Why Does the Scrotum Sag? What Is Normal, Conditions That Need Examination and Scrotoplasty

Sagging noticed in the mirror after a shower, more obvious in summer or increasing over the years… Many men are reluctant to ask anyone and wonder privately: “Why does my scrotum hang so low, is something wrong with me, and can it be corrected?”

The skin pouch that holds the testicles is called the scrotum. Its rising and falling during the day is part of a natural system that keeps the testicles cool, and sagging is usually not a sign of disease. This article covers why the scrotum sags, which situations are considered normal, which signs need an examination, non-surgical approaches and scrotoplasty surgery.

Why does the scrotum hang low in the heat and tighten in the cold?

Sperm production works better a few degrees below the body's core temperature; this is why the testicles sit outside the body. The dartos muscle beneath the scrotal skin relaxes in the heat, so the skin surface widens and heat loss increases; in the cold it contracts, the skin wrinkles and the scrotum shrinks. The cremaster muscle around the spermatic cord also pulls the testicles towards the body in the cold and during sexual arousal.

So it is expected for the scrotum to hang lower after a hot shower or in summer and to look more compact in the cold; what really matters is whether other symptoms accompany the sagging.

Is it a problem if one testicle hangs lower than the other?

Usually not. Anatomy sources note that the left testicle generally sits slightly lower than the right; this is linked to differences in cord and vessel structure on the left. In some men the right testicle is lower; this is also considered normal.

What matters is not a long-standing difference so much as a new change. If one testicle rises or drops within a short time, grows, hardens or changes position along with pain, it needs examining.

What makes sagging worse?

Several factors contribute to the scrotum hanging lower over time:

• Age and skin elasticity: With age, the scrotal skin can lose its elasticity; in later life a lower, looser scrotum is a common change.
• Warm surroundings: Hot weather, a hot bath, a sauna or sitting for long periods make the laxity more noticeable; in cool surroundings it usually eases.
• Weight change: With weight gain, groin tissues can become heavier; after marked weight loss, loose skin may be left behind.
• Underlying conditions: Fluid collecting in the scrotum, enlarged veins, an inguinal hernia or swelling due to lymphatic problems can weigh the scrotum down and pull it lower.

With the first three factors, sagging is usually similar on both sides and is not accompanied by swelling or pain; with the last, the problem lies not in the skin but inside the scrotum.

What might it mean if swelling or heaviness accompanies sagging?

Marked fullness on one side, or a dragging sensation, heaviness and ache that increase on standing or towards the end of the day, may point to something other than skin laxity. The main causes are:

• Hydrocele: Fluid collecting between the layers around the testicle; often a swelling that causes no pain.
• Varicocele: Enlarged testicular veins; seen mostly on the left side, it can cause fullness or a dragging feeling on standing.
• Inguinal hernia: A swelling that descends from the groin into the scrotum and becomes more obvious with coughing or straining.
• Spermatocele: A fluid-filled cyst arising in the sperm-carrying duct next to the upper part of the testicle.
• Testicular mass: Hardness or enlargement arising from the testicle itself; even without pain, it should be assessed without delay.

Telling these apart starts with an examination, supported if needed by a scrotal ultrasound. Most scrotal swellings are not cancer, but guessing which one it is from the outside is not appropriate. These topics are covered in separate articles on our site.

What can be done without surgery?

If there is no cause such as swelling, pain or a lump, and the sagging is only uncomfortable, the first step is usually not surgery. These measures do not remove the sagging but can improve comfort:

• Supportive underwear: Well-fitting underwear that holds the scrotum close to the body, or supportive sports underwear during exercise, can reduce swinging and chafing when walking and running.
• Keeping cool and dry: Breaking up long periods of sitting, choosing breathable fabrics and limiting hot baths and saunas can help the scrotum tighten and reduce sweat-related irritation.
• Weight management: If you are overweight, reducing the load on the groin can ease symptoms.

There is no reliable evidence that creams, gels and devices sold online as “tightening” reduce sagging. For methods such as lasers, only preliminary studies in a handful of people exist; products and procedures whose contents and risks are unknown should not be tried.

What is scrotoplasty, and for whom is it discussed?

Scrotoplasty is the general name for operations that reshape the scrotum; the type done for sagging is also called a scrotal lift or scrotal reduction. The general principle is to remove part of the excess scrotal skin together with the thin muscle layer beneath it and stitch the remaining skin. The incision site and the amount of skin removed are planned according to the person's anatomy; the testicles are not the target of the procedure.

The operation is usually discussed when sagging causes persistent discomfort and irritation when walking, during sport or during intercourse, and non-surgical measures have not been enough. In some men it is raised together with a penoscrotal web (“webbed penis”): scrotal skin attaching higher than usual on the underside of the penis and forming a skin fold between them.

This web may be congenital or may develop after a circumcision that removed too much skin from the underside of the penis; it can make the penis look shorter, cause tightness during erection or make intercourse difficult. Its correction is also a type of scrotoplasty; a web that causes no problems does not need surgery.

What are the risks of scrotoplasty?

As with any operation, scrotoplasty has risks, which should be discussed openly before deciding:

• Bleeding and haematoma: A collection of blood under the skin; it is the most commonly reported problem with this operation and sometimes needs draining.
• Infection: This may appear as redness, increasing pain, discharge or fever.
• Wound-healing problems: The suture line may open, particularly when it has been closed under tension.
• Scarring and altered sensation: A scar remains along the suture line; temporary or longer-lasting changes in sensation may occur around it.
• Asymmetry and renewed laxity: A difference may remain between the two sides; because the skin continues to age, it may loosen again over time.

Because the procedure is done at skin level and the testicles are not touched, no direct effect on sperm production or the erection mechanism is expected. However, there are no large, long-term studies on this; also, if more skin than necessary is removed, tightness or a pulling sensation may occur during erection. For this reason the result cannot be guaranteed, and planning is done cautiously.

What should recovery and expectations be like?

Recovery varies from person to person. Swelling, bruising and tenderness are common in the first days; supportive underwear, wound care and the timing of a return to work, sport and sexual activity are set according to the doctor's advice.

The aim is functional comfort in daily life and helping the person feel better about himself; a goal of “rejuvenation” or a flawless appearance is not realistic. If thoughts about appearance constantly occupy the mind or lead to avoiding changing rooms or intimacy, the possibility of body image anxiety should be discussed separately. Research shows that in people with marked body image problems, cosmetic procedures often do not reduce this distress; in that case mental health support may be the first step.

When should you see a doctor?

A urology and andrology assessment is recommended in the following situations:

• Sudden, severe pain in the scrotum or testicle (emergency; 112)
• A painful swelling descending from the groin into the scrotum that cannot be pushed back (emergency; 112)
• A hard area or lump felt in the testicle, or a new feeling of heaviness in the scrotum
• Fullness, a dragging feeling or ache that increases on standing or towards the end of the day
• A newly noticed change in the position or size of one testicle
• Sagging that causes persistent discomfort, irritation or marked anxiety

A scrotum that hangs lower in the heat and tightens in the cold, and testicles that sit at different heights, are usually normal. If swelling, a feeling of heaviness, a lump or pain is present, an examination comes first; for complaints due only to excess skin, non-surgical measures and, if needed, scrotoplasty can be discussed together with their risks and limits. Assoc. Prof. Zülfü Sertkaya practises in urology and andrology in Istanbul; scrotal sagging assessment is carried out on an individual basis and in confidence.

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