Dear Dr. G,

I am a 30-year-old man whose life crumbled after being diagnosed with testicular cancer two years ago. During an intimate moment, my wife noticed a lump in my right testicle. At first, I wasn’t worried about testicular cancer, as I never believed that cancer could happen to young men. However, as the lump grew bigger and my concern increased, I decided to see a doctor.

I was horrified when the doctors informed me that the painless lump was likely cancerous. They advised me to have my testicle removed as soon as possible. I am grateful that the operation was successful and the cancer was completely removed.

Two years later, during my medical check-up following the surgery, I received the good news that there was no recurrence of the cancer. I was somewhat taken aback when the doctors mentioned the possibility of a testicular prosthesis. Initially, I thought it was a joke until I researched more about testicular prosthetics.

I want to understand the necessity of having a prosthesis to fill an empty scrotal sac. What exactly are testicular prostheses, and what materials are they made from? How common are such prostheses, and who typically receives them? What are the pros and cons of having a prosthesis? Is there a genuine need to fake an empty sack with a prosthesis?

Yours truly,

Faking Freddie

A testicular prosthesis is offered when a patient desires restoration of scrotal appearance after losing a testicle. These occur following an Orchiectomy for cancer, trauma or torsion requiring surgical removal and severe infection or abscess requiring orchiectomy. Undescended testis (cryptorchidism), where the

testicle is absent or atrophic (Congenital anorchia), may also require a testicular prosthesis. Testicular prosthesis is also inserted for Cosmetic or Psychological Reasons. Patients with significant body-image concerns intend to reduce psychological impact, such as shame, anxiety, or altered self-image. Therefore,

testicular prostheses have become an important component of urological reconstructive care. Their primary purpose is to restore the cosmetic appearance of the scrotum after the loss or absence of a testicle. This is helping many patients regain confidence, body image, and psychological well-being.

Although testicular prosthesis is highly beneficial, it remains underused. Only 25–35% of men undergoing orchiectomy are offered a prosthesis at the time of surgery. Implantation rates vary by region, with higher insertion in North America, Australia, and Europe, and lower in Asia, due to cultural factors and

lower awareness. Satisfaction rates are 90–95% among patients who receive an implant. Barriers to Uptake are usually a lack of counselling or awareness, and stigma or embarrassment.

The concept of replacing a missing testicle dates back more than a century. Early attempts started in the early 1900s, when surgeons experimented with glass balls, silver, gold, paraffin, and ivory implants. These materials often caused infection, extrusion, or severe inflammation and were eventually abandoned. In the Mid-20th century, plexiglas spheres were introduced. They were more inert, but still rigid and uncomfortable. The first silicone gel–filled testicular prosthesis was introduced in 1993, representing a major leap in biocompatibility and comfort. Smooth or textured silicone shells filled with saline became the new standard, reducing concerns about silicone gel leakage. Today, most prostheses are silicone elastomer shells filled with silicone gel or saline, depending on regulatory and regional preferences. These are anatomically shaped and available in multiple sizes.

Sizing is both an art and a science. Measurement of the contralateral testis, for length, width, and firmness, is the usual practice. In bilateral absence, use standard anatomical averages for age. Assessing scrotal volume is crucial with the Orchidometer: a tight, small scrotum requires a smaller prosthesis, while a lax scrotum allows a larger, more natural feel. Many surgeons perform intraoperative sizing and evaluate cosmetic fit using natural hang and symmetry. The general sizing principles aim to match the existing testicle in unilateral cases. In bilateral implants, aim for normal adult size. A small testicle is 12-16 mL equivalent, medium size is 18–20 mL equivalent, and lastly, large is 22-25 mL equivalent. A well-sized implant should look natural and be comfortable long-term.

Testicular prosthesis is considered safe and well-tolerated. The rejection rates are low, and long-term durability and minimal maintenance are required. The surgical risk includes infection rates of 1–3%. This is usually associated with hematoma or scrotal swelling. The infection can result in pain or discomfort. In the longer term, complications such as extrusion can also occur, although this is rare with modern devices. Malposition or high-riding implant and Implant rupture. The need for replacement is usually when the lifespan is> 15–20 years. There is no evidence that prostheses increase cancer risk or interfere with cancer surveillance or tumour markers.

Testicular prostheses provide an excellent option for men who have lost a testicle or were born without one. They improve body image, scrotal symmetry, and psychological well-being with minimal long-term risk. Although the concept dates back more than a century, modern silicone and saline devices are safe,

comfortable, and highly effective. Despite their benefits, they are often underused because patients are not made aware of the option. With appropriate counselling, individualised sizing, and proper surgical technique, satisfaction rates are extremely high. Men facing empty scrotal sacs contemplating faking it with a prosthesis often put Dr G on the spot for opinion. His advice is: “Losing the authentic testicle for cancer is unavoidable, but modern prosthesis can still fake it almost to perfection!”