Andrew Siegel MD 12/30/17
It is “scrotum-tightening December cold” outside, a most opportune time to blog about scrotal laxity and “long balls.” Anyway, a few weeks ago the topic was vaginal labial hypertrophy, so to be fair to the male gender today’s entry deals with a parallel issue, the low-hanging scrotal sac. A complaint voiced not infrequently by my middle-aged and older patients is that their testicles hang loosely, similar to the pendulous breasts of older women. At times, men complain that when they are seated on the toilet, their scrotum actually touches the water. Ouch!
In Curb Your Enthusiasm, S06E07, Larry ends up in the ER because he caught his testicles in the fly of his underwear and was diagnosed with “long balls.” https://www.youtube.com/watch?v=gmHf_1kqJc0
In summer camp, one of the traditional songs sung by campers (to the tune of the children’s song Do your ears hang low?) was the following:
Do your balls hang low?
Do they wobble to and fro?
Can you tie ’em in a knot?
Can you tie ’em in a bow?
Can you throw them over your shoulder
Like a continental soldier?
Do your balls hang low?
I don’t know what the summer camp fascination with low-hanging balls was all about, but another song (to the tune of Italian love song That’s Amore) had the following lyrics:
When your balls hit the floor like a B-54 it’s a rupture.
Scrotal science 101
Attribution of image above: By OpenStax College [CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)%5D, via Wikimedia Commons
In early fetal development the testicles originate in the abdomen and by full-term they descend south into the scrotum (the sac that houses the testicles). At puberty, the testes increase in size substantially; with the increase in testes size there is a proportional increase in scrotal size, the scrotum being a very expansive cavity.
The scrotum has several roles, enveloping and protecting the testes as well as aiding in their function by regulating their temperature. For optimal sperm production, the testes need to be a few degrees cooler than core temperature; the dartos muscle within the scrotal wall relaxes or contracts depending on the ambient temperature, allowing the testes to elevate or descend to help maintain this optimal temperature. Under conditions of cold exposure, the dartos contracts, causing the scrotal skin to wrinkle and to bring the testicles closer to the body. When exposed to heat, dartos relaxation allows the testicles to descend and the scrotal skin to smoothen.
The testes are suspended via the spermatic cord, a rope-like “cord” of tissue that traverses the groin and contains the life supply of the testes. Both the testes and spermatic cord are covered by tissues that are extensions of the connective tissue coverings of three of the abdominal core muscles. The most important of these coverings surrounding the spermatic cord is the cremaster muscle, which elevates the testes north when it contracts.
Factoid: The cremasteric reflex is a reflex elevation of the testes from the scrotum to the groin when the upper thigh is gently stroked. The reflex is brisk in children and becomes weaker with aging.
Why does scrotal laxity occur?
The combined factors of the weight of the testes, gravity and time cause a continued southward journey of the testes throughout life, particularly so as collagen and elastin connective tissues weaken and scrotal skin (like skin everywhere else) becomes less supple. With aging, there is also loss of muscle strength of the dartos and cremaster muscles, causing scrotal relaxation and looser hanging testes, respectively. Years ago, a common hernia repair (Shouldice technique) that was in vogue stripped the spermatic cord of cremaster muscle, rendering the testicle on the side of the repair to be “dangly.”
What are symptoms of scrotal laxity?
Aside from the wet scrotum scenario when seated on a toilet bowl, since the low-hanging testes is much less protected, it is more vulnerable to trauma and irritation than the well-supported testes. The low-hanging testes is susceptible to injury when one sits down and discomfort when one participates in cycling, motorcycling, horseback riding and other sports. The low-hanging testes can cause hygienic issues as well as embarrassment and the desire not to be seen naked by a sexual partner, in a locker room or even at the beach in a bathing suit.
Factoid: Nutcracker Suite. A common complaint voiced by patients is a testicle getting crushed when getting into and sitting down in an automobile.
Factoid: The scrotum may hang so low that when one passes wind, the testicles may become airborne like a kite flying erratically in a sudden gust!
What to do about scrotal laxity
Try to maintain a healthy lifestyle, stay in good physical shape and keep your core muscles fit. Get in the habit of wearing briefs or boxer briefs, many of which are highly supportive like cycling shorts, as opposed to boxers.
If scrotal laxity has caused anatomical, functional or psychological concerns, know that there are effective surgical procedures to remedy the problem. Reducing the size of scrotum is known in medical speak as reduction scrotoplasty, a.k.a. scrotal lift. There are a variety of techniques used to tailor and re-contour the excessive scrotal skin, with the goals of elevating the testes, eliminating the redundant scrotal sac tissue, minimizing scarring and retaining natural pigmentation.
Bottom Line: Time and gravity can be cruel conspirators when it comes to testes and scrotal support. Although scrotal laxity is not a significant medical issue, it can result in quality of life and self-esteem issues. If you find your scrotum becoming waterlogged, testicles airborne, or have other functional and/or cosmetic concerns, reduction scrotoplasty (scrotal lift) is an effective procedure to improve the cosmetic appearance and resolve the annoying symptoms. This is a procedure that can be performed by a urologist on an outpatient basis.
Final factoid: Testes self-examination. There are no organs in the body—save the breasts—that are more external and easily accessible to examination than the testes. Unlike the ovaries, the testes are “gift wrapped” in the scrotal sac and can easily be and should be checked periodically for lumps and bumps. Although rare, testicular cancer is the most common solid malignancy in young men, with the greatest incidence being in the late 20s, striking men at the peak of life. Take advantage of this accessibility to do regular exams—it just might be lifesaving.
Wishing you the best of health in 2018,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.
Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:
MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health
THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health
PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food
These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.
Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (the female version is in the works): PelvicRx
Our Greatest Wealth Is Health 