Overview

What is orchidectomy?

Orchidectomy (or-kid-ekt-omy) refers to the process of surgically removing one or both testicles.¹ It is commonly performed in cases of testicular cancer, gender-affirming surgery or when there has been extensive damage to the testicle(s), also known as testicular trauma. Testicular trauma can occur as a result of sports injuries, accidents and direct blows to the area.² When there has been testicular trauma, the removal of the affected testicle(s) is only required if the testicle cannot be salvaged.² Such severe cases are rare, with the incidence of scrotal and testicular injuries being only 1%.³ 

Testicular trauma often occurs suddenly and requires immediate medical examination to determine if orchidectomy is necessary.² Studies have reported that removal of the affected testicle(s) was more common in cases when examination of the testicles was delayed (45%) than in cases when examination was done promptly (9%).³ Testicles are essential to the male reproductive system as they produce sperm cells and sexual hormones, also known as androgens (for example, testosterone).⁴ As a result, the removal of testicles can affect the hormonal balance and future fertility of the patient. It is therefore important for medical professionals to explore all other possible options before performing orchidectomy.² 

In addition to the physical impact of the surgery, orchidectomy has been found to have a negative psychological impact on patients’ mental health, including their body image, self-esteem and sexual well-being.² Testicular prostheses have been used to help reduce this psychological distress.⁵

What is a testicular prosthesis?

Testicular prostheses (plural of prosthesis) are artificial implants that can be used to replace the original testicle(s) after orchidectomy. They do not perform any of the testicular functions (sperm or hormone production) and are entirely for cosmetic purposes to reduce the psychological impact of getting an orchidectomy.^5,6 The implants are either made of silicone or saline-filled (filled with sterile salt water).⁷ 

The Testicular Prosthesis Placement (TPP) procedure is performed under anaesthesia. It consists of inserting the prosthesis into the scrotum through a small incision in the groin.^8,9 The neck of the scrotum is closed with stitches to avoid the prosthesis from moving. It can be performed at the same time as an orchidectomy or later.⁹

Psychology of orchiectomy

The loss of one or two testicles has been associated with a perceived loss of masculinity, which has been reported to lead to decreased self-esteem, body image and overall mental health. It can be associated with feelings of loss, discomfort and shame, particularly for young males.^2,9,10 This emotional and psychological distress can affect relationships as well as intimacy and sexual well-being. In 50% to 60% of cases, restoring the body symmetry with a testicular prosthesis has been shown to improve self-image, confidence and sexual function, which consequently increases overall well-being.^9,11 

Challenges and limitations

Complications

The rate of complications for TPP is low, with only 0.4% of people requiring prosthesis removal because of postoperative complications.¹¹ However, as is the case for any surgery, the procedure represents a risk of infection of the area being operated on.^11,12 Precautions are taken during the surgery to limit the odds of infection by thoroughly shaving and cleaning the area operated on, sanitising the implant and administering antibiotics to the patient before the surgery.¹¹ The risk of postoperative complications occurring is the same whether the TPP is performed simultaneously or after the orchidectomy.¹² Potential complications include:¹¹

• Scrotal contraction, either temporary or persistent
• Wound reopening
• Implant extrusion (protruding through the skin)
• Infection
• Pain 
• Swelling (accumulation of fluid in the body’s tissues)
• Bruise
• Numbness

Cost

The costs of TPP are often covered by health insurance, but they usually only do so if the prosthesis is implanted in the same operation as the orchidectomy.¹¹ However, for those without medical insurance, the high cost of the prosthesis alone ($2500-$3000) can be overwhelming. 

Recovery and long-term monitoring

Most patients go home the day of the surgery. Pain and discomfort might occur during the first 7 to 10 days, which can be eased with painkillers. Patients are also advised to regularly move the implant gently to their preferred position for the first two weeks post-operation to make sure that the prosthesis heals in the correct place.¹¹ It is recommended to avoid exercise for six weeks after surgery. 

Alternatives to testicular prosthesis

Testicular prostheses are used for cosmetic purposes and do not perform any testicular functions. There are, unfortunately, no alternatives to TPP that would allow the appearance of having two testicles after orchidectomy. However, considering the large psychological impact of the removal of testicles on self-esteem, body image and sexual function, alternatives to TPP could include psychological counselling and support groups. Indeed, such therapies can help to reduce the feelings of shame or “loss of masculinity” that have been reported in association with the procedure.^2,10 

FAQs

Is testicular trauma always treated with orchidectomy?

No, only cases where the testicular tissue is severely damaged and cannot be salvaged require treatment with orchidectomy.²

Is an orchidectomy always followed by the insertion of a testicular prosthesis? 

No, the insertion of a testicular prosthesis is a decision that is made between the patient and the surgeon before orchidectomy, although it can also be performed at a later date. Studies have reported that testicular prosthesis is often not offered as an option to patients or that the informational conversations are often too short.^9,11 Therefore, if you think TPP might be the right option for you, we recommend that you mention it to your doctor and discuss your options with them.   

What are the pros of getting a testicular prosthesis?

The pros of getting a testicular prosthesis include:^9,11 

• Restoration of the anatomical symmetry 
• Reduction of feelings of uneasiness and shame
• Restoration of sexual function
• Restoration of overall well-being

What are the cons of getting a testicular prosthesis?

The cons of getting a testicular prosthesis include:¹¹

• Cost of the prosthesis
• Risks associated with the procedure (pain, infection, scrotal contraction, movement of implant)

Are testicular prostheses only available to adults?

No, testicular prostheses are not only available to adults, with 10% of TPPs being performed in males under the age of 16.¹³ Although these cases have shown high patient satisfaction, getting testicular prosthesis at a young age requires regular monitoring, particularly through puberty, and a second surgery is usually needed to increase the size of the prosthesis following the development of the other testicle.^11,13

Summary

The removal of one or both testicles can be required as a result of trauma. Testicular prostheses have been created to combat the negative impact of losing one or both testicles on self-esteem, body image and sexual function reported in males after orchidectomy. Testicular prosthesis placement (TPP) surgery, which aims to restore the symmetry of the anatomy, can greatly reduce the psychological effects of orchidectomies. However, this option is not always available to patients, either because of a lack of information or high costs of the prosthesis. In conclusion, the possibility of TTP should be a topic of conversation between surgeons and their patients before orchidectomy to reach the best possible outcome for the patient’s overall well-being.