Testicles are essential to a man’s health—not just in terms of reproduction, but also for hormonal well-being, physical vigor, and general quality of life. Of the testicular conditions, it is one of the most frequently delayed in seeking medical assistance, as men are often reluctant to discuss scrotal symptoms or feel embarrassed to visit a doctor for this type of concern.
This reluctance can be seriously consequential. Testicular torsion (twisted testicle) is a urologic emergency, and a delay of even a few hours can result in permanent loss of the testicle. A painless hard lump in the testicle may be cancer. Varicocele silently destroys sperm quality over the years. If not treated early, epididymo-orchitis can cause irreversible impairment of fertility.
The testes (singular: testis) are two oval-shaped glands located in the scrotum, the pouch of skin that hangs below the penis. Each testis is approximately 4 cm in length and 2.5 cm in width and weighs 10 to 15 grams. Since the scrotal location provides this natural thermal regulation, they are located outside the body cavity, as optimal sperm production requires a temperature 2 to 3 degrees Celsius below core body temperature.
Each testis is covered by a tough fibrous outer coat called the tunica albuginea, which is in turn covered by a fluid-containing sac (tunica vaginalis). The testis is surrounded by the epididymis , a coiled tube about 6 metres long when uncoiled . In the epididymis the sperm mature and are stored . The epididymis is connected to the vas deferens which transports mature sperm towards the urethra during ejaculation. Each testicle has a vas deferens , testicular artery and veins ( the pampiniform venous plexus ) , lymphatics and nerves . These run from the testicle through the inguinal canal and into the abdomen . In varicocele, the pampiniform plexus becomes abnormally dilated; in torsion, twisting of the spermatic cord interrupts the blood supply to the testis.
Spermatogenesis (Sperm Production): The seminiferous tubules represent 80% of the testicular volume. Sertoli cells support the germ cells to develop into mature spermatozoa within a period of about 72 to 74 days. Any condition that increases scrotal temperature, compromises blood supply, causes inflammation or disturbs the hormonal environment (such as varicocele, orchitis, torsion and undescended testis) impairs spermatogenesis and fertility.
Testosterone Production: Leydig cells are scattered between the seminiferous tubules and produce testosterone in response to LH from the pituitary gland. Testosterone is responsible for secondary sexual characteristics, muscle mass, bone density, libido, mood and energy. In cases of severe orchitis, bilateral torsion, bilateral trauma, the testicular tissue is damaged to a great extent and the testosterone production is decreased leading to hypogonadism.
The four most common testicular conditions managed by Dr. Vikas Singh at Kokilaben Hospital, Indore, are:
Varicocele (Dilated Veins of the Scrotum)
Dilatation of the pampiniform venous plexus akin to varicose veins in the leg. Causes scrotal heaviness, dull ache and is the most common correctable cause of male infertility. Present in 15% of men and in 40% of infertile men.
The spermatic cord twists, cutting off the blood supply to the testicle. Sudden severe one sided testicular pain. Urological emergency. Needs to be surgically untwisted within 4-6 hours to save testical. Any sudden onset of testicular pain requires urgent emergency assessment.
A blunt or penetrating injury to the testicle causing scrotal pain, swelling and bruising, from a minor contusion to a testicular rupture. Ultrasound is necessary to determine the extent; rupture requires scrotal exploration and repair to save the testicle and preserve fertility.
Infection of epididymis and/or testis resulting in gradual onset of scrotal pain, swelling, fever and tenderness. Most commonly caused by bacteria . Sexually transmitted in younger men. Bacteria in the urine in older men . Treated with specific antibiotics. Delayed treatment risks fertility impairment.
Testicular symptoms are commonly dismissed or attributed to muscle strain. The following, particularly when new, persistent, or severe, require prompt urological evaluation:
Pain or Swelling in One or Both Testicles
Any new unexplained testicular pain or scrotal swelling >48 to 72 hours should be evaluated with a scrotal ultrasound. The pain may be dull and aching (varicocele, epididymitis) or acute and severe (torsion, trauma). Swelling may be diffuse as in infection or torsion, or localized as in a tumour or cyst. Never ignore the significance of scrotal pain with a clinical examination.
Testicular Torsion, Urological Emergency: Sudden, severe, one-sided testicular pain, especially in a teenager or young man, especially at night or after physical activity, is testicular torsion until proven otherwise.” Don’t wait to see if it will calm down. Direct to Emergency Department, Kokilaben Hospital, Indore. Twisted testicle . The time to save it is 4 to 6 hours from the beginning .
A hard lump in the testicular body in isolation from the epididymis at the back requires urgent assessment with scrotal ultrasound and tumour markers (AFP, beta-HCG, LDH). A hard intratesticular nodule is testicular cancer until proven otherwise. The lack of pain should not be reassuring; early testicular cancer is classically painless.
The most characteristic symptom of varicocele is a constant feeling of heaviness, dragging or dull discomfort in the scrotum which is aggravated by standing or exertion and relieved in the lying position. You may also have a dull ache in the lower abdomen or inner thigh on the affected side.
Epididymo-orchitis is highly suggestive in cases of fever with scrotal pain and swelling. The rigours suggest a systemic infection and urgent care. Scrotal doppler ultrasound helps distinguish between orchitis ( increased blood flow ) and torsion ( no or decreased blood flow ) . This is a critical distinction because the treatment is either antibiotics or emergency surgery.
Evaluation of both partners is indicated in a couple with infertility of 12 months’ duration. Male factor infertility is present in 40-50% of infertile couples. If the semen analysis is abnormal (low count, poor motility, or abnormal morphology) a scrotal ultrasound should be done because up to 35 to 40% of infertile men have a varicocele, which is the most common correctable cause.
Anatomical Abnormalities & Congenital Causes
The “bell-clapper deformity,” in which the testis is not completely attached within the tunica vaginalis, leaving it free to rotate, predisposes to testicular torsion. This deformity is often bilateral, which is why the contralateral testis is also surgically fixed during torsion surgery. Varicoceles are mostly left-sided because the left testicular vein drains at a right angle into the left renal vein, resulting in a higher venous back-pressure than on the right side.
In men younger than 35 years, sexually transmitted bacteria, Chlamydia trachomatis and Neisseria gonorrhoeae, are the most frequent causes of epididymo-orchitis. Enteric bacteria (E. coli, Klebsiella) from the urinary tract are more frequent in males older than 35 years and in boys. Mumps virus causes significant inflammation in post-pubertal males with mumps orchitis , and is an important preventable cause of testicular atrophy and infertility . This is prevented by MMR vaccination.
Sports injuries, road traffic accidents and industrial accidents are the most common causes of testicular trauma. When blunt trauma is sufficient to rupture the tunica albuginea, the tough fibrous covering of the testis, emergency surgical exploration, washout, and closure are indicated. Prompt repair of the testis is usually successful, but delayed treatment is associated with a markedly higher rate of orchiectomy.
Disruption of the hypothalamic-pituitary-testicular axis from pituitary tumours, hypothalamic disease or primary testicular failure impairs both sperm production and testosterone. High FSH with low testosterone and small testes suggests primary testicular failure. Low FSH/LH with low testosterone suggest secondary (central) hypogonadism, which is often treatable with gonadotropin therapy in men who wish to preserve fertility.
Infection, particularly mumps, can cause orchitis and subsequently the production of autoimmune antibodies against sperm (ASA). These antibodies reduce sperm motility and fertilising capacity and are a major cause of immunological infertility. ASA can be detected by a specialised semen analysis and are an important finding to look for in infertile men with a history of orchitis.
Cryptorchidism (undescended testicle) is present in approximately 3% of full-term males at birth. Orchidopexy is recommended between 6 and 18 months if the testicle has not descended by 6 months, before permanent spermatogenic damage occurs from the abnormal temperature. Undesended testis without treatment: 3 to 5 times increased risk for cancer of the testis and impaired fertility of the affected testis.
Sperm are produced in the testicles, and any damage to testicular tissue, elevation of scrotal temperature, reduction of blood flow, or disruption of hormonal signalling will result in decreased quality, quantity, or both:
Varicocele interferes with spermatogenesis through several interacting mechanisms: the dilated veins fail to cool the testicular blood sufficiently, raising scrotal temperature toward core body temperature; reflux of adrenal hormone metabolites through the abnormal venous drainage creates a toxic testicular environment; and increased venous pressure reduces oxygen delivery to the seminiferous tubules. So the analysis of semen shows the typical “stress pattern” with low count, low motility, high abnormal forms and high oxidative stress. Microsurgical varicocelectomy corrects these abnormalities in 50-70% of treated men with spontaneous pregnancy achieved in 30-40% of couples within 12 months.
Orchitis directly damages the seminiferous tubules and Sertoli cells. Severe bilateral orchitis, for example, mumps orchitis, can lead to permanent azoospermia (absence of sperm) or severe oligospermia. Epididymitis can cause scarring and possible obstruction of the epididymal tubules, which physically prevents the passage of sperm from the testicle to the vas deferens. Obstructive azoospermia due to prior epididymitis may be correctable by microsurgical reconstruction (epididymovasostomy). Early aggressive treatment of orchitis with appropriate antibiotics and antiinflammatories maximises preservation of testicular function.
Treatments are available for many types of testicular infertility. Microsurgical varicocelectomy is the most effective treatment of varicocele-related infertility. In selected cases of post-obstructive azoospermia secondary to prior epididymitis, microsurgical reconstruction can restore natural fertility. For non-obstructive azoospermia due to testicular failure, testicular sperm extraction (TESE or micro-TESE) can obtain sperm directly from the testicular tissue for IVF/ICSI in 40 to 60% of carefully selected patients. Dr Vikas Singh discusses fertility implications and options with each and every patient diagnosed with testicular condition.
Most testicular conditions respond far better to early treatment than to delayed management, and some, like torsion, are true emergencies where every hour matters. Please do not wait.
Sudden, severe, unilateral testicular pain, especially in a teenager or young man, especially at night or after physical activity, should be considered testicular torsion (a urological emergency) until proved otherwise. Other warning signs include rapid swelling and redness of the scrotum, nausea and vomiting or a previous episode of similar transient pain (intermittent torsion). If in doubt, go to the emergency room. It is always better to go and get yourself checked and be reassured than to sit at home and lose a testicle.
No, most lumps in the scrotum are benign. Common benign causes are epididymal cysts, hydrocele, varicocele and lipomas. However any hard lump felt within the testicular body itself (as opposed to the epididymis or surrounding structures) requires urgent assessment with scrotal ultrasound and tumour markers to exclude testicular cancer. The testicular body should be smooth, uniformly firm. Any internal nodularity or hardness is abnormal and should be investigated.
Yes, varicocele is the most common treatable cause of male infertility, affecting 15% of all men and 35 to 40% of infertile men. This impacts on spermatogenesis by increasing the temperature of the scrotum and the production of a poor hormonal and oxidative environment. Microsurgical varicocelectomy improves semen parameters in 50–70% of treated men and results in spontaneous pregnancy in 30–40% of couples within 12 months.
Both cause pain and swelling of the testes, but they differ critically. Torsion Sudden and severe onset Usually young men No fever at onset; Doppler ultrasound shows no or reduced blood flow to the testicle, needs emergency surgery. Orchitis: insidious onset hours to days, fever common, urinary symptoms or STI history, Doppler increased blood flow (inflammation), antibiotics. For an accurate diagnosis, any patient with scrotal pain needs a Doppler ultrasound that is performed urgently by Dr. Vikas Singh.
The recurrence rate is technique dependent. Open ligation: 10-15 per cent. Laparoscopy: 3 to 5%. Microsurgical subinguinal varicocelectomy performed by Dr. Vikas Singh has the lowest recurrence rate of any approach, at about 1 to 2%. The operative microscope permits accurate identification and ligation of all dilated veins, sparing the testicular artery, lymphatics and vas deferens; a combination which minimises both recurrence and complications.
Yes. Most men with one healthy testicle have normal testosterone levels and sufficient sperm production. Usually one healthy testicle is sufficient to produce normal levels of hormones and to allow fertility. Testosterone should be monitored at regular intervals. Men who require the removal of a testicle due to cancer need to discuss sperm banking beforehand if they want to preserve their fertility.
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