Background: While the normal size range of the male testicle is known, there is no aesthetic relationship measurement between the size of the penis and that of the scrotum that hangs beneath it. Certainly the two create an overall aesthetic unit (penile-scrotal complex) but the exact proportionate relationship between the two has never been studied. Trying to mathematically compare them would be difficult because the penis is measured by linear numbers while the size of the scrotum is more volumetric in assessment.
But despite the difficulty in measuring the aesthetic relationship between penile size to scrotal volume (penile-scrotal proportion) what ultimately counts is the patient’s perception of it. If the patient feels the scrotum lacks adequate volume then it is aesthetically deficient.
Besides the enveloping skin the major contributor to scrotal size is that of the testicles. Average volumes of testicle is around the range of 15 to 20ccs each but they decrease in size with age. Increasing scrotal size or fill has to be done by enhancing the existing testicles with implants. The most common method is the side by side technique where much larger implants are placed which displace the smaller natural testicles to the more hidden back end of the scrotum. It is not known whether this has any adverse effect on testicular function although it is presumed that it does not as their vascularity should be unaffected.
As a general rule, assuming that the exiting testicles are 3.5cms or less in size, solid ultrasoft silicone testicle implants that have at least a 6cm or .6.5cm size are used. These far exceed sizes that exist for saline testicle implants. How much beyond 6 or 6.5cm size patient wants to go depends on how much scrotal skin they have and the size of their existing testicles. I have had one patient in whom I went to an immediate 7cm testicle size which was successful despite having an indwelling penile pump. Then a patient came along who asked for initial 7.5cm implants….
Case Study: This male requested extra large (XL) testicle implants. He specifically requested 7.5cm implants which I had never done before. He did have a lot of loose scrotal skin and he had no existing penile device in place. While I agreed to try 7.5cm implants I also asked to have a 7cms size available just in case I felt the skin closure on 7.5cm implants was too tight or unsafe to keep them.
Under general anesthesia a 3.5cm long midline raphe skin incision was made on the middle portion of the scrotum. Keeping a thin segment of tissue intact int the midline scrotal pockets were bluntly dissected out pushing the existing testicles aside. An initial trial ft of 7.5cm implant on one side and a 7cm implant on the other side demonstrated that soft tissue closure would not be compromised.
The 7cm implant was then replaced by the larger one to have a paired 7.5cm implants. A four layer soft tissue closure was done with no tension on the skin level which used dissolvable sutures and a skin glue sealant.
At 7.5cms with a volume of 110ccs, these were the largest testicle implants I have ever placed. (220ccs added scrotal volume) His very large amount of loose scrotal size and the existing small 3.5cm size of his testicles suggested that such a large implant size was possible. Their space occupying effect will initially make the scrotum very high and round. But this will rapidly drop down after surgery as the swelling subsides and the loose skin envelope relaxes.
Highlights:
- In many cases of penile-scrotal disproportion, the side by side testicular implant technique can be very effective.
- The size of XL testicle implants that any scrotum can accommodate is primarily driven by the amount and laxity of the scrotal skin.
- All XL testicle implants, by virtue of having two of them, will take several months after surgery to drop down and hang more normally.
Dr. Barry Eppley
Indianapolis, Indiana