Bouncing Balls: Understanding Positional Changes of Your Testes
Andrew Siegel MD 12/12/2020
I was prompted to write this entry after office hours this past week when I saw three patients on the same day with issues related to the position of their testes. One was a young man who complained that one of his testes pulled up into his groin during sex, requiring him to manually pull it down afterwards. Another was a man in for a vasectomy consultation who was so nervous that his testes pulled up into his groin, making examination of the vas deferens (sperm ducts) impossible. The third was an elderly man with a sizable benign cyst of his epididymis that pushed the testes down so low that it interfered with activities such as driving, requiring him to get seated in his car with the utmost of caution, carefully adjusting himself to elevate the testes to avoid getting the testes crushed.
A complaint voiced not infrequently by my middle-aged and older patients is that their testicles hang loosely, like the pendulous breasts of older women, sometimes to the extent that when seated on the toilet, their scrotums touch the water!
What gives? To understand this, we need to review some scrotal science.
Scrotal Sac Science 101
Attribution of image above: By OpenStax College [CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)%5D, via Wikimedia Commons
During embryologic development the testicles originate high in the abdomen and by full-term they descend into the scrotal sac. At puberty, the testes increase in size substantially and with the increase in testes size there is a proportional increase in scrotal size.
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. This is why when you get into a hot bath or shower, the testes descend and are easiest to examine.
The testes are not free-floating balls packaged within the scrotal sac, but are suspended via the spermatic cord, a rope-like “cord” of tissue that travels in the groin and contains the life supply (artery, veins, nerves, sperm duct, lymphatics) of the testes. Both the testes and spermatic cord are surrounded 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 upwards when it contracts.
The cremasteric reflex occurs when the inner thigh is stroked and the testicle pulls up towards the groin via a contraction of the cremaster muscle. This is a brisk reflex in boys and tends to become less active with aging. It is a natural protective reflex that helps us avoid testicular injury when danger approaches, like a turtle pulling its head into its protective shell. When a male presents to the emergency room with a possible testes torsion (twist), the cremaster reflex is usually absent on the side with the torsion.
When Your Balls Ride High
Young men generally have great muscle tone, including their dartos and cremaster muscles with the testes well-supported in a tight scrotal sac, so it is normal for youth to be associated with higher-riding testes.
It is also important to know that as part of the normal male sexual response, accompanying erection there is thickening of the scrotal skin and an increase in testes size and elevation. My patient who complained of his testes pulled up to the groin during sex was experiencing a normal sexual response.
When a man is nervous or anxious, the cremaster muscle tends to contract, pulling the testes up. The bottom line is that the testes are not fools– when frightened they rise up and hide, cowering like a frightened dog in a thunderstorm! That explains the high-riding testes in my nervous patient in for a vasectomy consultation.
Some men have high-riding testes because they had incompletely descended testes during fetal development and never had this addressed; or alternatively, had surgery to reposition the undescended testes that was not 100% effective.
When Your Balls Hang Low
Time and gravity are cruel conspirators. As we age, the collagen and elastin content of our tissues diminishes, accounting for sagging, less supple skin. The scrotum is no exception. The combined factors of testes weight, gravity and aging cause a continued southward journey of the testes throughout life. As the years progress there is also loss of muscle strength of the dartos and cremaster muscles, causing scrotal relaxation and looser hanging testes, respectively. Years ago, a highly effective, common hernia repair in vogue (Shouldice technique) involved stripping the spermatic cord of cremaster muscle, rendering the testicle on the side of the repair to be “dangly.”
Since the low-hanging testes is 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.
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.” It was quite the funny scene!
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 summer camp song had the following lyrics (sung to the tune of Italian love song That’s Amore)
When your balls hit the floor like a B-54 it’s a rupture.
A classic sign of the low-hanging scrotum is that when one passes wind, his testes may temporarily become airborne like a kite flying erratically in a sudden gust!
What to do about scrotal laxity
Maintain a healthy lifestyle, stay in good physical shape and keep your core muscles fit. Remember that the cremaster muscle is an extension of one of your core muscles. Get in the habit of wearing briefs or boxer briefs, many of which are highly supportive like cycling shorts, as opposed to boxers. I often prescribe UFM underwear (Underwear for Men) that are fabulous for men with scrotal laxity or for men who undergo scrotal surgery and need good support and elevation. They have a pouch to seat the testes and a drawstring that can be cinched up to elevate the testes to whatever extent desired. They really work and I have tried them myself.
If scrotal laxity has caused anatomical, functional or psychological concerns, there are effective surgical procedures to remedy the situation. Reduction scrotoplasty, a.k.a. scrotal lift can tailor and re-contour the excessive scrotal skin, with the goal of elevating the testes, eliminating the redundant scrotal tissue, minimizing scarring and retaining natural pigmentation.
Wishing you the best of health,
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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. He is a urologist at New Jersey Urology, the largest urology practice in the United States. His latest book is Prostate Cancer 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families.
PROSTATE CANCER 20/20 is now available at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours).
Dr. Siegel’s other books: