than the normally descended one.
• • Trauma: Significant injury can lead to atrophy.

Evaluation and Management:

If you notice significant testicular shrinkage, assessment is important to identify the underlying cause and check hormonal function. This usually involves:

• • Clinical examination to assess size, consistency, and check for varicoceles.
• • Scrotal ultrasound to measure volume accurately and assess tissue appearance.
• • Hormonal blood tests (FSH, LH, Testosterone) to evaluate the pituitary-testicular axis.
• • Semen analysis if fertility is a concern.

Management depends on the cause. For example, repairing a varicocele associated with atrophy in an adolescent might allow for some 'catch-up' growth. Treating underlying hormonal issues or stopping offending medications (like anabolic steroids) can sometimes allow recovery. If atrophy is associated with low testosterone causing symptoms (hypogonadism), testosterone replacement therapy might be considered (after addressing fertility, as TRT suppresses sperm production).

Restoring Appearance and Confidence: Artificial Testicles

For men who have lost a testicle (due to cancer, torsion, trauma, infection, or severe atrophy) or were born without one, the absence can sometimes cause psychological distress or issues with body image. A testicular prosthesis is a synthetic implant designed to mimic the look and feel of a natural testicle, restoring scrotal symmetry and fullness.

Indications and Considerations:

The main reason for prosthesis implantation is cosmetic and psychological benefit. The decision is entirely personal. Prostheses are available in various sizes to match the remaining testicle (if present).

Factors to discuss include:

• • Timing (can often be done during the orchidectomy operation, or later as a separate procedure).
• • Material (usually saline-filled silicone).
• • Realistic expectations (it's for appearance/feel, it has no biological function).
• • Risks (like infection, bleeding, pain, implant extrusion, scarring, dissatisfaction with position/feel, need for revision surgery – though complication rates are generally low).

Surgical Technique:

Implantation is typically a short procedure performed under general or local anaesthesia with sedation.

• • If done during orchidectomy, it's placed through the same groin incision.
• • If done later, a small incision is made either in the groin or upper scrotum.
• • A pouch is created within the empty side of the scrotum.
• • The prosthesis is inserted into the pouch and often secured with a stitch to the bottom of the scrotum to prevent it rotating or riding too high.
• • The incision is closed in layers.

Outcomes:

Patient satisfaction rates are generally high, helping to restore confidence and body image. Recovery is usually quick, with scrotal support recommended for a few weeks.

Assessment is Key After Injury

If you sustain a significant blow to the scrotum resulting in immediate, severe pain, significant swelling, bruising, nausea, or difficulty walking, you should seek urgent medical attention (A&E or urgent care).

Evaluation will involve:

• • History: Understanding the mechanism and force of the injury.
• • Examination: Assessing the degree of swelling, bruising (haematoma), tenderness, and crucially, whether the testicle itself feels intact.
• • Scrotal Ultrasound: This is essential in significant trauma. It can:
• • Visualise the testicle to check for rupture (fracture) of the tough outer capsule (tunica albuginea).
• • Assess blood flow to rule out traumatic torsion or vascular injury.
• • Estimate the size of any blood collection (haematocele) around the testicle.
• • Check for injury to the epididymis.

Indications for Surgical Exploration:

While many cases of blunt trauma with an intact testicle on ultrasound can be managed conservatively (rest, ice, scrotal support, pain relief), surgery is indicated in certain situations:

• • Testicular Rupture: If the ultrasound clearly shows a break in the tunica albuginea with extrusion of testicular contents. Prompt surgical repair offers the best chance of salvaging the testicle.
• • Large or Expanding Haematocele: A large collection of blood around the testicle may require drainage to reduce pressure and pain, and allow inspection of the testis.
• • Uncertain Ultrasound Findings / Persistent Suspicion: If the ultrasound is unclear but clinical suspicion of rupture remains high.
• • Penetrating Trauma: Any injury that breaches the scrotal skin requires exploration.

Surgical Repair Techniques and Decision-Making:

Surgery is performed under general anaesthesia via a scrotal incision.

• • The scrotum is opened, and any blood clot (haematocele) is evacuated.
• • The testicle is carefully inspected.
• • If a rupture (fracture) is found, any dead or extruded testicular tissue is gently removed (debrided).
• • The tear in the tunica albuginea is repaired meticulously with absorbable stitches.
• • The aim is to preserve as much viable testicular tissue as possible.
• • A drain may be placed, and the scrotum is closed.

Salvage vs. Orchidectomy Decision:

The goal is always testicular salvage. However, in cases of severe trauma where the testicle is shattered beyond repair or its blood supply is irreversibly damaged, removal (orchidectomy) may unfortunately be necessary. This decision is made intra-operatively based on the extent of the damage.

Prompt evaluation and surgical intervention when indicated significantly improve the chances of saving an injured testicle and preserving its function.

The Testicle's Vital Role in Making Sperm

Optimal sperm production (spermatogenesis) requires healthy testicular tissue, the right hormonal signals (FSH, LH, Testosterone), and a slightly cooler temperature than the rest of the body. Various testicular conditions can disrupt this delicate process:

• • Varicocele: As previously discussed, impaired cooling can impact sperm parameters. Significant varicoceles are a treatable cause of infertility in some men.
• • Undescended Testicles (Cryptorchidism): Exposure to higher body temperatures damages sperm-producing cells, often leading to reduced fertility potential.
• • Infection (Epididymo-orchitis): Inflammation can temporarily impair sperm production. Severe infections can cause scarring leading to blockage (obstructive azoospermia) or permanent testicular damage.
• • Vasectomy: Intentionally causes obstructive azoospermia by blocking the vas deferens. Reversal is possible but complex and not always successful (see Male Infertility Hub).
• • Testicular Torsion: Loss or damage to a testicle reduces sperm production capacity.
• • Testicular Cancer & Treatment: The cancer itself and necessary treatments (surgery, chemotherapy, radiotherapy) can severely impact fertility. Sperm banking *before* treatment is crucial.
• • Testicular Trauma: Significant injury can directly damage sperm-producing tissue.
• • Hormonal Issues & Genetic Conditions: Directly disrupt sperm production signals or capability.

When Sperm Can't Get Out or Production is Severely Low: Surgical Sperm Retrieval (SSR)

For men facing infertility due to irreversible blockage (obstructive azoospermia - including post-vasectomy if reversal is not desired/possible) or severely impaired production (non-obstructive azoospermia), surgical sperm retrieval combined with IVF/ICSI offers a path to biological fatherhood.

Techniques aim to extract sperm directly from the epididymis or testis:

• • PESA (Percutaneous Epididymal Sperm Aspiration): Needle aspiration from epididymis (mainly OA).
• • MESA (Microsurgical Epididymal Sperm Aspiration): Microsurgical fluid collection from epididymal tubules (mainly OA).
• • TESA (Testicular Sperm Aspiration): Needle aspiration from testis (OA or NOA).
• • TESE (Testicular Sperm Extraction): Small open biopsy of testicular tissue (OA or NOA).
• • Micro-TESE (Microsurgical Testicular Sperm Extraction): Gold standard for NOA, using a microscope to find pockets of sperm production.

Your Action Plan for Testicular Concerns:

• • IMMEDIATE EMERGENCY (Go to A&E):
• • Sudden, severe testicular pain.
• • Significant testicular swelling occurring rapidly after trauma.
• • Reason: Primarily to rule out testicular torsion where time is critical.
• • URGENT APPOINTMENT (See GP or Urologist within days):
• • Discovery of any new lump *within* the testicle itself (painless or painful).
• • Significant, unexplained swelling or enlargement of a testicle.
• • Noticeable increase in firmness or hardness of a testicle.
• • Reason: To allow prompt investigation, particularly to rule out testicular cancer.
• • ROUTINE APPOINTMENT (Book to see GP or Urologist):
• • Gradual onset testicular pain or ache (after ruling out torsion).
• • Lumps clearly separate from the testicle (e.g., suspected epididymal cyst).
• • Large or bothersome hydrocele.
• • Symptoms suggestive of a varicocele (dull ache, 'bag of worms' feel).
• • Considering vasectomy or discussing vasectomy follow-up/concerns (e.g., PVPS).
• • Concerns about testicle size or consistency (atrophy).
• • General concerns about fertility related to testicular health.
• • Discussion about previous conditions (e.g., undescended testis follow-up).
• • Reason: To discuss concerns, get a diagnosis, plan appropriate management or reassurance, or discuss procedures like vasectomy.

What to Expect After Common Procedures:

Recovery varies, follow your surgeon's specific advice. General guidelines:

Vasectomy:

• • Anaesthesia: Local usually.
• • Recovery: Minimal downtime. Rest 1-2 days. Ice packs, scrotal support, simple painkillers. Avoid heavy lifting/sports 1-2 weeks. Resume sex when comfortable (usually ~1 week). Use other contraception until PVSA clearance (typically 12+ weeks & 20+ ejaculations).
• • More Detail: See the dedicated Vasectomy Recovery Section above.

Hydrocelectomy / Epididymal Cyst Excision:

• • Anaesthesia: General/Spinal/Local+Sedation.
• • Recovery: Day case usually. Significant swelling/bruising expected (weeks/months to settle). Scrotal support vital (1-2+ weeks). Ice initially. Regular painkillers. Avoid heavy lifting/straining 2-4 weeks. Driving/sex often 2-4 weeks+.
• • More Detail: See expanded post-op sections under Hydrocele and Epididymal Cyst descriptions above.

Orchidopexy (Undescended Testis Repair):

• • Anaesthesia: General (usually in childhood).
• • Recovery: Day case usually. Mild discomfort. Small incisions. Limit rough activity few weeks.

Inguinal Orchidectomy (for Cancer):

• • Anaesthesia: General.
• • Recovery: Overnight stay typical. Groin incision pain. Avoid heavy lifting 4-6 weeks. Requires specialist follow-up/further treatment planning. Sperm banking essential beforehand.

Surgical Sperm Retrieval (TESE/Micro-TESE):

• • Anaesthesia: General/Regional/Local+Sedation.
• • Recovery: Day case. Scrotal discomfort/swelling/bruising. Painkillers, support. Avoid strenuous activity 1-2 weeks. Requires coordination with IVF unit.

Common Post-Op Advice Includes:

• • Keep wounds clean and dry. Follow showering/bathing advice.
• • Wear supportive underwear.
• • Use ice packs (wrapped) as needed initially.
• • Take pain relief regularly.
• • Avoid constipation.
• • Watch for signs of infection (increasing pain, redness, discharge, fever).
• • Attend follow-up appointments.

You Are Not Alone: Finding Support

Dealing with testicular conditions, particularly cancer, chronic pain, infertility, or making decisions about procedures like vasectomy, can be emotionally challenging. Connecting with others and finding reliable information is key.

Consider exploring resources from reputable organisations (examples relevant to the UK):

• • Orchid Cancer Appeal: Focuses on male cancers (testicular, penile, prostate). Offers information, support services, and raises awareness. [Placeholder: Link to Orchid website]
• • Macmillan Cancer Support: Wide-ranging support for people affected by all cancers. [Placeholder: Link to Macmillan website]
• • Cancer Research UK (CRUK): Reliable information about testicular cancer. [Placeholder: Link to CRUK website]
• • Fertility Network UK: Support and information for fertility problems, including male factor infertility and post-vasectomy options. [Placeholder: Link to Fertility Network UK website]
• • British Association of Urological Surgeons (BAUS): Patient information leaflets on urological conditions/procedures. [Placeholder: Link to BAUS Patient Information]
• • Faculty of Sexual & Reproductive Healthcare (FSRH): Guidelines and patient information on contraception, including vasectomy. [Placeholder: Link to FSRH website]

Your GP or urology team may also be able to signpost you to local support services or specific counselling if needed (e.g., pre-vasectomy counselling, support for PVPS).

The information presented on this page reflects current understanding and clinical guidelines in urology and andrology. For those seeking more detailed medical literature, key areas of research and guidelines include:

• • Core Guidelines

1. 1. European Association of Urology (EAU). Sexual and Reproductive Health (incl. Male Infertility). Arnhem: EAU Guidelines Office; 2024–2025 updates available online. uroweb.org
2. 1. European Association of Urology (EAU). Testicular Cancer. Arnhem: EAU Guidelines Office; 2024 update. uroweb.org
3. 1. European Association of Urology (EAU). Chronic Pelvic Pain (Pocket Guideline). Arnhem: EAU Guidelines Office; 2024. d56bochluxqnz.cloudfront.net
4. 1. American Urological Association (AUA), American Society for Reproductive Medicine (ASRM). Male Infertility: Guideline (latest amendment 2024). Linthicum, MD: AUA; 2024. healthbook.org
5. 1. American Urological Association (AUA). Diagnosis and Treatment of Early-Stage Testicular Cancer (2019; amended 2023; J Urol 2024 print). Linthicum, MD: AUA; 2023–2024. AUA
6. 1. American Urological Association (AUA). Vasectomy Guideline (2012; amended 2015). Linthicum, MD: AUA; 2015. AUA
7. 1. Faculty of Sexual & Reproductive Healthcare (FSRH). Male and Female Sterilisation. London: FSRH; Sept 2014 (current). CoSRH
8. 1. World Health Organization (WHO). Laboratory manual for the examination and processing of human semen. 6th ed. Geneva: WHO; 2021. World Health Organization

UK resources used in practice (where applicable)

1. 1. National Institute for Health and Care Excellence (NICE). Suspected cancer: recognition and referral (NG12). London: NICE; last updated 1 May 2025. NICE
2. 1. National Institute for Health and Care Excellence (NICE). Chronic pain in over 16s: assessment of all chronic pain and management of chronic primary pain (NG193). London: NICE; 2021. NICE
3. 1. British Association of Urological Surgeons (BAUS). Patient Information Leaflets (urology procedures). London: BAUS; current web collection (ongoing updates). BAUS

Textbook

1. 1. Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, Wein AJ, eds. Campbell-Walsh-Wein Urology. 12th ed. Amsterdam: Elsevier; 2020–2021. Elsevier Health

Journals routinely referenced on the page

1. 1. European Urology (Elsevier). European Urology
2. 1. The Journal of Urology (AUA/Wolters Kluwer). (See AUA testicular cancer guideline article above.) PubMed
3. 1. BJU International (BJUI) (Wiley). BJUI
4. 1. Fertility and Sterility (ASRM/Elsevier). (Examples include vasectomy and semen analysis methodology updates.) Fertstert
5. 1. Human Reproduction Update / Andrology / Journal of Sexual Medicine as topic-specific sources when indicated.

Dealing with testicular conditions, particularly cancer, chronic pain, infertility, or making decisions about procedures like vasectomy, can be emotionally challenging. Connecting with others and finding reliable information is key.

Consider exploring resources from reputable organisations (examples relevant to the UK):

Here is the updated list in English with the verified direct links for your website:

• • Orchid Cancer Appeal: Focuses on male cancers (testicular, penile, prostate). Offers information, support services, and raises awareness. Orchid Official Website
• • Macmillan Cancer Support: Wide-ranging support for people affected by all cancers, providing practical, medical, and financial support. Macmillan Official Website
• • Cancer Research UK (CRUK): Reliable information and the latest research regarding testicular cancer and other urological malignancies. CRUK Testicular Cancer Section
• • Fertility Network UK: Support and information for fertility problems, including male factor infertility and post-vasectomy options. Fertility Network UK Website
• • British Association of Urological Surgeons (BAUS): Comprehensive patient information leaflets on a wide range of urological conditions and surgical procedures. BAUS Patient Information
• • Faculty of Sexual & Reproductive Healthcare (FSRH): Clinical guidelines and patient information on contraception, including vasectomy and reproductive health. FSRH Official Website